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UBC Theses and Dissertations

The process of change during three interventions for claustrophobia Booth, Richard 1990

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THE PROCESS OF CHANGE DURING THREE INTERVENTIONS FOR CLAUSTROPHOBIA By RICHARD BOOTH B.A.(Mod.), T r i n i t y C o l l e g e , D u b l i n , 1978 M.Sc., U n i v e r s i t y o f S t r a t h c l y d e , G l a s g o w , 1980 M.Sc, T r i n i t y C o l l e g e , D u b l i n , 1981 M . P s y c h . S c . , U n i v e r s i t y C o l l e g e , D u b l i n , 1983  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE  REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY  in THE  FACULTY OF GRADUATE STUDIES (Department o f P s y c h o l o g y )  We a c c e p t t h i s  t h e s i s as c o n f o r m i n g  to the r e q u i r e d  THE  standard  UNIVERSITY OF BRITISH  COLUMBIA  /  A u g u s t 1990 ©  Richard  B o o t h , 1990  In presenting this thesis in partial fulfilment of the  requirements for an advanced  degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department  or  by his  or  her  representatives.  It is  understood  that  copying or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department The University of British Columbia Vancouver, Canada  Date  DE-6 (2/88)  V  K  r%C,V!>T  mo  ABSTRACT  The  purpose of t h i s  change d u r i n g provide  three  study  interventions f o r claustrophobia,  d e s c r i p t i v e data  participants,  was t o i n v e s t i g a t e t h e p r o c e s s  about t h i s  exposure t o the locked  test  exposure to the s e n s a t i o n s exposure),  through  t o one o f f o u r  c l o s e t used of anxiety  modification of underlying  on  f o r assessment,  (interoceptive negative  cognitions, over  three  The e x p o s u r e g r o u p p r o v e d s u p e r i o r t o t h e c o n t r o l  a wide r a n g e o f m e a s u r e s .  of r e p o r t e d heart  the l o c a l  groups:  o r a c o n t r o l g r o u p . A l l i n t e r v e n t i o n s were g i v e n sessions.  and t o  fear. Forty-eight  r e c r u i t e d f r o m t h e community  m e d i a , were r a n d o m l y a s s i g n e d  of  f e a r and p a n i c ,  In the c o g n i t i v e group,  but not p r e d i c t i o n s of f e a r or  r a t e , were l o w e r e d , an i m p o r t a n t  finding  g r o u p had no e x p o s u r e t o t h e c l o s e t d u r i n g i n t e r o c e p t i v e g r o u p made  translate into reduction  the  timing of fear reduction, provided  change. S t r u c t u r e d  since  but these d i d  i n fear scores.  An a n a l y s i s o f  and o f t r e a t m e n t  some c l u e s a s t o t h e m e c h a n i s m o f  interviews  provided  data  the  fear i n c l u d i n g i t s onset,  patterns  of current  and  common s a l i e n t  the  light  of recent  this  t r a i n i n g . The  some modest g a i n s ,  not  generalization,  scores  c o g n i t i o n s . The r e s u l t s f i n d i n g s on p a n i c  on a s p e c t s  of  avoidance,  are discussed i n  disorder.  iii  TABLE OF CONTENTS Abstract Table of contents L i s t of t a b l e s L i s t of f i g u r e s Acknowledgements  INTRODUCTION  i i i i i v v vi  ••••  1  APPROACHES TO ANXIETY Exposure C o g n i t i v e approaches I n t e r o c e p t i v e exposure  4 11 19 25  METHODOLOGIES  28  CLAUSTROPHOBIA  35  THE PRESENT STUDY  46  METHOD  60  SAMPLE SELECTION  60  MEASURES  61  APPARATUS  68  PROCEDURE  68  HYPOTHESES  74  EXPERIMENTAL STUDY:* HYPOTHESES  74  A PHENOMENOLOGICAL STUDY OF CLAUSTROPHOBIA: OUTLINE. 78 RESULTS  79  EXPERIMENTAL STUDY  79  PHENOMENOLOGICAL STUDY The Sample P r e - I n t e r v i e w Questionnaires Cognitions and P h y s i c a l Sensations. , S t r u c t u r e d Interviews DISCUSSION  ,  DIRECTIONS FOR FURTHER RESEARCH CONCLUSION  98 98 100 104 107 122 150 154  iv  REFERENCES  157  APPENDICES  168  Appendix  A : Structured interview  Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H Appendix I Appendix J Appendix K Appendix L  /  : : : : : : : : : : :  Anxiety S e n s i t i v i t y Index P r e d i c t i o n of f e a r Report of fear/Report of panic Negative C o g n i t i o n s C h e c k l i s t P h y s i c a l Sensations C h e c k l i s t G e n e r a l i z a t i o n Test Consent Form Consent Form ( C o n t r o l Group) D e b r i e f i n g Report Treatment I n t e g r i t y Adjusted means f o r question 1  168 170 171 172 173 174 175 176 177 178 179 180  V  LIST OF TABLES TABLE 1 Summary and  timing of  assessment  TABLE 2 Means and standard d e v i a t i o n s p r e - and p o s t - i n t e r v e n t i o n  for  67  seven  variables 83  TABLE 3 U n i v a r i a t e ANCOVAs on p o s t - i n t e r v e n t i o n between the four groups  differences  TABLE 4 S i g n i f i c a n c e of the d i f f e r e n c e s between the i n t e r v e n t i o n s and the c o n t r o l group  84  three 85  TABLE 5 Means and standard d e v i a t i o n s f o r seven v a r i a b l e s at p r e - i n t e r v e n t i o n , p o s t - i n t e r v e n t i o n , and at follow-up  88  TABLE 6 U n i v a r i a t e ANCOVAs on d i f f e r e n c e s between the three i n t e r v e n t i o n groups, f o r time, and group x time, at p o s t - i n t e r v e n t i o n and f o l l o w - u p  89  TABLE 7 Predicted anxiety reduction  93  at  TABLE 8 Planned comparisons three i n t e r v e n t i o n s TABLE 9 Selected  findings  six  time p o i n t s  on the t i m i n g of  during  fear  change i n  the 95  from the  structured  interview....  109  LIST OF FIGURES FIGURE 1 P r e d i c t e d anxiety reduction. . . .  at  six  time p o i n t s  during  fear 94  ACKNOWLEDGEMENTS  I take pleasure  i n acknowledging the h e l p  p e o p l e . The 48 p a r t i c i p a n t s o f t e n taking part,  and t h e i r  r e v i v e d a sagging of my c o l l e a g u e s and  Steve T a y l o r .  invaluable.  interest  spirit.  The a s s i s t a n c e  Dimitri  advice.  gratitude  t o my s u p e r v i s o r  memorable.  courage i n  i n the study a t times  Lori  the help  Taylor,  and  Cindy  o f Maureen W h i t t a l  P a p a g e o r g i s was p a i n s t a k i n g  editorial  made t h e y e a r s  showed g r e a t  I appreciated  D e b b i e Sansom,  of a v a r i e t y of  B u t , above a l l , I w i s h  support  Lopatka, was  in his  t o e x p r e s s my  J a c k Rachman who, i n many ways,  d u r i n g w h i c h t h i s was w r i t t e n  b o t h happy a n d  1  INTRODUCTION  In discuss  1980  held  i n Albany,  t h e most p r o m i s i n g d i r e c t i o n s  approaches One  a c o n f e r e n c e was  to anxiety disorders  less  e m p h a s i s on  done l i t t l e  straightforward  call  that  disorders.  I f i t was  efficacious  treatment  w o u l d c o n s e q u e n t l y be  had  that at least  there  serious  limitations  performance-based  p r o c e d u r e s , but  and  complete  i n d e e d . Not  are'unimproved  (their  only are underlies  i t was  Even  at  the  recognized that  Barlow  to encourage  s u g g e s t more o p t i m i s t i c  of treatment,  t h a n one  complacency. current  i n two, There  figures.  been  (1981) p o i n t e d o u t or unable  e s t i m a t e i s 2 5 % ) , as w e l l  as a r e s u l t  i n t e r v e n t i o n s number l e s s statistic  s u c h work  there i s c o n t r o v e r s y over  takes account of those u n w i l l i n g  treatment  that  an  i n t h e t r e a t m e n t o f s i m p l e p h o b i a had  o v e r e s t i m a t e d . M a v i s s a k a l i a n and i f one  been  area  t o our k n o w l e d g e o f what  conference i n Albany,  improvement r a t e s  who  in this  s u c h t e c h n i q u e s c a n be f u r t h e r d e v e l o p e d .  time o f t h a t  has  v a l u e , then such a  c o n c l u s i o n w o u l d h a v e been p r e m a t u r e  that  certain  than o t h e r a n x i e t y  been d e v e l o p e d ,  of l i t t l e  have  than o t h e r s . This  of simple phobias  felt  1981).  outcome s t u d i e s , w h i c h  t o be more e f f e c t i v e  i n studies  to  t h e r e s h o u l d be f a r  f o r a g r e a t e r emphasis on p r o c e s s v a r i a b l e s  l e s s heeded  how  & Wolfe  t o e n h a n c e our knowledge o f why  treatments appear  York,  for behavioural  (see Barlow  o f t h e main r e c o m m e n d a t i o n s was  New  as  to those  successful  hardly i s no  a  evidence to  2  This  study  research  starts with  is called  both p r a c t i c a l  and  claustrophobia, with the  some o f  former are  cognitive strength  phobia  & Whittal,  may  intriguing curiosity  possibilities. about the  opposed to p a n i c  disorder,  implicated  (see  particularly sensations  can  add  Barlow  held be  Though to in  the  (see  less  ( 1 9 8 8 ) has  a case of p a n i c  a suggestion  on  features  unusual  are  so may  cognitions  even  disorder  which opens  up  i n simple  Beck 1987,  Clark  sensations  suggestion  that  1 9 8 7 ) . No  of  as  less is  anxiety,  exposure t o  much t o p s y c h o l o g i c a l  (Barlow & Cerny,  phobias  where t h e y have been more  physical  with the  be  be  In p a r t i c u l a r , i t h e i g h t e n s  r o l e of  i n t e r e s t i n the  disorder  cognitions  be  common  impervious  may  for  will  disorders.  t o be  to c o g n i t i v e m o d i f i c a t i o n . claustrophobia  focus  sharing  1988), and  process  simple phobias  claustrophobia  w i t h more l i m i t e d a v o i d a n c e ,  the  yet  considered  with which a s s o c i a t e d  that  commonly  study of  that  more w i d e s p r e a d a n x i e t y  intervention,  resistant  premise  t h e o r e t i c a l r e a s o n s . The  generally  Rachman, B o o t h ,  stated  f o r i n the  a simple  the  the  such  treatments  of  panic  1988). (  In c o n t r a s t will  be'to  look  to at  t r e a t m e n t outcome s t u d i e s , shorter  a v a r i e t y of p o i n t s . interventions which,  In  i s given  in isolation,  interventions  this  s t u d y one  to volunteer  are  of  and  the  study  intention change  three  p a r t i c i p a n t s , two  f a r f r o m what a c l i n i c i a n  of  would  at  usually  p r o p o s e , and  s p e c u l a t e . The  a b o u t whose e f f e c t  first  i s one  which focuses  cognitions,  c h a l l e n g i n g and  frightening  thoughts which the  attempting  u s u a l a c c o m p a n y i n g e x p o s u r e and  The  second  are  exposed to t h e i r r a c i n g and  again  without  intervention,  t o change  sensations  of by  change,  that  overbreathing),  which i n v o l v e s c o n t a c t w i t h  the  only  situation,  i s the  subject  standard  p o i n t s , but groups o f f e r  place  on  an  and,  and  the  a  protocol for  any  subjects  the  study  aims n o t but  on  gauge to focus the  g r o u p s . By m o n i t o r i n g  different  change the  inclusion  i t i s hoped t o b e t t e r u n d e r s t a n d  of  what  f e a r , what c o n t r i b u t e s t o i t s m o d i f i c a t i o n , occurs.  on  changes  methods d u r i n g  i n a d d i t i o n , through the  t h e manner i n w h i c h f e a r r e d u c t i o n  are  i n t e r v e n t i o n . While  a b a s e from w h i c h t o  i n each of the  d e s c r i p t i v e data, underlies  without  that  with  third  individualized  i s t h e most e f f e c t i v e ,  p o i n t s and  The  i s exposed to i n c r e a s i n g l y  cues o r d e r e d  three  interventions,  as  one  two  at d i f f e r e n t  (such  and  i t i s emphasized  take  subjects  feared stimulus.  a t two  w h i c h of t h e  assignments.  anxiety  h i e r a r c h y . A c o n t r o l group i s i n c l u d e d i n which  latter  without  the  anxiety-provoking  the  only  the  i n which the  d i z z i n e s s b r o u g h t on  i n which the  assessed  yet  contact with  claustrophobic exposure  as  e x c l u s i v e l y on  behavioural  i s i n t e r o c e p t i v e exposure feared  can  s u b j e c t s r e p o r t , but  the  heart  one  4 APPROACHES TO ANXIETY  A striking anxiety are  feature  i s the s t r e n g t h  often daring,  studies  out  that w i l l  a not inconsiderable  review of p s y c h o l o g i c a l  t o be e x h a u s t i v e , be d i s c u s s e d  but r a t h e r  He p r o p o s e d n o t o n l y  e m o t i o n became more i n t e n s e , e m o t i o n became more s a l i e n t attention in  approaches does n o t s e t  i s Easterbrook's  the f i e l d  relatively intensity  that  that  little  cues r e l e v a n t  that  I t i s not u n c h a r a c t e r i s t i c later,  severe anxiety  and p a n i c  on c o m p e t i n g  beyond d i s p u t e  but, f u r t h e r than t h i s ,  (Gilligan  there  is still  known a b o u t t h e r e l a t i o n s h i p between t h e  numbing e f f e c t  have been n o t e d  to the  concurrent  o f e m o t i o n a n d c o g n i t i o n . The common  observation  (1959)  emotional  a t t h e expense o f  some 30 y e a r s  example,  a t t e n t i o n n a r r o w e d as  but that  to i r r e l e v a n t s t i m u l i .  concepts  the study. A good  of "narrowing of a t t e n t i o n " d u r i n g  arousal.  have t o o  d r a w b a c k t o any  aims t o i n t r o d u c e  throughout  t h o u g h n o t one o f t e n m e n t i o n e d , concept  which  similarly  and, more s e r i o u s l y , t h e r e s u l t i n g d a t a  This  on  and s t i m u l a t i n g . A l a s , t h e  by s u c h t h e o r i e s have n o t been  s e l d o m been s u p p o r t i v e , theory.  literature  of the t h e o r e t i c a l approaches  imaginative,  stimulated  imaginative  of the p s y c h o l o g i c a l  rational  clinical  seem t o e x e r t  cognitive activity i s more  complexities  i n the r e l a t i o n s h i p than c l e a r f i n d i n g s  & Bower,  1984).  a  5  A link found  from t h i s  t o more c o n t e m p o r a r y  i n t h e work of B a r l o w whose o u t s t a n d i n g  (1988) w i l l important  be  frequently r e f e r r e d to  construct  i n h i s approach  a p p r e h e n s i o n " which i s not  Barlow suggests  physiological  sensations  particularly suggesting they  concerns are  a r e matched by  an  e m o t i o n , and  that  to e x t e r n a l Scheier,  i s a cue  stimuli  Carver  in this  & Matthews,  A second h i s t o r i c a l appraisal  theory  They p r o p o s e d d e p e n d i n g on been an  has  the to  He  the  context train  always  i n the  n e g a t i v e l y ; and,  behaviour associated with arousal  negative,  intensity  is a failure  by  to  of  the  habituate also  1983).  Schachter  i n which of  of  goes f u r t h e r  Easterbrook and  Singer  t h a t g e n e r a l i z e d a r o u s a l w o u l d be  1979); u n e x p l a i n e d  absence of  "anxious  self-focused attention,  i t occurred.  thought, The  arousal  can  in  1962.  Theirs  original  t e n d s t o be  clearly  (Barlow & M a v i s s a k a l i a n ,  has  theory  as  experiment  (e.g. M a r s h a l l  most d a m a g i n g o f a l l , anxiety  was  appraised  though the  n e v e r been s u c c e s s f u l l y r e p l i c a t e d  reported  An  a t t e n t i o n a l mode (see  been h e a v i l y c r i t i c i z e d .  Zimbardo,  study.  be  Easterbrook's  almost  increase there  work  perception  landmark a f t e r  o u t l i n e d by  influential  w h o l e has  to  of a s e l f - e v a l u a t i v e n a t u r e .  t h a t these  prevailing  that  in this  recent  i s t h a t of  unrelated  observations.  that  t h e o r i z i n g can  &  always reports  occur  1981).  in  and the  a  6  There and  i s , nevertheless,  t h e work o f A a r o n Beck  although anxiety  the  latter  (e.g.  very  largely  s u c c e s s f u l work on  focused  hypervalent  continually  t h o u g h t s and  distortions  i n the  weakness o f  t h e model i s n o t  there  are  processing  that  i t can  underlying  accepted  that  anxiety?  While  selectively  could  i t i s already  perceive  and  that automatic  reported,  two  points  also likely  preceding  i s by  no  that  be  been d i s c o v e r e d  States  this  clients  difficult  thoughts  to  "disprove" can  that  i t be  do  nonanxious  t h r e a t are  often  to the The  precede the argument  theory  first  is  anxiety.  that  s c h e m a t a have s i m p l y less  trained  anxious p a t i e n t s  of  the  A  non-cognitive  i s s u e s here.  i s , as m e n t i o n e d ,  danger.  have t o be  - a t what p o i n t  clear that  thoughts or  are  unreasonable  experience  important  is  of a n x i e t y  information.  (a n o t  means c l e a r and  automatic  being  c o r r e c t i n g the  w h e t h e r a n x i o u s c o g n i t i o n s a l w a y s do Evidence  s e e n as  often raised i n relation  t o be  from  f o r t h e most i t  t h r e a t more o f t e n t h a n  patients,  are  of  cognitions  a client  structure  images r e l e v a n t t o  and  automatic thoughts  assumption) but  His  c o g n i t i v e s c h e m a t a where r e a l i t y  i s d i r e c t e d at f i n d i n g  their  and  problems are  of  where d a n g e r i s  taken the  i n t e r p r e t e d as d a n g e r o u s .  thus a s s o c i a t e d with  find  has  a theory  of a n x i e t y .  instances  theory  1985),  s e e n as  depression,  t r a n s f e r w e l l . The  on  to  o r e x a g g e r a t e d . He  appears to  to  Beck & Emery,  i s more a c c u r a t e l y  i s confined  misperceived  Therapy  between a p p r a i s a l  d i s o r d e r s r a t h e r than a theory  theorizing  his  a link  the not  than c o n v i n c i n g .  A  second p o s s i b i l i t y  i s that  the  automatic  thoughts are  epiphenomena, and  that  both they  and  have a c a u s e t h a t  lies  elsewhere  (Beidel & Turner,  Hallam,  efficacy,  ( 1 9 7 7 ) , shows t h e of  anxiety  cognitions  one  of  mastering a feared reduction  central  i n anxiety.  He  He  self  situation  treatments.  e x p e r i e n c e and  the  i m p o r t a n c e w h i c h he  i n c r e a s i n g one's sense of  tenets  has  theorized  efficacy  leads  observed  to  or  that  direct  accomplishments probably  watching others perception.  construct  procedures  these various  efficacy.  is limited  Barlow  i n that  inputs  who  efficacy  change t h a n stimulated (Williams  self  i t s mediator. a great  deal  & Rappoport,  Lang's  this point,  at  out  that  to to the  performance.  Borkovec  much o f  the  (1978),  it  that  of has  supportive  1983).  since least  summate  However i t i s a c o n c e p t  of r e s e a r c h ,  most  confidence  i s more a r e f l e c t i o n  (1985) " b i o i n f o r m a t i o n a l  to e v a l u a t e  behavioural  predicts  harsher, notably  that  in  anxiety  self  then  O t h e r s have been r a t h e r suggested  that  contribute  (1988) p o i n t s i t only  the  (information,  p e r f o r m s u c c e s s f u l l y ) can  A l l of  produce s e l f  other  on  c o n s t i t u t e the  that  but  Bandura  successful  and  At  1986;  competence  i n c r e a s i n g one's s e n s e o f  efficacy,  of  also places  p o w e r f u l means o f  harder  response  1985).  Self  role  the  merel  i t has i t can  not be  approach" yet  said  is  rather  g e n e r a t e d much d a t a that  i t numbers some  8  important  admirers  (Barlow,  1988; P r i t c h a r d ,  1987). E m o t i o n i s c o n c e p t u a l i z e d stored  i n memory a n d a c c e s s e d  which i n v o l v e  the processing  1990; S e l i g m a n ,  as " a c t i o n  tendencies"  i n a v a r i e t y o f ways, a l l o f of information.  b y p a s s e s t h e r e q u i r e m e n t o f an i n t e r v e n i n g appraisal  since  "meaning p r o p o s i t i o n s "  cognitive  i n t e r p r e t a t i o n s ) are only  It cleverly cognitive  (which a r e b a s i c a l l y  one t y p e o f p r o p o s i t i o n  among many, none o f w h i c h a r e s e e n a s e s s e n t i a l a n t e c e d e n t s . Meaning, c o n t e x t , all  contribute  arousal  and a h o s t  to the l i k e l i h o o d that  of other  propositions  an e m o t i o n w i l l  be  a c c e s s e d . Weak o r i n c o m p l e t e m a t c h i n g o f p r o p o s i t i o n s only are  lead  to part  o f t h e r e s p o n s e , b u t i f most  m a t c h e d t h e n a n e m o t i o n c a n be a c c e s s e d  level,  e v e n i f one p r o p o s i t i o n  a theory  i n construction  supported. A f u r t h e r psychophysiological variable.  There  i s likely  paper  cognitidn  I will  strong  missing.  as y e t only  It is weakly  i s a n o v e r r e l i a n c e on  as t h e p r i m a r y  dependent  c r e a t i v e and i m a g i n a t i v e  and  have c a u s e t o r e f e r .  t o be more i n t e r e s t i n L a n g ' s work  with  g e n e r a t e d by B a r n a r d a n d T e a s d a l e ' s  (1990) w h i c h a n a l y z e s  and a f f e c t u s i n g  information there  recording  t o which  i n t e r e s t being  latest  shortcoming  I t i s , though, h i g h l y  another theory  the  and, a s s t a t e d ,  propositions  at a  i s completely  may  processing  t h e r e l a t i o n s h i p between  s i m i l a r r e p r e s e n t a t i o n a l and  constructs.  In t h i s  framework, t o o ,  i s a n e m p h a s i s on d i f f e r e n t f o r m s o f m e n t a l  representation  encoding  information:  nine d i f f e r e n t types of  9  information production is  that  are  emotion. A major  i m p l i c a t i o n of  there  is a distinction  between two  expressed  first  i n the  or f a l s e .  code p a t t e r n s sensory  also  statements that  second  i s termed  include  to modify  therapy, the  latter  of  a l l , at  anxiety,  I t should  accepted  core  in a later  are  not  thought On  of  cognitive  been d i s a p p o i n t i n g .  o r downplay t h e  (1980) n o n - c o g n i t i v e  the  of  Teasdale t o be  argue more  incorporate  psychotherapeutic  sense,  cognitive current  cognitions  contrary,  as to  are  shall  a l s o many t h e o r i e s  cognitive role,  thus be  isolate  p r o c e d u r e s have a l m o s t  view of  from  focus  most p o p u l a r  that  the  There are  as  1987).  l e a s t i n a loose  of a n x i e t y .  be  evaluated  t h e r a p i s t s to  c e r t a i n l y the be  be  likely  s e c t i o n , experimental attempts  contribution  ignore  cognitive  (Greenberg & Safran,  These a r e  system  directly  B a r n a r d and  more e x p e r i e n t i a l l y o r i e n t e d  focus.  on  can  is often  some o f  theories  call  former  and  strategies  such a  " i m p l i c a t i o n a l " , where  successful, the  the  l e v e l s of  elements d e r i v e d  While the  in cognitive  attempts  to  i s l a b e l l e d " p r o p o s i t i o n a l " which can  form of  The  sources.  attention that  contribute  of  meaning. The  true  s p e c i f i e d w h i c h can  notably  the  seen  the  invariably which  Zajonc's  arousal.  /  The  only  such theory  t o be  S e l i g m a n on  "preparedness".  forward the  interesting notion  o u t l i n e d here  S e l i g m a n and that  i s the  work  H a g e r i n 1972  genetic  endowment  put  of  10  provides a specialized how  readily  According  an o r g a n i s m  associate  substantial  preparedness  be  appear.  elaboration  held  output,  i f at a l l .  verification  to  learn but  While  biological of i n n a t e  The  theory, while stimulating,  (see McNally,  that at least  some p a r t  1987)  but  i t is  of the f e a r  is still  response  may  innate.  The  purpose  of t h i s  introduce concepts will  also  be  situation,  selective  that w i l l  i n t r o d u c e d but  major approaches  the  selection,  t h a n o t h e r s . They  painstakingly  i n subhuman s p e c i e s ,  are  i n humans i s much more c o m p l i c a t e d t h a n i t  at f i r s t  widely  evolutionary  a s s o c i a t i o n s with minimal  associations  determines  organisms  e v i d e n c e c a n be m a r s h a l l e d t o s u p p o r t  preprogramming  undergoing  that  by e x p e r i e n c e .  of preparedness,  e v e n t s more e a s i l y  primed  unprepared  apparatus  influenced  constructed, through  certain  biologically  might  c a n be  t o the p r i n c i p l e  biologically  the  associative  be  o v e r v i e w has  used  t h e r a p y and,  feared sensations.  study.  to Others  i n the context of the t h r e e  to a n x i e t y : exposure  cognitive  in this  been  to the  feared  most r e c e n t l y ,  exposure  to  Exposure  In t r y i n g to convey the understood  about e x p o s u r e ,  P r i m e M i n i s t e r n o t e d as to  the  cut  I am  an  status  academic, r a t h e r  politics.  He  lampooned  for dismissing  practical  ideas  uncertain  how  still  not  c l e a r how  one  doubts  suited  regularly  b e c a u s e he  was  A s i m i l a r problem  that  i t s e f f e c t s are  Irish  than w e l l  u s e d t o be  t h e y w o u l d work i n t h e o r y .  w i t h e x p o s u r e . No  o f what i s  r e m i n d e d of a r e c e n t  t h r u s t of  arises  and  current  i t works, but  achieved  (Foa  i t is  & Kozak,  1986).  It  had  seemed q u i t e  t i m e , b o t h how reduced.  In the  f e a r was  strengthened  alone could  phobic r e a c t i o n , since several  failure to the  not  of  CS,  acquired  and  the  fact  through simple  vicariously  f o r the could  selectivity  that  fears  1978).  with  not  and  the  traumatic  genesis  of  accommodate other  of p h o b i a s ,  despite  p r o v i s i o n of  (Rachman 1977,  conditioning  a b o u t e t i o l o g y . By  p h o b i a s . Among  of phobias to e x t i n g u i s h  be  that a l l  behaviour therapy  account  of  best  argued  traumatic  conditioning  t h e s e were t h e  i t could  becoming c l e a r that  f a c t s about c l i n i c a l  objections,  for a period  strongly  assumption  1960s, however, i t was  conditioning  how  through  success  this  and  very  simply  Wolpe, 1958). The  phobias late  learned  1950s i t was  p h o b i a s were l e a r n e d (e.g.  straightforward  repeated  the exposure  phobias can  information  as  be well  as  12  The be  explanations  similarly  habituation  f o r why  s t r a i g h t f o r w a r d . The and  However among a h o s t  theory  of  of  fear  (e.g.,  see  Similarly,  proponents of  explaining  a s e r i e s of p o i n t s ,  the  s i t u a t i o n before  p r o v e d more s a t i s f a c t o r y .  biological  harsh  model of  processes".  However he  i s no has  during  notion  anxiety  I t must t h e n be  certain  circles  unfashionable s u c h a way.  data  of  in  from  been  reached  theories  being  " t o u g h e n i n g up", that  " i t has  a  little  " d e s c r i p t i o n of of  a l l three  o f what i s  accommodates  three  the  relatively  systems".  a s k e d what has by  process  become o f t h e of  f e a r can  (1986), n o t a b l y ,  notion  a s s o c i a t i o n . In  i t a p p e a r s t o h a v e become  to acknowledge t h a t  on  reduction  has  specification  a construct  learned  Bandura  the  1987).  h a v e more r e c e n t  e x p o s u r e , none e a s i l y  independent response  the  to escape  more g r o u n d s t o say  "learned"  as  anxiety  allowed  more t h a n a  "In a d d i t i o n to poor  be  are  says of  theories:  f e a r can  & Rachman,  s u c h as  fear reduction,  meat" and  strong  f o r much o f  Barlow i s perhaps  when he  theoretical  that  Craske  to  both  shortcomings,  maximum a n x i e t y  (Rachman e t a l , 1986). N e i t h e r  unnecessarily  of  " e x t i n c t i o n " have d i f f i c u l t y  even though s u b j e c t s  feared  af  other  h a b i t u a t i o n cannot account  r e t u r n of  occurring  principles  work seemed  e x t i n c t i o n e a c h a p p e a r e d t o have  cases.  the  exposure should  gives  almost be  learned  i t scant  in  13  attention. short  space  principle recent one  This  seems u n f o r t u n a t e , f o r w i t h i n  of time  a v a r i e t y of t e c h n i q u e s based  have h e l p e d l a r g e numbers o f p e o p l e .  a phenomenon i t i s , i s i l l u s t r a t e d  o f i t s most v o c i f e r o u s  even  list  After  exposure  a remarkably  proponents,  on t h i s  (Just  how  i n the f a c t  that  I s a a c Marks, d i d n o t  i n t h e i n d e x o f h i s m a j o r book i n 1969).  t e n t a t i v e b e g i n n i n g s w i t h Meyer i n London i n 1963, and  a f u r t h e r decade exposure  characterized  by l i m i t e d  has a c h i e v e d broad a c c e p t a n c e  enthusiasm,  as a p o w e r f u l  technique.  Rather classical which the  than  fear conditioning,  he g i v e s  widespread  patients 1982).  reactions  DCS)  chemotherapy  to "neutral  fundamental  strength  a c q u i s i t i o n of conditioned  these patients  administering  I favour Barlow's  nausea  ( e . g . , Redd &  d e v e l o p moderate  stimuli"  associated  properties  conditioned  powerful combination,  i n just a single  trial.  nausea staff  example o f t h i s  f o r c o n d i t i o n a b i l i t y i n these p a t i e n t s  and t h e i n t e n s i t y o f t h e i n i t i a l  Andrykowski,  with nursing  t h e therapy, i s an e x c e l l e n t  of the nausea-producing  i n cancer  to severe  l a w o f l e a r n i n g . Among f a c t o r s t h a t  appropriately  approach i n  a n example t o r e f r e s h i t i n memory, namely  undergoing  That  account  t e d i o u s l y o u t l i n i n g the paradigm of  seem t o i s the  of the drug (the  r e a c t i o n . But g i v e n an  an i n t e n s e  f e a r c a n be  14  However, a common f i n d i n g individuals is  i s that,  q u i t e unusual  particularly  extreme p o s i t i o n  such  a problem as  that  vicariously.  The  ingeniously  e x p l a i n e d by  Barlow  are c o n d i t i o n e d not  "false study his  alarm".  An  of d r i v i n g  30  phobics  that  appeared  identify,  feared d r i v i n g  t h e y had  learning  which the fully  worked  false  alarm  context  of the  twice  causes  intensity,  the  individual  false  through is likely  alarm by  o c c u r r e d . The  of  t o be  from which escape  may  sort  anxious  m o d e l has  in  in  not  been  that  a  i f the  example he  be d i f f i c u l t ,  of  causes  situation  t o become a l e a r n e d a l a r m The  now  having  this  that  they  and  B a r l o w , b u t he d o e s b e l i e v e  i n some way.  that  that  while d r i v i n g  p a s s i n g r e l e v a n c e to c l a u s t r o p h o b i a , the study.  s u c h as a  reason  (or a s i m i l a r ) o b j e c t or  i s "prepared"  situations  "panicked"  when o f a s u f f i c i e n t  first  fear,  F o r no  a  Though s i x o f  panic attacks. I t i s exactly  t o o c c u r and  the presence  incident.  by  the  retrospective  (1984).  their  up  that  but  a g a i n because of the p o s s i b i l i t y  f u r t h e r unexpected alarm,  such  to cause  an  been  a traumatic event  by Munjack  pick  argues  example i s p r o v i d e d i n a  number r e p o r t e d no  false  d i s c r e p a n c y has He  learning  i s t o adopt  primarily  (1988).  fears, i t  a clear  subjects reported a traumatic incident,  collision,  could  by  such  u n l e s s one  phobics  fears  fears  w i t h more s i m p l e  f o r them t o have had  e x p e r i e n c e . T h i s poses  their  on q u e s t i o n i n g p h o b i c  gives i s  o f more  focus of  this  than  15  Most r e s e a r c h on panic-disordered  false  patients.  alarms  Whether s u c h  simple phobias assumed t h a t a variety  cues  i s not  and  of another  y e t known; i t had cues  interoceptive  Hout e t a l , 1 9 8 7 ) ,  "internal" that  false  can s e r v e a s i m i l a r  only external  fear  that  alarms  can p l a y  o f e v i d e n c e t o show t h a t  d i s o r d e r do den  the p o s s i b i l i t y  internal  t.aken p l a c e w i t h  It i s clear  c a n become a s s o c i a t e d w i t h f a l s e come t o s i g n a l  has  alarm. function  certainly this  one,  " a t t e n t i o n may  role.  needs t o r e f l e c t  since  t h e r e i s no  experiences  the f a l s e full  obvious  a false  attention w i l l  be  the l a r g e s t  cause  f o c u s e d on  of a f a l s e  share of a t t e n t i o n  who  experience f a l s e  i f one  is likely  Barlow  alarms  other e x c l u s i v e l y ,  but  v a r y i n g mixture of  internal  safe  cues  alarm while unable  "trapped" s i t u a t i o n .  from  internal  t h e o t h e r hand,  the  far  i n many d i f f e r e n t If  is clear  are u n l i k e l y  are l i k e l y and  t o be  necessarily  only  internal  fear  ways,  one that with  to escape,  then  t o be d i r e c t e d t h a t most o f to fear  one  apprehensive  at  those or  the  about  e x t e r n a l c u e s . Thus i t i s  only external  c l e a r why  true  e x p e r i e n c e s the  cues  and  claustrophobics agoraphobics  c u e s , a l t h o u g h s u c h a t r e n d may  n o t , however, f u l l y  a  associated  t o p r e s u m e , f o r example, t h a t  will  fear  cues.  alarm, u n l i k e  f o r alarm".  van  on how  a l a r m a t home, i t i s more l i k e l y  a l a r m . On  effects  allocated  There i s  ( R e i s s e t a l , 1986;  during a false  be  in  been  c o u l d become a s s o c i a t e d w i t h e x t e r n a l o r i n t e r n a l Barlow m a i n t a i n s t h a t  can  patients with panic  cues  b u t one  they  cues  a claustrophobic  appear. should  It is feel  a  16  "safe" would  i n a range  people  e t a l (1986) have p o i n t e d o u t  seem t o e x p e r i e n c e a l a r m s  t h o s e who  actually  possibility n o t be  that  t h a t p e o p l e who disorders, anxiety  Barlow  But  develop  their  f a c t o r s he  suggests  reactivity,  If  One  the alarms  simply  to r e s u l t  and more l i k e l y  and  susceptible  because  coping s k i l l s  or s o c i a l  these points cast  fear acquisition,  clinical  possibility  is  phobic  to developing  psychological  of the alarms  in  of a c o m b i n a t i o n  are b i o l o g i c a l l y  than  disorders.  factors.  based  p e r c e p t i o n s of u n p r e d i c t a b i l t y  uncontrollability  learned)  f u l l - b l o w n panic or  alarms  biological  of  agoraphobic  t h a t many more  and  i s that  intensity  another  individual  poor  proposes  are s p e c i f i c a l l y  over  (false  present with c l i n i c a l  of s u f f i c i e n t  complication.  and  i n which the  not.  Norton  may  of s i t u a t i o n s  of  Among  the  stress and  or other n e g a t i v e  events,  support.  a r a t h e r new  light  then there i s s t i l l  on  t h e method  the q u e s t i o n of  f e a r r e d u c t i o n t o c o n s i d e r . Though t h e t h e o r e t i c a l  wrangling  seems s e t t o c o n t i n u e , a t l e a s t  that  b r o a d method o f e x p o s u r e questions  such  encouraged exposure 1986),  w o r k s . Debate now  as w h e t h e r a p e r s o n  not  ( s e e de  how  t h e r e i s agreement  to escape Silva  intensive  focuses  s h o u l d be  strongly  from a f e a r e d s i t u a t i o n  & Rachman, 1984;  exposure  s h o u l d be  on  during  Rachman e t a l , (Jansson &  Ost,  the  17  1982) et  and what  technique salutary  less  seem r a t h e r p e r i p h e r a l  t h a t has shown i t s e l f t o l o o k more c l o s e l y  improvement  after  readily  claustrophobia, for  f o r the t h e r a p i s t  (Mathews  a l , 1981).  T h e s e may  are  i s the best r o l e  treatment available  questions f o r a  so p o w e r f u l ,  a t r a t e s of  with  but i t i s  clinical  exposure.  Though  f o r a simple phobia  the f i g u r e s  from  agoraphobia  statistics  such  as  g i v e some  concern.  For agoraphobia,  and t h e r e i s no r e a s o n t o  suppose t h a t  i t i s untypical,  c l o s e r a n a l y s i s h a s shown  there  a r e many e x a m p l e s o f f a i l u r e ,  clinical  improvement. J a n n s o n & O s t  median dropout Furthermore, reflecting complete  rate  from  treatment  that fail  of f u n c t i o n i n g .  reported following at  not reach c l i n i c a l l y  who  showed  themselves  only  some  as b e i n g c o m p l e t e l y  Munby & J o h n s o n  (1980) o b s e r v e d  a l t h o u g h many s u b s e q u e n t l y  level  of  who 60-70%,  meaningful  improvement.  improvement  18% o f t h o s e  i n as many a s 50% o f c l i e n t s who  clinically, previous  of a l l agoraphobics  behavioural treatment,  symptoms. F i n a l l y  are also  F o r example M c P h e r s o n e t a l (1980)  t h a t among c l i e n t s  follow-up rated  occurring  may  the  i s 12%.  t o b e n e f i t . Of t h e r e m a i n i n g  a s u b s t a n t i a l percentage levels  treatments  that  s u c c e s s r a t e s o f 60-70%  30-40%  that  limited  (1982) e s t i m a t e  exposure-based  data reporting  the f a c t  r e l a p s e and  cause  contacted free  of  relapses  had b e n e f i t e d  returned to  their  18  What emerges, t h e n , a complex  etiology,  very  t h e a c t u a l mechanism and phobias. any  An  progress  unfortunate is likely  developments -  i s that little process  though t h e y i n t e r e s t has  b e e n shown i n  of change i n  p o s i t i o n promises t o come a b o u t  serendipitously.  appear t o have  like  simple  t o be most  maintained: previous  19 Cognitive  If  exposure  uncertain a polar should  approaches  i s e f f e c t i v e f o r a r a n g e of  reasons,  opposite. work b u t ,  remarkably  t h e n c o g n i t i v e a p p r o a c h e s can There are  f o r the  ineffectual.  extremely  most p a r t , One  depression  to anxiety quite  conspicuous.  sense, matched the amount o f  irrational current  1985),  where c o g n i t i v e  disorders, should  features  transfer  have a l s o  been  the  adamant i n h i s cognitive  relief  from  any  (1988) i s "Challenging  or r a t i o n a l r e s t r u c t u r i n g , rehearsal  are  and  largely  of p h o b i c problems". Other major  1987). E a r l y  studies  were a l t o g e t h e r  however, and  some w o u l d a r g u e t h a t e m e r g i n g once  implied  conclusions.  with  Cognitive  that  p r o m i s e t h a t m i g h t be  r e v i e w s h a v e come up  promise are  they  in  self-statement  f o r the  as  However, s u c h a p p r o a c h e s have n o t ,  beliefs,  t y p e s of  redundant  w i t h mood  t h e o r e t i c a l i n t e r e s t . Marks  characteristically  seen  t h e y have been  (Beckham & L e b e r ,  disorders  be  for  c l e a r r e a s o n s why  would have thought  t e c h n i q u e s w h i c h have worked w e l l notably  anxieties  s i m i l a r conclusions  (see  Last  more p r o m i s i n g ,  signs  of  a return  of  such  again.  interventions  for anxiety  always v e n e r a b l e h i s t o r y . A s s o c i a t e d  have a l o n g ,  names i n t h i s  i f not  century  /  might range  from the  Dale Carnegie of  the  French p s y c h i a t r i s t Emil  (1948) and  earliest  Norman V i n c e n t  controlled research  Peale  d i d not  Coue  (1922)  to  ( 1 9 6 0 ) . Much  take p l a c e  until  20  the  early  1970s and  two  authors.  I t was  such g e n e r a l i z e d t h a t was  one  on  self  15  y e a r s ago  Their  in  of  say  received  an  fears  the  things  reducing  s h o c k . The but  as  f e a r s by  to  modifying  former group  t o y o u r s e l f may may  in real  criterion  task  have t o t r y o u t  s i t u a t i o n s that  " f o r any  fostered  be  the  e f f e c t t o be  through the  (see  who in  their  "saying  the  condition  self-statements  e f f e c t of  Rachman & W i l s o n  of  their  the  noted". Optimism  animal phobias, t e s t anxiety,  speaking anxiety  form  reduced  s i m i l a r to  apparent  that  statements  a sufficient  are  group  subjects  that  these  what  initially  significantly  not  as  w i t h one  self-controlling  shock,  work  follow.  demands were i n c r e a s e d ,  the  fail,  f a r back  rehearsal  t r e a t m e n t . They c o n c l u d e d  gradually  p r o c e d u r e s on  t o use  electric  c h a n g e " . One  further  f o r much t h a t was  p r e c i p i t o u s l y . In c o n t r a s t ,  following  'right'  on  why  influential  " a p p l i c a t i o n t r a i n i n g " i n the  electric  opportunity  confronting  subsequent  self-instructional  well  latter  tend to  t h e m s e l v e s . They compared a t r e a t m e n t  only  rose  to the  work w i t h Cameron as  ground  focused  a p p e a r e d t o do  for  paths to h i s  addition received  anxiety  unrelated  p r o h i b i t i o n s or exhortations  s e t the  to  not  Meichenbaum's i n v e s t i g a t i o n i n t o  the  research  exposure to  had  in fact  i n s t r u c t i o n s . His  clients who  was  and  was  cognitive public-  1980).  /  When t h e  focus  s h i f t e d away f r o m  participating  f o r c o u r s e c r e d i t , the  so  Emmelkamp e t a l  promising.  student  subjects  r e s u l t s were n o t  (1978) s e t up  the  first  nearly  21  clinical had  trial,  several notable  cross-over cognitive  design and  g r o u p s . The in  using  fact  that  r e s u l t s were q u i t e t o be  and  very  superior  a host  slight  and  restructuring"  interventions,  form of  in exposure  treatment  of measures; the  to  latter  (1981a) u s e d a m e t h o d o l o g y w h i c h  resembled  one  in  improvements a t a l l .  Emmelkamp's. T h o u g h t h e i r  a w i d e r range of p h o b i c s ,  cognitive  both  study-  including a  c l e a r - c u t . Prolonged  a clearly  Wilson  certain respects  of  fact  Their  e x p o s u r e b a s e d , were a d m i n i s t e r e d  produced only  included  the  r e s t r u c t u r i n g on  Biran  subjects.  methodological features  and  one  vivo proved  cognitive  a g o r a p h o b i c s as  i t was  e x p o s u r e methods. T h e i r  i n t e r v e n t i o n was  very  again  a  in  study  comparison  "cognitive  similar, involving  the  same t h r e e  elements of r e l a b e l i n g , r a t i o n a l r e s t r u c t u r i n g of  irrational  beliefs,  previously,  this  techniques which  and  p r o v e d no  the  effects too,  cognitive  subjects one,  physiological  who  treatment.  did generalize  that  gains.  for subjects  cognitive  match f o r t h e  t r a i n i n g . As  performance  l e d t o a s e r i e s of d u r a b l e  follow-up) behavioural successful  self-instructional  failed  In a l l c a s e s  to d a i l y  i n the  ( s i x month  Exposure a l s o proved  had  life.  based  highly  t o b e n e f i t much f r o m these  treatment  I t was  exposure c o n d i t i o n ,  displayed  an  overall reduction  reactivity  at  posttest.  interesting, but in  not  in  the  22  The  same a u t h o r s ' n e x t  restructuring chose  study  (1981b) a p p e a r e d  a more s p o r t i n g c h a n c e .  To b e g i n w i t h  s c r i p t o p h o b i a , the fear of w r i t i n g  documents  i n front  circumscribed  of people. Apart  avoidance  behaviour,  from this  highly problem  a n x i e t y about  scrutiny  With s u c h an e v i d e n t  with for  social  consequences,  encouraging  Exposure  more p o s i t i v e  was h e r e  preoccupation  cognitive  restructuring  levels,  adjunct"  t o i n v i v o exposure  changes  and " i t does n o t a p p e a r t o be a f o r producing  Though w i t h  concluded  alone d i d not produce  baseline  arena  and r a t i o n a l s e l f - s t a t e m e n t s .  r e s t r u c t u r i n g with exposure.  restructuring  entails  being exposed t o the  s m a l l number o f s u b j e c t s (N=3), t h e y  cognitive  also  seems a more p r o m i s i n g  compared w i t h b o t h  a l o n e and c o g n i t i v e a very  this  they  or signing  a more g e n e r a l i z e d s o c i a l of other people.  to give  that beyond  necessary  behavioural  change.  T h e s e e x a m p l e s were by no means restructuring  driving also  ( W i l l i a m s & Rapport,  avoidance  and  of  exposure  obsessive p a t i e n t s with  a f e a r of  1980). The l a t t e r  out a l a r g e r - s c a l e  sampled/participants'  being  of e i t h e r  e t a l , 1980) o r a g o r a p h o b i c s  carried  Cognitive  d i d n o t enhance t h e e f f e c t i v e n e s s  i n vivo i n the treatment (Emmelkamp  isolated.  study  researchers  (1983) i n w h i c h  they  c o g n i t i o n s during the b e h a v i o u r a l  task to v e r i f y  that  their  implemented. They c o n c l u d e d  follow-up, cognitive  treatment  cognitive  that  at both  was a d d i n g  treatment  was  posttreatment nothing to  23  exposure helped  on i t s own. R e s u l t s f r o m  t o s e t t h e tone  unearthed phobic six  leaving and  slight  just  performance  four positive.  e t a l ' s (1982) s t u d y  approaches  comparison  might  limited  "perhaps  concession that  the weighting  r e s e a r c h has y i e l d e d with that  i n h e l p i n g some  in his overall  of exposure  failed  tally,  "The a b u n d a n c e  a lean therapeutic harvest alone, which i s a b e t t e r  In the great m a j o r i t y of  c o g n i t i v e methods a l o n e h a d l i t t l e  combined w i t h e x p o s u r e of  there  interventions.  way t o improve most p h o b i a s . studies,  with  that  however, h i s c o n c l u s i o n i s h a r d l y s u r p r i s i n g .  in  phobics  t o be made by c o g n i t i v e  phobics". Given  cognitive  were  etc.),  on s o c i a l  on p i a n i s t s  c o g n i t i v e methods c a n p l a y a s m a l l r o l e  of  to  22 were n e g a t i v e ,  a n x i e t y t o g i v e any i n d i c a t i o n  l e d to h i s very  social  He  Two o f t h e l a s t  e t a l ' s (1984) s t u d y  some c o n t r i b u t i o n  This  that  (1987).  ( s t u d e n t s u b j e c t s , no f o l l o w - u p  Butler  Kendrick  cognitive  Of t h e s e he f o u n d  e q u i v o c a l and j u s t  relatively  be  f o r Marks' review  32 s t u d i e s i n v o l v i n g  problems.  t h e s e and s i m i l a r s t u d i e s  e f f e c t and  t o enhance t h e amount o r speed  improvement".  A c u r i o u s and d i s a p p o i n t i n g f e a t u r e o f t h e r e v i e w i s that later  i t overlooked or omitted study  exposure  dissipated  follow-up, improve.  Emmelkamp  some i m p o r t a n t  (1982) f o u n d  that while  studies.  the e f f e c t s of  somewhat between p o s t t r e a t m e n t a n d  the s e l f - i n s t r u c t i o n a l  Interestingly,  In a  group c o n t i n u e d t o  b o t h M a r s h a l l (1985) and  24  Mavissakalian contributed efficacy was  (1983) a l s o  little  increased  during  t h a t measurement was  (1986) s u g g e s t e d t h a t brief  findings  and of  strategies  that  a  the w h i l e  not  to  employ  an  increase  after  the  One  g o i n g on  possibility,  long  enough  interventions. V a l l i s  the  this  "sleeper  follow-up.  cognitive  b r e v i t y might a c c o u n t effect"  f o r the  treatment  has  with  the  Segal might  for  that  stopped t h a t  t e c h n i q u e s more f u l l y ,  in effectiveness  and  coping i t is  subjects result  from p o s t - t r e a t m e n t  be  the  cognitive  forward  then,  and  interventions  j u s t m e n t i o n e d . They put  perhaps only  self-instruction  to exposure at posttreatment, i t s  p e r h a p s n e i t h e r were t h e  too  found  to  get being  follow-  up.  The t h o s e on  second group of  studies  panic  I n h i s d e f e n c e , many o f  appeared a f t e r surprising t h a t were  /  that  disorder. he  went t o p r e s s ,  he  emerging.  g a v e no  t h a t Marks has  though i t i s  inkling  of  the  ignored  are  these  still  dramatic  findings  25 Interoceptive  An  exposure  important  d i s t i n c t i o n made by  between e x t e r o c e p t i v e refers are  t o the  information idea  their  and  i n the and  approach, during which feared  some o f  have used the  to feared  The  not  sensations.  (1988),  role,  and  area  of panic  results  replication, exciting  overstate are  16  than four panics  either h e l d up Klosko  results with  one  i n the  study  s u b j e c t s who  similar  be  developments  In a recent in  Barlow f e e l s  by  prior  yielding  small. that  or  The  others  principle  i f i n a much l e s s  the  confirmed  " i twill  very  object  The  implications studies  yet,  i s to  situation  c a s e when he  i t has  dramatic  a d d i t i o n a l research  of  the  Beck  most i m p o r t a n t  ( 1 9 8 8 ) , p a n i c was  and  eliminated  been h a v i n g  shown  i n a number o f p a t i e n t s s u f f e r i n g f r o m  panic  impressively  (1985, 1990)  more  have  or without  et a l  and  psychotherapy".  t o t r e a t m e n t had  a week. C l a r k  success.  says t h a t i f  by  h i s t o r y of  by  prominent  d i s o r d e r , at l e a s t ,  p a r t of a l a r g e r package with  B a r l o w does n o t  subjects  I t i s a t r e a t m e n t method s h a r e d  Beck  recent  as  to a f e a r e d  (1987) and  been u s e d as  are,  former  situation.  u n w i t t i n g l y . The  Clark  i n the  or  numbers o f  although  technique  individual  object  i t s theoretical  second area novel,  (1988) i s  i n t e r o c e p t i v e e x p o s u r e . The  been d i s c u s s e d .  i s simple  expose the but  with  for this  have a l r e a d y  may  traditional  confronted  reasons  and  Barlow  agoraphobia. Their early r e s u l t s  i n a follow-up  e t a l (1988) have shown t h a t  o f more t h a n two this  new  have  years.  treatment  shows  26  a much b r o a d e r p a t t e r n group  receiving  The (1988).  of p o s i t i v e  alprazolam  most a d v a n c e d He  f a r has  collecting  been by  d a t a on an  subsample of p a t i e n t s w i t h p a n i c d i s o r d e r not  t o one  of f o u r groups.  condition.  The  structured  exposure  common b a s e , relaxation  i n that  data  internal  The  to a second  is a  do  randomly  waiting-list  s e n s a t i o n s . To  a r e added t o one  and  a combination  this  group, of the  two  numbers a r e as y e t t o o s m a l l t o p e r m i t a  analysis,  suggest  producing  to feared  cognitive procedures  the t h i r d .  first  they  r e m a i n i n g t h r e e a r e a l l c e n t r e d on s y s t e m a t i c  training  comparative  The  Barlow  unusual  show s u b s t a n t i a l a v o i d a n c e b e h a v i o u r . They a r e  allocated  to  change t h a n a  (Xanex).  study thus  i s currently  therapeutic  that  but the v e r y e n c o u r a g i n g  t h e combined  therapeutic  measures t o e i t h e r  effects  treatment that  preliminary  seems t o  a r e s u p e r i o r on  the somatic or c o g n i t i v e  be some  treatments  alone.  Several points arise p r e l i m i n a r y d a t a . The ingredients elements the  way  first  treatment which  of somatic  situations.  to answering  interoceptive  this  exposure  includes  control,  symptoms, and Barlow  i f , as y e t ,  i s t o a s k what a r e t h e  including respiratory  origins  provoking  of t h i s  from t h e s e e x c i t i n g  basic  exposure  active  a variety  of  e d u c a t i o n on to anxiety-  l o o k s t o have a l r e a d y gone some  q u e s t i o n f o r h i m s e l f by  placing  a t the h e a r t of a l l h i s t h r e e  27  treatment groups. While approach  ( 1 9 8 7 ) , he  components; to  this  plays  interoceptive  exercises  This  i s an  their  theoretical  approaches,  style  is similar,  i t does  exposure  of e i t h e r  but, since  their  n o t make i t e a s y  of p a n i c .  on p h o b i a s . T h i s has  as  important d i s t i n c t i o n  cognitive modification  i n the reduction  cognitive  are used merely  of  tools in  practical  to assess the or  It also  q u e s t i o n u n a n s w e r e d as t o t h e e f f e c t exposure  i n Clark's  t e n d s t o f o c u s more on t h e  change c o g n i t i o n s .  influence  a part  interoceptive  leaves the  interoceptive  o n l y been a d d r e s s e d i n one  s t u d y , u n p u b l i s h e d , and w i t h a sample o f  just  three  subjects.  Rygh and linked  true  Barlow  and  exteroceptive  false  (1986), alarms  exposure.  interoceptive  exposure  exposure.  an u n e x p e c t e d  feared object.  e t i o l o g i e s would  It is difficult  results  o f such a t i n y  study  i s that  f o r the f i r s t  whether/interoceptive  On  time  exposure  other than panic disorders.  intriguing  q u e s t i o n had  r e s u l t s d i d not  an  individual  p a n i c might  those  exteroceptive  a n y t h i n g from  The  importance  the of  the  the q u e s t i o n of  be u s e f u l l y  Seen i n t h a t  been p u t f o r w a r d and  seem d i s c o u r a g i n g .  respond  t h e o t h e r hand,  i t raised  could  study,  and  respond b e s t to  sample.  small  i m a g i n a l or i n v i v o  to determine  mixed  fears  that  e x p o s u r e w i t h o u t any  to t h e i r  with nonpanic  to i n t e r o c e p t i v e  They p r o p o s e d  whose p h o b i a a r o s e a f t e r to  in a tantalizingly  applied  light,  the  an  initial  to  28 METHODOLOGIES  There a r e a great v a r i e t y carry is  o u t r e s e a r c h i n an a r e a  worth l o o k i n g b r i e f l y  limitations  The  o f ways i n w h i c h one c o u l d such  as c l a u s t r o p h o b i a , a n d i t  a t some o f t h e s t r e n g t h s and  of s i x designs.  first  o f these  are s t u d i e s which are,  part,  descriptive.  study  w h i c h was one o f t h e f i r s t  f o r t h e most  An example w o u l d be B e c k e t a l ' s (1974) t o look  a t the c o g n i t i v e  components o f g e n e r a l i z e d a n x i e t y d i s o r d e r . They were to  identify  rejection,  common themes s u c h or failure.  A decade  t h a t work a l i t t l e f u r t h e r , about the c o n t e n t including  anxious  events,  with  thoughts,  thoughts, intensity,  personal r i s k ,  observations  i n turn preceded  episodes  t h a t t h o u g h many j o u r n a l s t e n d  descriptive  s t u d i e s , i n many a r e a s  called  indeed,/it  would  f o r increasingly.  & Bergin  seem a t l e a s t  c l a r i t y and clear  the l a t t e r  of anxiety.  that study  It is  t o shun  of psychology  In therapy  i s currently considered  (see G a r f i e l d  but a l s o  seen t o precede  interesting  being  took  on t h e s e q u e n c e o f  p h y s i c a l sensations being  which  (1984)  studies i t i s abundantly  overestimate  a l s o making i m p o r t a n t  Hibbert  social  i n t e r v i e w i n g subjects not only  on f r e q u e n c y ,  From b o t h  people  later  of t h e i r anxious  questions  credibility.  as f e a r o f death,  able  process  they a r e research,  something of a p r i o r i t y  1986). F a r f r o m b e i n g  useful to include c a r e f u l  derided, i t descriptive  29  data  i n a higher percentage  of s t u d i e s  focused  on  experimental questions.  An  important d i s t i n c t i o n  i s between c o n s t r u c t i v e  component d e s i g n s . I n c o n s t r u c t i v e d e s i g n s , one added t o an e m p i r i c a l l y against  this  isolate  the potency  proven  of p a r t i c u l a r There  f o r m e r , m i x e d between t h o s e unnecessarily  is  long l i s t  contribute  a s s i g n e d a group  that  elements  then  from  the  little  t o one  cognitive  except and  those  of three  graduated  exposure,  versus graduated those  showed n o t o n l y t h e m o s t r a p i d , improvements a c r o s s t h e  of  which treatment  this  t h e most  as w e l l as a t t h e end  such of  f o c u s away from t h e s i n g l e  i s c a u s i n g an e f f e c t ,  having minimal  groups  stable  Features  i s t h e most e f f e c t i v e .  t h e s e d e s i g n s and  graduated  was  treatment  The  s i n g l e q u e s t i o n , t o t h e e x c l u s i o n o f how  intervention of  exclusive  but  t h r e e systems.  at mid-point,  help to take  alone. I t  i n t h e combined  contributed  v a l u e . I t causes  has  latter  cognitive  p r o g r e s s i v e deep muscle r e l a x a t i o n p l u s  that  that  randomly  therapy plus  exposure  to  example o f t h e They  to  treatment  add  e t a l (1987).  of a g o r a p h o b i c s  a  exposure,  assessment  compared  the  i m p o r t a n t p o i n t s . An  treatments:  interesting  is  a r e many e x a m p l e s o f  o f outcome s t u d i e s ,  t h e s t u d y by M a r c h i o n e  behavioural  element  t e c h n i q u e a l o n e . Component d e s i g n s a r e u s e d  p a c k a g e o f known e f f i c a c y .  really  t e c h n i q u e and  and  as  treatment question  emphasis  on  an  been t h e  shortcoming  t o a g r e a t d e a l o f work little  wonder t h a t  those at  30  the  Conference  discouraging  i n Albany, c i t e d  studies that  focused  Component a n a l y s i s , on as much as example was  work o f V a l l i s  Meichenbaum's S t r e s s  t r e a t m e n t approach can phases  Application). interactive procedural a study strength  I n an  role  on  with  be  outcome.  (1984). His  Skills  distinct  independent  c o n d i t i o n s . The  known, and  i n t e r v e n t i o n s , has  is clearly  not  t o be  illustrated  already  which  uncharted  area.  difficulty  in assessing  how  (isolating behavioural, components) as  a basis  most a p p r o p r i a t e  used the  clients  and  his  clinicians' will  respond  Three-System-Model  p h y s i o l o g i c a l , and f o r matching  to  i s treatment  1984). In r e s p o n s e t o  they  in  been  i n t h e work o f O s t  individual  about  with  (1981, 1982,  treatments,  study's  whose e f f i c a c y ,  a technique  discussed  and  them i n  a subject matter  colleagues  specific  general  included a l l  investigation into a relatively  consonance, w e l l  interest  s y s t e m a t i c a l l y v a r i e d each of  i s already  out  A c q u i s i t i o n , and  stems f r o m i t s d e a l i n g w i t h  fourth design  of  Training. This  " t o examine t h e  eight treatment  This  find  outstanding  focus  divided into three  attempt  p h a s e s , and  established.  to  adamant i n  hand, aims t o  of each phase", V a l l i s  comparison to other  The  other  Innoculation  (Education,  which a g r e a t d e a l  open an  the  only  were so  p o s s i b l e a b o u t a s i n g l e a p p r o a c h . An  i s the  procedural  earlier,  cognitive  individual  treatment. With s o c i a l ,  client  to  claustrophobic,  and  31  finally  agoraphobic c l i e n t s ,  "physiological" more b e n e f i t  they i n v e s t i g a t e d  and " b e h a v i o u r a l "  whether  r e a c t o r s would  f r o m a method s u i t e d  to t h e i r  achieve  response  pattern  t h a n one w h i c h was n o t . T h i s  i s n o t t h e o n l y way  clients  b u t i t was a r e a s o n a b l e  c o u l d be s u b d i v i d e d ,  decision,  and i n two o f t h e i r  promising results.  studies  followed  reasons f o r t h i s  merits  and  the f a c t  of t h e i r  "unique a n x i e t y  i t i s only  i tisdifficult Further,  not  easy t o s a t i s f y :  difficulties.  the p h y s i o l o g i c a l  the notion  o f a "consonant"  Is paradoxical  best  changing behaviour o r c o g n i t i o n s ? While  tailored  i t i s premature  and t h e i n c l u s i o n  i f / aless r i g i d  isolating  reactors,  t o be o f f e r i n g  I t may be more  viable,  i s made o f c o n s o n a n c e ,  quantitative  Rather than comparing  i t might  t h e r e a r e many  of attempts t o p r e d i c t  interpretation  f o r example n o t j u s t  differences.  l i k e l y to  t r e a t m e n t s , i t i s c e r t a i n l y an  outcome c o u l d be made more o f t e n . too,  treatment has  r e s p o n d e r s ? ; i s e x p o s u r e a method f o r  reasons t o suggest that  important goal,  1981),  response  intention  many c o g n i t i v e  These  component  (see Hugdahl  suit  individually  of the  t o compare change a c r o s s  systems. been  profiles".  a r e n o t b a s e d on any d o u b t s  that  this  i n d i v i d u a l s were s e l e c t e d f o r  i s e a s i l y measured and i d e n t i f i e d that  yielded  reviewed, but r e l a t i v e l y  of the approach but i t s p r a c t i c a l  include that  favourably  i n which  t r e a t m e n t on t h e b a s i s The  studies  T h e r e was much d i s c u s s i o n a b o u t  a p p r o a c h w h i c h h a s been few  three  that  but q u a l i t a t i v e  degrees of c o g n i t i v e  seem more p r o f i t a b l e  to look a t the  32  particular  s t y l e of c o g n i t i v e  dysfunction stress could  of  and c h o o s e a t r e a t m e n t  innoculation  Why  should  treatment  i t be t h e c a s e t h a t  noted  "cognitive"  p o t e n t i a l f o r improvement  (Mackay & L i d d e l l ,  1986)? They a l s o  that  c o n t r o l m i g h t be e x e r t e d .  Michelson  function treatment  fashion,  approach  suggested subjects  attempt  with  i t s i n f l u e n c e as  by t h e work o f D.A. exclusive  & Hollon,  (see a l s o  1981) w o r k i n g  constructs.  "concomitant  to assess  to mediate m a l a d a p t i v e  a number o f w o r k e r s  relevant  the almost  be impeded w i t h o u t  methodology u t i l i z e d  Kendall  a t which  lag"  f o c u s on  t r e a t m e n t , he h a s shown a c o n c e r n t h a t  progress w i l l  purported  to  i t s moderating  increasing  i s characterized  (1988). H i g h l i g h t i n g  cognitive  subjects  progresses".  A fifth Clark  appearing t o manifest  i n a delayed  i n these  I t i s intriguing, too,  (1986) s h o u l d n o t e a " t e m p o r a l  "consonant s t a t u s  More  regardless  t h e i r p h y s i o l o g i c a l r e s p o n s e down t o a l e v e l  cognitive  of  often  t r e a t m e n t s m i g h t be "mixed", a s i n t e a c h i n g  bring  the  ( f o r example  as opposed t o b r e a k i n g o f l i n k s ) .  t o have a g r e a t e r  that  accordingly  a l s o be made o f t h e o b s e r v a t i o n s  studies. tend  misinterpretation or  His recent  advances i n  the c o g n i t i v e  responding".  further  constructs  He i s t h u s one  Ingram & K e n d a l l ,  1986;  t o improve t h e assessment o f review  (1988) i s a  solid  t o d e v e l o p an e m p i r i c a l l y b a s e d model o f c o g n i t i v e  a s s e s s m e n t . Such an a p p r o a c h y i e l d s i m m e d i a t e and u s e f u l information  on t h e s t r e n g t h s  and l i m i t a t i o n s o f d i f f e r e n t  33  forms o f  assessment. I t a l s o r a i s e s p o i n t e r s  need to l o o k cognitions, belief  not but  only  at the  their  presence or absence  emotional  i n which they are  s u c h as  held,  i n t e n s i t y , the and  the  the  of  degree  difficulty  of  with  which  they are c o n t r o l l e d .  It on  the  i s i n the "process"  involves  the  studies,  s u c h as  maintenance  not  noting  approach fraught  o f how  scale,  1985)  looking  and  a rather  i s Last  the  a t the  o f t e n appeared  focusing  in  on immediate  some r i s k .  It  could  by  a p p r o a c h , however, principle  asking  clearly fuller  i s only  conclusions  i s t o go  multiple  and An  subjects,  efficacy.  reader  likely  s t u d i e s which l a c k  the  studies  how  t o and  neat  further  The  example, t h o u g h on  is left  t o be  need  more d e s c r i p t i v e a  (Last,  1984,  treatments  on  these  A f t e r studying  taken p r i o r  drawn a r e  and  of  questions,  hypothesized.  e f f e c t s of a v a r i e t y of  of phobic  treatment  assessment  These are  work  In p a r t i t  than merely  et a l ' s s e r i e s of  t h e i r m u l t i p l e measures, the if  and  with  change t a k e s p l a c e .  cognitions to  a b y s s . The  specified  aims t o g i v e  related  discordance  a single question  small  the  seen.  already  c l e a r h y p o t h e s e s . The  each c a r e f u l l y  picture  be  generalization rather  i n t o s u c h an  than asking  result  best  approaches t h a t  i n t o t r y i n g t o make s o m e t h i n g o f a murky mass  without slide  these f i v e  of change can  outcome. I t i s an  data  of  i n c l u s i o n o f what has  and  deteriorate  light  in  the  i n no  turn  r e s u l t s of doubt  that  a f t e r treatment,  very  simplistic.  ends t h a t  i t might  be  34  comforting  to find,  i f not always easy  to  interpret,  comes a c r o s s as v a l u a b l e a n d a u t h e n t i c . A f t e r  an  overview  but t h e i r  detail,  o f work a l r e a d y c a r r i e d  claustrophobia,  this  theme w i l l  out i n the area of be t a k e n  up a g a i n .  35 CLAUSTROPHOBIA  Claustrophobia clinical  research.  treatment  Very  few c l a u s t r o p h o b i c s  In Marks'  (1987) v o l u m i n o u s  butterflies.  all  general al, is  i n women  claustrophobia with  estimates  population  a s on a v e r s i o n  i s r a t h e r more on t h e f e a r o f  ( R o b i n s e t a l , 1 9 7 4 ) . Of  i s among t h e most common ( C o s t e l l o , ranging  from  5% t o 13% o f women i n t h e  r e p o r t i n g i t a s an i n t e n s e  1969; K i r k p a t r i c k , 1984). The h i g h e s t reported  P h o b i a s and  p h o b i a s were f o u n d t o be t h e most p r e v a l e n t o f  mental d i s o r d e r s  1982)  fear  i s n o t s e e n more f r e q u e n t l y a t t h e c l i n i c  the s i g n i f i c a n c e of the problem.  often not motivated  cope w i t h they  the problem  simply  avoid.  Secondly,  treated, or that /  sufficiently  serious  1982). M a t c h i n g  t o seek t r e a t m e n t  this  nothing  Claustrophobics  because they can  i n a way t h a t n o t a l l p h o b i a s  most e i t h e r do n o t t h i n k be  of f e a r  reason  a p p e a r s t o be i n f l u e n c e d by two f a c t o r s w h i c h have  are  (Agras e t  frequency  i n t h e a g e g r o u p 18 t o 25. The  claustrophobia  t o do w i t h  small  Y e t i n t h e NIMH c o l l a b o r a t i v e e p i d e m i o l o g i c a l  simple  these,  a very  "Fears,  a s much i s w r i t t e n on t h e s u b j e c t  to the s k i n s of peaches; there  study,  attend f o r  a n d t h e s u b j e c t has a t t r a c t e d o n l y  literature. Rituals",  may n o t seem t h e most p r e s s i n g a r e a f o r  that  i t h a s become a p p a r e n t this  i s a problem that  their disability to merit  that could  w o u l d n o t be  p r o f e s s i o n a l attention (Ost,  lack of enthusiasm  a t t e n t i o n h a s been a g e n e r a l  permit:  t o seek p r o f e s s i o n a l  lack of research  interest.  36  Indeed,  i t has  attempt  that very  review.  I t i s p o s s i b l e that claustrophobia w i l l  important  r e c e i v e d so  focus  r a r e task, the  of  interest  panic d i s o r d e r r a i s e Claustrophobia interesting  will for  be  vital  to both  up  questions  literature  curious assortment  on of  efficacy papers The  of  (Miller  these  single-case criticisms  are  s t u d i e s . He  and  other  his colleagues  endure over  1300  years  the  questions  of  there  How  sometimes  and  the to  1973).  clinical treatment  of  e x c e l l e n t review or  f i n d i n g s or  entirely.  (1968, 1970)  a  (e.g., Gehl,  experimental  c o u l d have b e e n h a r s h e r  i n t h e mind a f t e r  trials?  ground  (Knapp e t a l , 1 9 7 8 ) ,  l a m e n t e d i n an  for i t is rarely  but  section i t  & B e r n s t e i n , 1972)  f o r t h e most a n e c d o t a l  approach that l i n g e r studies,  has  phobias,  from questions  s t u d i e s a p p l y i n g b e h a v i o u r a l methods t o t h e  (1982),  simple  interest.  s t u d i e s . These range  Ost  fears.  in recent  o f t h e work, however, i s made up  As  on  of these w i t h i t s  although  imaginal procedures  claustrophobia.  an  studies  about o t h e r  i n the p s y c h o a n a l y t i c t r a d i t i o n  bulk  of  c l a u s t r o p h o b i a b r i n g s up  demand c h a r a c t e r i s t i c s  become  a l w a y s been a t e s t i n g  questions,  could  literature  s e c t i o n . In t h i s  not  have b e e n some f i n d i n g s o f  The  least  i n the next  important  exhaustive  p a n i c d i s o r d e r and  shown t h a t i t has  such  a t t e n t i o n t h a t one  s i n c e the r e s u l t s  i s h a r d l y the  links  a theme t a k e n  little  in his  imaginative  reading  these  How  Leitenberg  did  p e r s u a d e an  d i d Gatchel  individual  (1977)  to  overlook  of  37  that  by  g i v i n g 14  enclosed giving  hours of biofeedback  cubicle within  his subject  the  treatment relatively  that  their  the  subject  relaxed wearing  very  (1982) p o i n t t o draw any  s m a l l , and  study  had  at  that  i s well  yet been p u b l i s h e d . "must be  discussed  considered  claustrophobic  behaviourally  as  both  the  his  i t w o u l d be from these  area  a whole.  but  quite and  had  been outcome  the the  fact  in  the  I t i s p a r t of  a  individual differences,  s e c t i o n . He  (exposure) or  classified  or  then s t u d i e d the  method  of  claustrophobia  into "behavioural"  method  physiologically-focused  with  against  on  in this  previous  r e a c t o r s and  focused  goal  published".  prominence to  subjects  "physiological"  rarely  just  literature  i n the  the  remain  also noted that  c o n t r o l l e d group study  was  are  He  O s t ' s own  due  as  Bernstein  c o n t r o l l e d treatment  failures  s e r i e s which g i v e s  and  subjects described  treatment  behaviour therapy  to  taken that  t i m e no  not  able  conclusions  number o f  (1982) i s o u t s t a n d i n g  as  be  also  phobic  having  s l e e p i n g bag,  general  that  encouraging r e s u l t s  f o r , by  an  a s u r g i c a l mask, h i s h e a d a t  feet tied?  s t u d i e s . The  exposure to the  should  hands and  similar  was  subject  of a f u l l y - z i p p e d  impossible  l a b o r a t o r y , t h a t he  s i t u a t i o n were S p e l z  wrong end  Ost's  in  extensive  s i t u a t i o n ? What r e a l - l i f e (1979) p r e p a r i n g  training  effect  of  a  a  ( a p p l i e d r e l a x a t i o n ) . With  38  this  sample,  results achieved  though not  supported  the  later  hypothesis  when t h e method u s e d  p a t t e r n t h a n when i t d o e s  Ost  and  Hugdahl  i n which phobic acquired  their  with  agoraphobics  that greater  fits  the  patient's  (animal,  social,  or  prominent  i n those  who  responses  subjective  vicariously did  not  acquisition  and  anxiety  two  interesting  p r o b l e m had  than those  nor  of  comparison to those  acquired with  as  (a h i g h e r  r e p o r t ) . In  had  d i d the  reports  fears information.  the  failing  the  2/3  reported  a result  of  support and were,  of  that  a  f i g u r e than f o r the  fears,  other  these  i n heart  fears i n d i r e c t l y . two  They  23  l a r g e r 'increase  other  to  conditioned  laboratory testing  their  ways  i n s e v e r i t y . There  sample, over  a significantly  who  (thus  f i n d i n g s . Of  been a c q u i r e d  experience  f e a r s i n the  s u b j e c t s had  components  phobias d i f f e r  claustrophobics'in their  conditioning  their  transmission  hypothesis),  acquired  however, o t h e r  their  similarly  a c l e a r c u t r e l a t i o n s h i p between t h e  Rachman's 1978 indirectly  t o have a c q u i r e d  or through the  find  higher  were  attributed their  questioned  with  ways  interested in  They  w o u l d be more l i k e l y  response  about the  phobias to c o n d i t i o n i n g e x p e r i e n c e s . whether those  are  claustrophobic)  f e a r s . They were p a r t i c u l a r l y  t o be  "the  not".  i n v e s t i g a t i n g whether p s y c h o p h y s i o l o g i c a l more l i k e l y  effects  (1981) were a l s o c u r i o u s  patients  (1984),  the  In  rate  39  claustrophobics more n e g a t i v e  showed more p h y s i o l o g i c a l r e a c t i o n s ,  thoughts,  In a r e c e n t 1988), t h e  and  engaged  questionnaire  experiences  i s , as  satisfactory  way  and  i n the  previous  by  of  age  experiences related  to  miners  14-  i n an their  i s an  enclosed current  see  been as w e l l  s t r u c t u r e d as  is  a t an  interesting was  on  the  (Ploeger's o f how  Rachman, 1 9 8 9 ) . T h i s  e a r l y stage questions  of  p r e s e n c e and  the  Ost  entirely  from e i t h e r larger some  thrown up  aversive saw  as  causally  study  of  trapped  this  f e a r can  survey  but  may  not  i t has  c o g n i t i o n s and examples  catastrophic  an  social  I'm  stuck  nature  upset"),  7  and  ("it will  was  "there'll  Some r e c o r d e d  be  subject  said  non-cognitive  to cause a r e - p a n i c .  be  a l m o s t as  that her  thoughts of  and  This  the  seen  panic  p o t e n t i a l of  r a i s e s the  focus  the of  a more this  common a theme  first  and  earthquake  so h u m i l i a t i n g t o be  embarrassment was  e n t r a p m e n t . One s i t u a t i o n was  i n here".  have  y i e l d e d some  r e s p o n s e s were v a r i a b l e . Some g a v e c l a s s i c  while  become  some p r o b l e m s . The  i n f l u e n c e of  t h o u g h t s s u c h as  37%  (1981) q u e s t i o n n a i r e ,  formulation,  and  early  space w h i c h they  account  conditioned,  Usually  an  - i n h i s study  to d e t a i l  fear.  interesting  not  common  their  prank, a r a t h e r  (1978) r e p o r t e d  were a b l e  a l s o t h e most  study,  data).  p a r e n t a l punishment or a s i b l i n g t h a n Ost  was  i n t e r p r e t a t i o n of  of c o l l e c t i n g  proportion  worrying.  (Rachman, B o o t h , & W h i t t a l ,  conditioning explanation  (though s u b j e c t s ' r e c a l l  the  i n more  had  question  as  in a thoughts of  whether  40  cognitions quickly.  play a lesser role  Another  back a l o t of no  worry of  neither cast  " an  identify  any  or p r e v i o u s  and  images. One  impossibility", relevant  they  reported  do  not  of a n x i e t y  think  be  has  she  though  Several  interesting  stronger h e l d no  possibility less  been  Catastrophic  i n the  feared  credibility  likely  beliefs  at a l l .  having broken a of  q u i t e unable  that at the  to  on  this  peak  of  think!)  which  n o t e d once a c e r t a i n  (such  a l m o s t no  effect.  I t was  many f e l t  that c o g n i t i v e therapy  promising  a p p r o a c h and  "you  hardly  were a l w a y s a g r e a t outside  were h e l p f u l , as  t h a t were  Some f o u n d  therapy  anxiety.  had  that cognitions (severity t o be  situation;  cognitive  their  was  she  reached.  techniques  that  that  having  a t a l l ( o r so t h e y  breathing  state  i n brought  finds lack  she  reported  T h e r e were a v a r i e t y o f p o i n t s surprising.  shut  thoughts, c a t a s t r o p h i c or not,  occasions.  f r e q u e n c y ) may  level  being  images, b u t  l e g e i g h t times because  movement  the  that  frightening childhood  t h o u g h t s nor  anxiety  reported  very  c u r r e n t harm. However, some r e p o r t e d  on h e r  raises  subject  i n f e a r t h a t peaks  but  are  therefore  i t , they  deal  often  that d i s t r a c t i o n  or  self-induced  being  r i d i c u l o u s " ) had  somewhat p u z z l i n g t h a t  s o u n d e d t o be  needed l i t t l e  o r no  t h o u g h t s were i n f a c t  a  very  encouragement  a t the  so  root  of  to  their  41  I n many c a s e s simply It  i t was d i f f i c u l t  b e c a u s e so much a v o i d a n c e  was i n d e e d  striking  just  to get recent  behaviour  how e f f e c t i v e  examples  was.engaged i n . current  avoidant  strategies  a r e , a s w e l l as t h e l e n g t h s u n d e r g o n e t o  accomplish  them. Though v e r y  treatment,  some 50% s a i d  opportunity  The  i f they  subjects  few h a d e v e r  t h a t they  knew i t was  considered  would take  up t h e  available.  i n c l u d e d one o u t s t a n d i n g  example o f  p i c k i n g up a f e a r v i c a r i o u s l y .  The f a t h e r o f a p a r t i c i p a n t  had  trapped  had a t r a u m a t i c  experience  i n a h o t sauna  f o u r o t h e r s . The a t m o s p h e r e  "went r e a l l y  temperature  finally  increased until  f r o m t h e o u t s i d e . She h a s a v e r y like, her  and i n an e n c l o s e d  a g i t a t i o n more t h a n  with  c r a z y " as t h e  t h e d o o r was axed i n  s t r o n g image o f what i t was  s p a c e o r i n a crowd what anything  else  increases  i s an i n c r e a s e i n  temperature.  One o f t h e m a i n d i f f i c u l t i e s study is  was t o e s t a b l i s h  n o t easy  agoraphobia spaces  17%  f u r t h e r complicates  e t a l (1984),  of agoraphobics  and e x c l u s i o n c r i t e r i a . I t  (claustro  the issue. Fear  with  of enclosed  has been d e s c r i b e d as  " u s u a l " by  and i n D o c t o r ' s  (1982) o n l y  found  = closed)  survey  c l o s e d - i n spaces  p r o b l e m " . A t one e x t r e m e , b e i n g space  i n s e t t i n g up t h i s  t o d e f i n e c l a u s t r o p h o b i a , and i t s o v e r l a p  i n agoraphobics  Johnston  inclusion  faced  such  t o be "no  c o n f i n e d i n an e n c l o s e d a s a l o c k e d room, d o e s n o t  42  pose a problem. surely has  not  But  always  waiting  indicative  i n d i c a t e d (1989).  d e p e n d i n g on classifying  the  o f p h o b i a s one (1987).  social  I f one  category,  which are  able  of  the  claustrophobia  few and  (1981) i n t h e i r variables  t o be  allows  simple  walking  out  i n the  a walk t a k e s  groups to d e f i n e a g o r a p h o b i a was  Neiger  d i s o r d e r s . They do claustrophobics  f r e s h a i r while  diagnosis.  and  so on  his  the  fear  basis  n e v e r have  trouble  i s at  i f such  by  distance  aggravated  by  thirdly,  to reduce  claustrophobic manifestations, While t h i s  of  the  "safe place"; help  between  associates  a g o r a p h o b i c s do,  " s a f e p e r s o n " does n o t  and  cognitions  remain u n a f f e c t e d  f r o m home o r  agoraphobic d i f f i c u l t i e s .  a  p e r s o n a l i t y and  agoraphobic problems are  of  III-R  the d i s t i n c t i o n  f r o m home, w h i l e  a  assessment  DSM  I n c l u s i o n of  difficulties  likelihood  the  them away f r o m home; s e c o n d l y ,  increasing distance  multiple  p h o b i a s as  claustrophobic's  presence of  longer  e n c o u r a g e a more f l e x i b l e  points. F i r s t l y ,  of  employed o n l y when a g o r a p h o b i a  f a c t o r a n a l y s i s of  i n phobic  fears  open t o  t o improve on  p h o b i a have been r u l e d out.  One  habit  is  Rachman  a range of  i s s u r e l y no  those  as  were t o i n c l u d e a b r o a d e r  w o u l d be  i n assessment might  three  signify  situation  I t c u r r e n t l y only  residual  of c l a u s t r o p h o b i a  I t could  particularly  interpretation.  at a supermarket  p r e c i s e c o g n i t i o n s . The  f e a r s by  appropriate,  in line  the  i n contrast  least  an  the  to  attempt  43  at d e f i n i n g d i f f e r e n c e s ,  i t i s not  a t a l l c l e a r how  g r o u p s were a c t u a l l y d i s t i n g u i s h e d  What one have f e a r s o f  can  conclude  closed  s p a c e s , but  some c l a u s t r o p h o b i c s  One  cautious  illustrated  by  Ost  unsubstantiated  i n going  et a l  the  f u r t h e r than t h i s  a r e more c o n c e r n e d w i t h  the  attacks),  actual  afraid  could  of  the  be  space per  i n the  s i t u a t i o n s . The  avoid  phobic  s i t u a t i o n s may  a g o r a p h o b i c s compared ways t o r e n d e r t h e  to  elevator".  Not  only  a g o r a p h o b i c s , but that the  claustrophobic This  in fact  distinguishing  tendency be  are  safety  frightened  f a c t o r s of  the  the  of  to  this i s more  e.g.  (e.g.,  own  completely  who  instead  an  in  often by  of  find  leaving the factor  Rachman,  enclosed  one  of  space,  linking  two  disorders.  of  1989)  o f what m i g h t b e f a l l the  well-  agoraphobics  his/her  s i g n a l s a noted  is frightened is surely  "a  much s t r o n g e r  stairs  most w o u l d a r g u e  f a r from being  there.  than of  s i t u a t i o n more s a f e , the  that  ( i . e . panic  claustrophobics,  doors unblocked or u s i n g  is  claustrophobic  se  fears.  as  s i t u a t i o n s where  reactions the  i s that  fear i t s e l f  t r i g g e r e d . The  closed  always  unusually  r e m a r k s . They w r i t e  agoraphobia  reaction  i s not  have i s o l a t e d f o c a l  known c h a r a c t e r i s t i c o f  more t h a n t h e  study.  reverse  (1984) i n an  s e r i e s of  two  s a f e l y i s t h a t many a g o r a p h o b i c s  found s i n c e must be  in their  the  rather him  rather  than  44  Many o f t h e s e (1989) c h a p t e r of  i s s u e s have been r a i s e d i n Rachman's  on c l a u s t r o p h o b i a  the l e n g t h i e s t pieces  many  strengths.  without  which, though s h o r t ,  i n t h e whole a r e a .  Putting panic  possibilities Lopatka,  (Rachman & L e v i t t ,  1988). The " l i n k s "  c o g n i t i o n s are very sensitization, important.  Of t h e l a s t  whether i t a c h i e v e s  opens up many  present  f e a r and e x p o s u r e he a s k s t h e v i t a l  i t s effects directly  f e a r and a g r o p i n g  the process  possible vestigial  worth n o t i n g .  fear of being  Might  question and  as t o  independently,  of c l a u s t r o p h o b i a  behavioural  t h i s make  up t h a t a r e  He s t a t e s f i r s t l y  that  spaces  i n a way t h a t  but f a i l s  explanation  occur".  Rachman b r i n g s  trapped  to elaborate  i t more l i k e l y  " i t is  is a  prevents on  this  that there  a non-cognitive  quality to fears i n claustrophobia?  Secondly, while  i t seems p l a u s i b l e t h a t t h e p e r s o n ' s  not  of the e x t e r n a l circumstance,  i s an  procedure f o r  towards a c o g n i t i v e  t h a t t h e human f e a r o f e n c l o s e d  e s c a p e when t h r e a t e n e d " question.  i s extremely  c o g n i t i o n s . He sums up  by w h i c h t h e changes  T h e r e a r e two p o i n t s particularly  and  k n o w l e d g e when he s t a t e s t h a t " a t  u n e a s y m i x t u r e o f an e f f e c t i v e  for  &  and t h e d i s c u s s i o n o f  our grasp of the r e d u c t i o n  reducing  exciting  1985; Rachman, L e v i t t ,  or through the i n f l u e n c e of f e a r f u l much o f o u r c u r r e n t  setting,  between b o d i l y s e n s a t i o n s  interesting  symbolic  I t c e r t a i n l y has  i n an e x p e r i m e n t a l  l a c t a t e or i t s equivalents,  i s one  c o u l d be  fear i s  i t i s not convincing  that  45  the  critical  stimulation".  f e a t u r e i s "the s i g n i f i c a n c e  of i n t e r n a l  The m i s i n t e r p r e t a t i o n o f b o d i l y s e n s a t i o n s  d o e s n o t seem t o p l a y  t h e same c r i t i c a l  role i n  c l a u s t r o p h o b i c p a n i c s , and Rachman's s t i c k i n g Clark such on  i s likely  as agoraphobia.  avoidance  focusing  still  almost last  back a t p r e v i o u s  anxiety,  next  interest  situation,  i n behaviour i n this  area  i t h a s become an a r e a focuses  induction of panic,  therapy. For but i n the of  the role  interest  of c o g n i t i o n s i n foranxieties  panic d i s o r d e r . These a r e a l l addressed  s e c t i o n i n which s p e c i f i c  anxiety.  on t h r e e a r e a s : t h e  and t h e u s e o f i n t e r o c e p t i v e e x p o s u r e  than  without  s t u d i e s on c l a u s t r o p h o b i a one  a d e c a d e t h e r e was a l u l l  two o r t h r e e y e a r s ,  can s u r e l y c e n t r e  changes accompanying  c h a r t many d e v e l o p m e n t s  laboratory  thoughts  o r escape from t h e phobic  once a g a i n . T h i s  other  t o h o l d on t o o u t s i d e an a r e a  Maladaptive  on t h e p h y s i o l o g i c a l  Looking can  to prove hard  so c l o s e t o  questions  i n the  are formulated.  46  THE  In  this  outline and  section  PRESENT STUDY  t h e aim w i l l  the i s s u e s which w i l l  be t o b r i n g t o g e t h e r and  be a d d r e s s e d  i n this  study,  l a y o u t t h e i n t e r v e n t i o n s a n d measures t h a t w i l l  be  used.  In  the l i t e r a t u r e  the apparent disorder. received  success  review,  much m e n t i o n h a s b e e n made o f  of current treatments  The r e v e r b e r a t i o n s o f s u c h very  little  a dramatic  the findings  first  q u e s t i o n that i s c o n s i d e r e d here  Barlow  (1988),  approach.  would  It will  be n o t e d  panics  be  than be  benefit  i f they w i l l  those  panic?  setting.  t o s e e how  settings  this i t  typically  referred with  useful.  Will  any g a i n s  e x t e r n a l cues  panic disorder? W i l l i t  exercises that w i l l  that are experienced the backing  i n the feared s i t u a t i o n ?  less  i t r e m a i n s t o be  i n t h e f a c e o f f a r more p o t e n t  those  such as  However, w i t h much  the technique  Can i t work w i t h o u t  training  c e n t r e s on  c l a u s t r o p h o b i c s . They, t o o ,  i n everyday  find  possible to find  resembling  q u i t e t e n t a t i v e . The  p r e v i o u s work, a r e p r o n e t o e x p e r i e n c e  of panic  diminished  are s t i l l  be o f g r e a t i n t e r e s t  from  have  s e e a s t h e l y n c h p i n o f t h e new  i n an e x p e r i m e n t a l  experience seen  themselves  e x p o s u r e w h i c h some i n v e s t i g a t o r s ,  intervention will will  finding  c o n s i d e r a t i o n , perhaps not s u r p r i s i n g l y  since  interoceptive  f o r panic  b r i n g on s e n s a t i o n s  during claustrophobic of experience or  T h e r e a r e many  questions  47  surrounding anxiety  A  the  other than panic  i s that  practiced, researchers  as  the  enlarge  cognitive  having  Clark  little  had  been c o n d i t i o n e d .  literature.  Cognitive  ineffectual  w i t h the  of  the  appears that  the  If  as  bulk  i n the  a  reappraisal  the  to  fears  social  i f the  then  and  of  there  how  strong  conditioning  either  s i t u a t i o n s or p h y s i c a l  simple with  It fear  only  by  the  is a of  now  panic  disorder,  at  (Hawton e t a l , 1 9 8 9 ) . w o u l d have t o be benefit  t h i s can  a  from a  be  predicted.  t o have a p a r t i c u l a r l y  sensations.  t h e n be  It  a  crucial  h i s t o r y , w h e t h e r t h i s be  not  phobias,  l e s s of  phobias.  treatment  after a l l , is likely  f e a r may  exercise  in off  disorders.  evidence i n  Oxford group  firm,  intervention,  conditioned  the  b o t h of what g r o u p s m i g h t  Panic disorder,  anxiety  contribution  successful  p r a c t i c e d by  is surprising  f i n d i n g b a c k e d not  of  to  l a r g e l y been w r i t t e n  conditioned  s u c h as  cognitive  t h i s f i n d i n g holds  cognitive  was  strongly  component  i n the  panic  a p p r o a c h e s were p a r t i c u l a r l y  conditioning  least  had  some, i f l i m i t e d , v a l u e  ingredient  for  i n which i t i s  t h i s component. T h i s  This  by  an  component. Some  a particularly fruitless  most t h e o r i s t s b u t  exposure to  (1987) h a v e , o v e r t i m e , moved  to c o n t r i b u t e  considered  treatment  cognitive  contribution  was  while  the  major c e n t r e s  i s a strong  s u c h as  s t r e n g t h e n and  of  i n a l l the  there  interoceptive  disorder.  second n o t a b l e p a r t  disorder  that  a p p l i c a t i o n of  A  linked  to  highly  a good b a s i s  for  excluding  48  a cognitive predicting  intervention.  I t may be t h a t  the potency of c o g n i t i v e  another basis f o r  interventions  emerge s u c h a s , f o r example, t h e s t r e n g t h associated  dysfunctional  would a g a i n  This  cognitions  with  will  which  are held.  Claustrophobia  a p p e a r t o be a good t e s t i n g g r o u n d .  last  point  helps  t o make i t c l e a r t h a t  a better  u n d e r s t a n d i n g o f a f e a r s u c h as c l a u s t r o p h o b i a ,  will  importance  t o be  i n the reappraisal that  seems l i k e l y  be o f  n e c e s s a r y a f t e r t h e d u s t has s e t t l e d on t h e t r e a t m e n t o f panic  disorder.  senses  Much c a n l e a r n e d  i n which claustrophobia  similar,  and s u g g e s t e d  and p a n i c  from t h e  disorder  and t h e s i g n i f i c a n c e o f t h e ways i n w h i c h  are r e a l l y they  differ.  But  even w i t h o u t  the r e s u l t s from p a n i c  disorder,  there  w o u l d be no s h o r t a g e o f q u e s t i o n s  t o ask o f comparative  interventions  This  which to study  f o r claustrophobia.  i s an i d e a l  t h e mechanisms o f c h a n g e . Rachman and W h i t t a l  (1989) have r e f e r r e d t o t r y i n g t o c a t c h a glass  format i n  s u c h mechanisms " i n  j a r " . The a m b i t i o n s h e r e w o u l d be somewhat more  modest, a n d p a r t i c u l a r l y self-reported  anxiety,  relate to monitoring  cognitions  changes  and p h y s i c a l  across  sensations.  How do Changes i n t h e s e systems compare b e t w e e n t h e t h r e e interventions? effect?  What  i s the d i f f e r e n c e  i n timing  of t h e i r  49  Turning researchers having  now  to methodology,  have f a v o u r e d  a variety  of  increasingly  to perform  Rachman and  1988), however, have f o u n d  "levels" here.  of  The  test with, the  chief  the  agoraphobic  The  latter  measure of a n x i e t y  the  alarms,  that w i t h i n the  narrower range of  an  anxiety  There area w i l l  i s general  by w h i c h t h i s  short  favoured  a series  of  i t easier  self-  than  situations  advantage f o r the r e s e a r c h e r situations,  is  the It is  ground f o r s u b j e c t i v e r e p o r t s  unable  consensus, too,  to  should  stretch either  be  physiological but  i t s theoretical  as t h e most r e l i a b l e the  advent of  Freedman e t a l , 1985;  assessment there  are  in  of  this or  method  done i s h o t l y d e b a t e d a l t h o u g h  ( L i e b o w i t z e t a l , 1985). S i n c e (see  that research  p h y s i o l o g i c a l a s s e s s m e n t . The  i s usually recognized  limited,  (1987,  panic.  be  monitoring  becomes  o p t i o n was  find  by  Mavissakalian  r e c e i v e many more c u e s f o r p a n i c .  a p p l i e d wings w i t h o u t  rate  the  excellent testing and  options  between s e v e r a l  s m a l l e r range of  associated with  thus  t h a t some  his associates  i s thus  c l a u s t r o p h o b i c may  claustrophobic w i l l  as  that  a t most, a c h o i c e  to a v o i d  noted  i t more u s e f u l t o h a v e a  same t a s k .  r e p o r t s . While the  (such  f o r agoraphobics  difficult).  standardized  be  v a r y i n g the b e h a v i o u r a l  tasks  e t a l ' s [1983] " c o u r s e "  i t can  marker  ambulatory  T a y l o r e t a l , 1983),  i n a l a b o r a t o r y s e t t i n g might  important  answered i n such a s e t t i n g .  questions  I f the  heart  t h a t can  seem  be  cognitive intervention is  50  effective, reduction  f o r example, i n heart  misinterpreting  pioneers  questionnaires  f o r research  Cognitions  Questionnaire  sensations  i n this  area.  sensations  solid  pertaining to of a n x i e t y ,  (BSQ) i s a l i s t  associated with  a  The A g o r a p h o b i c  (ACQ) h a s i t e m s  Questionnaire  (1984).  t h a t have p r o v e d  thoughts about the r e s u l t s  Body S e n s a t i o n s  physical  of p h y s i o l o g i c a l response?  have been Chambless and h e r a s s o c i a t e s  foundation  the  t o a marked  o f s e l f - r e p o r t e d c o g n i t i o n s and  They have d e v e l o p e d  catastrophic  i t leads  r a t e , o r a lower p r o b a b i l i t y o f  t h e same l e v e l  In the area the  i s i t that  anxiety  that  while  of clients  frequently  r e p o r t t o be d i s t u r b i n g . T h e r e have b e e n  variations  on s c o r i n g t h e ACQ, t h o u g h t h e most common means  has  been t o r a t e e a c h t h o u g h t  occurs".  from  F o r t h e BSQ t h e s u b j e c t  "never o c c u r s "  i s allowed  some  t o "always  more l a t i t u d e a s  t o how t h e s e n s a t i o n s  are perceived, with  frightened or worried  by t h i s  sensation"  (score of 1), to  f r i g h t e n e d by t h i s  sensation"  ( s c o r e o f 5 ) . The  "extremely scores  on i n d i v i d u a l  items,  choices  whether i n d i c a t i n g  p r e s e n c e o r i n c l u d i n g p e r c e p t i o n , a r e summed as  either a total  The but  importance  merely  and  expressed  score.  o f outcome has t h u s  t h a t i s n o t t o say t h a t  However, i n p l a c e a  o r an averaged  from "not  f a r been  i t i s t o be t o t a l l y  downplayed, ignored.  of a comparison of t h e d i f f e r e n t  s i n g l e measure, t h e r e w i l l  be g r e a t e r  focus  g r o u p s on  on w h i c h  51  treatment generalizes One of  of  the  ( 1 9 7 8 ) . He  procedures  undifferentiated  that  "are  is likely  each f a r e s  the  risks  change was the  often  outcomes a k i n  behaviour  how  on  of measuring  i s both c r i t i c a l  psychological  any  and  c l e a r e s t statements  a single point  that  better  and  Bandura  e f f e c t s of judged  i n terms  "vary  and  markedly  of  points  times".  o u t c o m e s , he  In p l a c e  appeals  w h e t h e r a method  w h e t h e r the  states,  "the  settings  At first solely  often  ceased  less well  this  point  Such a design study  the  (e.g.  major point  i s that  be  anxiety  he  measured of  cognitive e f f i c a c y even 1985), and  in  yet  unfamiliar  cognitions. elicited,  will  be  clarified.  t o mind: i t i s one  such c o g n i t i o n s there  systems,  p r o m i s e s t o be  Marshall,  interventions w i l l  exclusively at  showing how  since  the  1981).  i n t e r v e n t i o n comes e a s i l y and  response  improve t h e i r  i n reducing  (Biran & Wilson,  change, w h e t h e r  amorphous, i n a d e q u a t e l y  seem t o  of  m a i n t a i n e d o v e r t i m e . As  in this  provoking thoughts w i l l follow  of  overdue".  t r e a t m e n t has  have f a r e d  more a n a l y t i c q u e s t i o n s  s i t u a t i o n s and  changes are  relevance  interventions after  across  retirement  outcomes i s l o n g particular  f o r the  at  such u n d i f f e r e n t i a t e d  induces p s y c h o l o g i c a l  changes g e n e r a l i z e and  of  out  in different  e n v i r o n m e n t a l s e t t i n g s t o w a r d d i f f e r e n t p e o p l e and different  time.  limitations  made by  to cure r a t e s "  to  over  be  The and  aimed  client's  anxiety-  training will  m i g h t be no  The  countered.  exposure to  the  The  feared  52  situation. will  I t seems a l m o s t  be l e s s s u c c e s s f u l  situation  experience  an anxious  high  cognitive  i s likely  this  therapy  point  should  should  Is i t that i s too  e x p o s u r e , a n d what e f f e c t two s y s t e m s b o t h  i n panic  that  there  personal  over  (1988) h a s c a l l e d  disorder,  but i t i s only  h a s b e e n any s i g n communication,  be made c l e a r a b o u t t h i s  f o r a moment t h a t  ideally  of c o g n i t i v e  cognitions to  t o change?  s i t u a t i o n s . Teasdale  (P.M. S a l k o v s k i s ,  i s not proposed  style  one n e e d s  1990).  One It  other  the feared  i n t e r e s t t o e s t a b l i s h whether  s t u d y was i n i t i a t e d  a response  April  with  t o be p u t i n t o a c t i o n ? I t  t o have on t h e o t h e r  s u c h an i n t e r v e n t i o n  since of  techniques  c a n be c h a n g e d w i t h o u t  time and a c r o s s for  f o ra cognition  c e r t a i n l y be o f g r e a t  cognitions this  than d i r e c t contact  s i t u a t i o n the p h y s i o l o g i c a l arousal  t o allow  would  such an i n t e r v e n t i o n  b u t i t i s n o t c l e a r why. I s i t t h a t  evidential in  c e r t a i n that  this  be c a r r i e d o u t .  therapy  that  s i t u a t i o n . Beck a n d Emery  unequivocally  that  for  interventions  cognitive  i s how  cognitive  There i s n o t a s i n g l e  w o u l d a i m t o change  i n t h i s manner, i . e . w i t h o u t  the feared  intervention.  including (1985)  exposure  state  simple phobias are not a s u i t a b l e since  "the c o g n i t i v e  target  set i s  a c t i v a t e d w i t h a minimum o f p r i m a r y and s e c o n d a r y appraisals",  and t h e c o g n i t i v e  responses are " r e f l e x i v e " ,  " a u t o m a t i c " and " f a r removed f r o m v o l u n t a r y appraisal".  I t i s t o exposure  that  c o n t r o l and  Beck l o o k s  t o move  53  clients  f r o m what he t e r m s  Bandura  ( 1 9 7 7 ) , t o o , i s adamant t h a t  i n d u c e d and arising this to  r e f l e x i v e to r e f l e c t i v e  c o g n i t i v e processes are  a l t e r e d most r e a d i l y "by  experience of  from e f f e c t i v e performance".  s t y l e o f s t u d y i s t o be a b l e  see what happens,  thinking.  One  mastery  of the freedoms  to include  without b e l i e v i n g that  an  of  intervention  i t can  n e c e s s a r i l y match o t h e r i n t e r v e n t i o n s .  It  i s i m p o r t a n t t o d e c i d e on t h e s t y l e o f  cognitive  i n t e r v e n t i o n . As  developed  and p r o l i f e r a t e d , i t no  group  theories  " c o g n i t i v e a p p r o a c h e s " as  and p r a c t i c e have  l o n g e r makes s e n s e t o  i f t h e y were a s i n g l e  phenomenon. T h e r e i s c e r t a i n l y a s t a r k approach will  o f Meichenbaum and  lead  latter  to i d e n t i f i c a t i o n It is this  I t i s one  Emery, 1985)  Barlow's  and has  second group  and  c o u n t e r i n g of  been  clearly  The  former  situations  transferred relatively  astonishing  i s also relatively  so i n g e n i o u s l y  that  used  well  from  the  give  an  easy t o s e l e c t . to the  than to p a r t i c u l a r  simple that  i t had n o t b e e n  (1988) does  be  depression.  of exposure, r a t h e r  was  dysfunctional  s p e c i f i e d ( s e e Beck &  d e c i s i o n to d e s e n s i t i z e p a t i e n t s  "sensations"  Barlow  f o r example.  between t h e  second approach which w i l l  t h a t has  same a u t h o r s ' work on  The  Beck,  contrast  t o a v a r i e t y of c o p i n g s e l f - i n s t r u c t i o n s , the  thoughts. here.  this  used  once  years  s e e n i t was  previously.  i n t e r e s t i n g a c c o u n t o f some v e r y  54  early  examples  of t h i s  either misinterpreted  approach which  o r i g n o r e d . Wolpe  inhalations  b u t saw them o n l y  relaxation.  Orwin's  inadvertently Little,  he b e l i e v e s  (1958) u s e d  subjects  also  case r e p o r t s  by Lum  (1976) and L a t i m e r ( 1 9 7 7 ) . Thus i t was n o t u n t i l workers  such as C l a r k  ( 1 9 8 4 ) , L e y ( 1 9 8 5 ) , Rapee use  interoceptive  test  specific  desensitization.  (1987) and B a r l o w  (1988) came t o  t h a n as a d e l i b e r a t e  focus of  F o r many o f t h e r e a s o n s m e n t i o n e d t o be  i n v i v o , b u t much c a n be l e a r n e d  i t could  such as C l a r k  doubt  that  exert  other  t h a n when o p p o r t u n i t y m i g h t  i n the  effective from s t u d y i n g i t s  e f f e c t s when i t i s a p p l i e d w i t h o u t t h e b e n e f i t Indeed r e s e a r c h e r s  et a l  i t was a s o f t e n u s e d t o  p r e v i o u s p a r a g r a p h , i t i s more l i k e l y practiced  the mid-  (1985), S a l k o v s k i s  exposure, though  hypotheses  2  t o t h e somatic cues o f p a n i c .  t o o , was made o f some e a r l y  1980s t h a t  C0  a s a means o f f a c i l i t a t i n g  (1973) " r u n n i n g t r e a t m e n t "  exposed  were  of exposure.  (1990) have e x p r e s s e d g r a v e  any s i g n i f i c a n t  effect  be p r o v i d e d  on i t s own,  to challenge a  cognition.  To groups  some e x t e n t i t i s t e m p t i n g t o have so a s t o f a c i l i t a t e  balance there are d i s t i n c t which r a t e s is  o f change m i g h t  inclusion  advantages  b u t on  t o having groups  be compared. An o b v i o u s even  The main l i m i t a t i o n  o f exposure would  t h e s e two  within-group analysis,  t o have an exposure group,  difficulties.  just  i f this  brings  i s the r i s k  detract  choice  about  that the  from the p r o c e s s  with  some  55  emphasis o f  the  study;  reader to note t h a t (the  i t w o u l d be  t h i s was  the  of  the  important "pure"  changes i n the  point  form of  reported.  i s that  When he  dysfunctional  three  reactions,  they r e p o r t e d  issues  how  any  is possible  cognitions.  Since  both before  and  also  included  Another  there  the  (1986) w h i c h of  students  i s the  a p p e a r t o be  issue  to  of the  looked  these  s e l e c t i o n . This  dispassionately  more s t r o n g l y  than  type c a r r i e d out  specifically  a n a l o g u e outcome r e s e a r c h . commonest  source of  stimulus  interventions.  i s subject  considered  at  the  The  use  criticism  influenced  that  a c o n t r o l group i s  e f f e c t of the  to  be  i s exposure to a f e a r e d  of  i t was  suggests  t e n d s t o g e n e r a t e more h e a t  i s required  validity  study  interventions,  to  experience  much l e s s e m p h a s i s  time p e r i o d  important  discussion often  et a l  very  a f t e r the  t o p i c w h i c h n e e d s t o be  More s t u d y  work f o r t h i s  c o n t r o l l i n g f o r the  assessments over  related  f o r m of mute e x p o s u r e w o u l d  to give  exposure  difficult  suggests that  it  has  challenging  treatment p r o t o c o l . While h i s  early pilot  a  (1986)  foster  adhere to the  impractical,  second  easy to a d m i n i s t e r  thoughts, or a d d r e s s i n g  response prevention,  the  interventions. A  t h e r a p i s t s to  clients'  for  important  i n p r a c t i c e , as W i l s o n  required  without e x p l a i n i n g  so m i s s t h e  i t i s not  exposure  easy  most e f f e c t i v e i n t e r v e n t i o n  a l m o s t c e r t a i n outcome) and  detail  a l l too  by  by  is a  since i t s light. Emmelkamp  external of  college  since  they  f a c t o r s such  as  do  56  demand c h a r a c t e r i s t i c s  and  (Emmelkamp e t a l 1975)  than  possible  (and  again  this  expectancy  c l i n i c a l patients.  a r e more e f f e c t i v e w i t h  who  more e a s i l y  of  difference  intelligent  i s t h a t student  Wilson,  (Lader, 1981;  1967). S i n c e  subjects are  likely  low in  physiological  student  l i m i t e d data  on  still  quoted,  "As in  l o n g as the  the  manipulations  The  with c l i n i c a l  patients.  with  yet,  (1976) i s  clear  data:  simple  (i.e.cognitive  likely  t o be  a b o u t w h i c h a few  makes good s e n s e .  He  by  Lang  i n 1964  s i n c e each c o u l d g i v e out  used  to define fear  a false  on  found  words three  still  warned t h a t n e i t h e r v e r b a l , m o t o r  c o u l d be  and  least,  W i t h r e g a r d t o t h e measurement o f t h e forward  for  limitation  or a t very  are thus  concepts  systems; the p o s i t i o n put  concepts  ineffective,  that  i s s t r o n g l y present  components  sterner tests  T h e r e r e m a i n a few  somatic  a  immediate a n x i e t y r e a c t i o n ,  be  &  effective  Borkovec's view  component  o f t h e o t h e r two  said.  t o be  yet supported  physiological  inefficient".  s h o u l d be  suggested  v o l u n t e e r s . T h e r e a r e , as  i f not  overt-behavioural) w i l l  to react  (Biran  a g a i n w o u l d be  the q u e s t i o n but  individual's  have  i s only l i k e l y  reactors, this  studying s o l e l y  widely  1980)  area  clinical  several authors  Rachman & W i l s o n ,  cognitive restructuring  students  t o c o g n i t i v e demands. A t h i r d  w i t h a much s l i g h t e r d e g r e e o f a r o u s a l t h a n subjects  It is  i s open t o t e s t i n g ) t h a t c o g n i t i v e  interventions can a d a p t  of t h e r a p e u t i c gain  their  l e a d . Though w i d e l y  nor own used,  57  it  i s a system t h a t  considers and,  that  has i n v i t e d c r i t i c i s m .  i t i s a r b i t r a r y to focus  moreover, m i s l e a d i n g  since  somehow s e p a r a t e and i g n o r e s emergent p r o p e r t y concern i s that  that  and  "the n o v e l ,  dimensions they are  Peterson's  study, valid  this  t h e p r o b a b i l i t y o f chance  findings  these cautions,  bettered  and i s now  Hollandsworth  flawed construct  point  the t r i p l e  to bear  "As l o n g  with  specific  and f a l s e  a person's that  sense  alarms.  i t i s possible alarms,  on an i n d i v i d u a l b a s i s learned  subjects  will  experience. Rather  response.  Barlow's  It is a distinction  of a retrospective  such events as f a l s e  difficult  way  for its simplicity  h a d been h o p e d t o i n v e s t i g a t e f u r t h e r  makes on t h e b a s i s  are  modes  u s e s and d e f i n i t e  applicability".  in a general  As  i s p r e s e n t e d as a t e n t a t i v e and e v e n  or p r a c t i c a l  of true  i s not yet  as t h e t r i p l e  t h e n one n e e d n o t a p o l o g i z e  notion  system  i n the f i e l d .  limitations,  It  i n this  i n mind. However  response  firmly established  (1986) w r o t e :  of v i e w i n g t h i n g s  best f i t  W i t h t h e number o f h y p o t h e s e s  i s an i m p o r t a n t  (1984)  i n t h e number o f  c a n l e a d t o an e m p h a s i s on a few v a r i a b l e s t h a t  one's p r e c o n c e p t i o n s .  he  that  (1978)  i n t e r a c t i v e or  acquire".  the r e s u l t i n g increase  measurements i n c r e a s e s  on t h r e e  i t implies  patterns  Schwartz  interview.  to e s t a b l i s h that i t becomes much to determine  In t h i s  study  Though there  more  the causes of  i t i s anticipated  show a r a n g e o f a v o i d a n c e and than g e t t i n g embroiled  which  panic  in differentiating  58  claustrophobia  from agoraphobia,  b a s e d s o l e l y on closet  i n the  subjects' other  degree of anxiety  laboratory.  avoidance or  situations will  exclusion  from, the  A final sensitivity likely as  the  t o be  t o how  place.  experienced and  l e v e l s of e x p e r i e n c e d  anxiety  f o r i n c l u s i o n i n , or  t o be  briefly  discussed  is  Whether o r  not  study.  symptoms o f  anxiety. the  physical sensations  question  are  must be  triggered  Shear  might r e s u l t from  patients".  that  Reiss'  A way  those  i n the  and  first  susceptible  of measuring  little  frequently  evidence  to a p a n i c  Index and  are  bodily i s with  the  i n t e r o c e p t i v e exposure w i l l  for a  This  attack  such s e n s i t i v i t y  Sensitivity  panic  nonspecific  s e n s i t i v e to n o t i c i n g t h e i r  (1986) A n x i e t y  between t h i s  finds  are  answered  i n such p h y s i o l o g i c a l a c t i v i t y .  perhaps p a r t i c u l a r l y sensations.  they  (1988) i s t h a t  "transient,  However, she  primary disturbance then suggests  in  a basis  A h y p o t h e s i s p r o p o s e d by  panic  the  used,  p e r i p h e r a l p h y s i o l o g i c a l c h a n g e s w h i c h o c c u r more in  in  be  be  misinterpreted,  vulnerability  selection will  Though a s s e s s e d  not  construct to  subject  relation  be  particularly  noted.  It is ;  being  stressed  that  process research  a t h e o r e t i c a l . P r a c t i c e and  anxiety  disorders  from each o t h e r :  theory  i s not  i n the  have t e n d e d t o r e m a i n q u i t e advances  proposed  field far  i n p r a c t i c e have r a r e l y  of  removed been  as  59  derived  t h e o r y . What i s n e e d e d i s some c l e a r  evidence  w h i c h c a n have b e a r i n g on more t h a n one t h e o r i s t .  I t i si n  trying  from  t o meet s u c h a n e e d t h a t  planned,  the following  study has been  and emphasis p l a c e d on t h e i m p o r t a n c e o f  descriptive  as w e l l  as e x p e r i m e n t a l d a t a .  60  METHOD 1.  SAMPLE SELECTION  Forty-eight  p a r t i c i p a n t s were s e l e c t e d  community a f t e r e x t e n s i v e newspapers. T h i s the  advertising in local  publicity  stressed  (a) t h a t  s t u d y w o u l d be on t h e f e a r o f s m a l l  although  fears of l a r g e r spaces,  shopping malls,  (c) that  participants  confidentiality filled  visits  paid  and t a k e n p a r t  (b) t h a t  study  the  coping  that  having  answered a v a r i e t y o f  i n the three  session  and g i v i n g a d v i c e  intervention,  solely to  specifically  tailored to  needs o f each p a r t i c i p a n t .  Criteria  f o r exclusion.  Exclusionary treatment psychosis; including or  participants  and (d) t h a t  a minimum o f a f u r t h e r h o u r w o u l d be d e v o t e d answering queries  spaces,  i n which  I t was e x p l a i n e d  o u t some q u e s t i o n n a i r e s ,  questions,  enclosed  n o r were p a i d ;  was a s s u r e d .  the focus of  in a particular  t h i s was a r e s e a r c h  neither  r a d i o and  such as a i r c r a f t o r  m i g h t a l s o be e v i d e n t ;  w o u l d be t r a i n e d o v e r t h r e e strategy;  from t h e  criteria  were  (a) those c u r r e n t l y i n  f o r a mental d i s t u r b a n c e (b) t h o s e  or with a h i s t o r y of  s u f f e r i n g from a major  any c a r d i o v a s c u l a r  respiratory disease  those t a k i n g medication  (such  disorder  (such  illness as h y p e r t e n s i o n )  a s asthma o r b r o n c h i t i s ) ; ( c )  (other  than minor t r a n q u i l i z e r s )  61  that  could not  e i t h e r pregnant  Criterion  The  be d i s c o n t i n u e d ; and or  (e)  for  criterion  f o r i n c l u s i o n was  claustrophobic  o r more g e n e r a l f e a r  Scale  [VAS]  laboratory defined  r a t h e r t h a n on  s c o r e of more t h a n 0-100) a f t e r  two  tied  o f t h e UBC  years  student  specific  t h e b a s i s of any survey. 50  minutes  general  Subjects  (on a V i s u a l  as c l a u s t r o p h o b i c . Such a s c o r e  two  to the  exposure  t e s t - c l o s e t were, f o r t h e p u r p o s e s  percentile last  of  were  inclusion.  study  a fear  t h o s e who  epileptic.  demands o f t h e  reported  (d)  who  Analogue  to  the  of t h i s  i s above t h e  p o p u l a t i o n sampled o v e r  (Rachman, B o o t h ,  study, 99th the  & W h i t t a l , 1989).  2. MEASURES  The measures intervals and  a s s e s s m e n t was (seven  of three  s e t s of dependent  i n a l l ) t h a t were g i v e n a t  throughout  the i n t e r v a l s  presented  made up  i n Table  t h e s t u d y . A summary  different of these  measures  a t w h i c h t h e y were a d m i n i s t e r e d i s 1.  62  ASSESSMENT I  The  first  p a r t of the assessment c o n s i s t e d of a s i n g l e  measure a d m i n i s t e r e d and  at pre-intervention, post-intervention,  at follow-up:  The  Anxiety  This  Sensitivity  Index  i s a measure o f a n x i e t y  ( R e i s s , 1986)  sensitivity,  which  Reiss  e t a l (1986) h a v e d e f i n e d as "an i n d i v i d u a l d i f f e r e n c e variable anxiety  consisting causes  anxiety".  provoking it  experience anxiety Subjects  but i t s importance  likely  illness, item  (4 p o i n t s ) .  reliability  study  i s that  "very  little"  An i n d i v i d u a l ' s  e t a l (1986) have p r o v i d e d p r o p e r t i e s of the s c a l e , and v a l i d i t y .  include  embarrassment a n d l o s s  from  While  The s c a l e  consequences t o the  i s t h e sum o f s c o r e s on t h e 16  psychometric  anxiety-  i n this  o f a n x i e t y . These c o n s e q u e n c e s  r a t e each  important  o f becoming n e r v o u s " .  s p e c i f y i n g negative  or fear,  Reiss  t o have  "to increase a l e r t n e s s to s t i m u l i  the p o s s i b i l i t y  " v e r y much" Score  is likely  including motivation to avoid  i s considered  16 i t e m s  that the experience of  embarrassment o r a d d i t i o n a l  sensitivity  stimuli,  signalling has  illness,  Anxiety  consequences,  of the b e l i e f  additional of c o n t r o l .  ( s c o r e d as 0) t o  Anxiety  Sensitivity  items.  evidence  of the  demonstrating  i t i s similar  its  to other  "fear  63  of  fear" scales,  i t i s the  first  t o have b e e n shown  measure s o m e t h i n g d i f f e r e n t f r o m t h a t conventional  anxiety  between a n x i e t y note that  and  scales, anxiety  though high  sensitivity.  scores  on  with agoraphobia  disorders,  r e s u l t s from s t u d i e s  contradict  ASSESSMENT  The  the  focused  at p r e - i n t e r v e n t i o n , test  the  Behavioural  post-intervention,  fear  0-100  V i s u a l Analogue Scale  length sit  of  that  closet, subjects  t h e y were l i k e l y  t h e y were i n t h e heart  their  same  article  closet  the  of  five  Approach Test  (BAT)  follow-up,  at  and  space.  a  Before  predicted  the  to experience,  (for a period  m e a s u r e d by  with readings  r a t e measure was  their  made up  peak  using  a  (VAS).  r a t e was  earlobe  time b e f o r e  quietly with  strongly  anxiety  i n a second e n c l o s e d  laboratory  seconds: A h e a r t  to  association.  on  of  to  a unique  more  i n the  a s s e s s m e n t was  level  attached  reported  the  the  their  s c a l e are  of  entering  minutes),  I t i s important  than with other  view of  of g e n e r a l i z a t i o n  While  the  distinction  II  second p a r t  measures and  by  thus v a l i d a t i n g the  associated  clearly  measured  to  BAT,  also  a  taken  two  pulsemeter  taken every  when s u b j e c t s  eyes c l o s e d  of  15  for a similar were a s k e d  ( r e s t i n g heart  rate).  to  64  After (VAS  t h e BAT,  0-100), as w e l l  Subjects also Checklist, thoughts  Physical  as whether o r n o t  filled  (0-100%) w h i l e  and  percentage  and  each  (b) a  unpleasantness scales  for  to a s i n g l e by  score f o r  i t s accompanying  samples,  validity.  by  Cognitions  the r e l i a b i l i t y  of  these  The  measures  as w e l l as t h e i r d i s c r i m i n a n t and They draw a t t e n t i o n  to treatment,  and  to t h e i r  to the  stability  sensitivity  Changes made f o r t h i s  study  of  to are  r e l e v a n t to claustrophobia, notably c o g n i t i o n s t o e n t r a p m e n t , and  endorsed  by  Rachman & L e v i t t , on  the o m i s s i o n of  c l a u s t r o p h o b i c s ("I  someone"). W h i l e  available  they  total.  relating  hurt  and  t h e Body S e n s a t i o n s Q u e s t i o n n a i r e .  change w i t h t r e a t m e n t . additions  The  the Agoraphobic  a u t h o r s have d e m o n s t r a t e d  scores p r i o r  the  to which  a r e d e r i v e d from q u e s t i o n n a i r e s d e v i s e d  Q u e s t i o n n a i r e and  construct  including  item endorsed  summing t h e  Chambless e t a l ( 1 9 8 4 ) :  on c l i n i c a l  Cognitions  i n the c l o s e t ;  s e n s a t i o n s are reduced  scales  fear  panicked.  the degree  symptoms e x p e r i e n c e d .  by m u l t i p l y i n g  Both  t o mind, but  Symptoms C h e c k l i s t ,  cognitions  of  o n l y w h i c h commonly r e p o r t e d n e g a t i v e  were b r o u g h t  (0-100%) o f any  level  they  i n : (a) a N e g a t i v e  n o t i n g not  were b e l i e v e d  each,  subjects reported their  these  am  items  going b l i n d " ;  p r e v i o u s l y used  with  1 9 8 6 ) , no p s y c h o m e t r i c  this  data  adapted q u e s t i o n n a i r e s .  not "I  will  group  i s yet  (see  65  When t h e p o s t - i n t e r v e n t i o n  assessments had been  c o m p l e t e d , p a r t i c i p a n t s were a s k e d t o go a s e c o n d room where there the  was an e v e n s m a l l e r  e f f e c t s of each  first to was  t e s t - c l o s e t , used  to assess  i n t e r v e n t i o n had g e n e r a l i z e d .  c l o s e t , i t was s o u n d p r o o f  s i g n a l the return  Unlike the  a n d h a d no b u t t o n w i t h  o f t h e e x p e r i m e n t e r . The t i m e  a l s o c h a n g e d f r o m two m i n u t e s t o "a t i m e ,  drawn, between two a n d f o u r m i n u t e s " , a l t h o u g h a l w a y s two a n d a h a l f m i n u t e s  i n this  randomly this  was  i n p r a c t i c e . P a r t i c i p a n t s were  locked ("no  and l i g h t  o n , t o d o o r o f room c l o s e d ,  o f f ) , using  fear to t e r r i f y i n g  select  and c a r r y  they  second c l o s e t under s i x c o n d i t i o n s  d o o r s open a n d l i g h t  which  period  a s k e d t o make a s e t o f p r e d i c t i o n s a b o u t how a n x i o u s would f e e l  how  (from  closet  a V i s u a l Analogue S c a l e 0 - 1 0 0  fear").  They were t h e n a s k e d t o  o u t one o f t h e s e  conditions.  ASSESSMENT I I I  An  aim o f t h i s  frequently Since  there  training  s t u d y was t o m o n i t o r change more  t h a n by s i m p l y could  f o r two o f t h e g r o u p s ,  cognitions  report the  i n the feared  each s e s s i o n  before/after  be n o e x p o s u r e t o t h e c l o s e t  r e g u l a r measures o f h e a r t  after  recording  during  i t was n o t p o s s i b l e  rate, physical  sensations,  s e t t i n g . Assessment b e f o r e  o f t r a i n i n g was t h u s c o n f i n e d  measures, o f w h i c h a n x i e t y  most c e n t r a l . T h u s ,  measures.  once a g a i n  p r e d i c t i o n was using  a Visual  t o take and and  to selfconsidered Analogue  Scale,  a t t h e b e g i n n i n g a n d end o f e a c h  s u b j e c t s were a s k e d if  t o p r e d i c t how  training  anxious  session  they would f e  t h e y were t o go i n t h e c l o s e t f o r a two m i n u t e  period  67 Table  1  Summary a n d t i m i n g o f assessment-.  MEASURES Assessment I  (Anxiety  Assessment  II  (Predict/Report Anxiety) (Report p a n i c ) (Heart Rate) (Negative C o g n i t i o n s C h e c k l i s t ) (Physical Sensations C h e c k l i s t )  Assessment  I I I (Predict  Sensitivity  Index)  anxiety)  TIMING OF ASSESSMENT Assessment I Assessment I I Intervention: Beginning Beginning Assessment Assessment  PRE-TEST End o f S e s s i o n 1 and end o f S e s s i o n 2 and end o f S e s s i o n 3  Assessment I I I Assessment I I I Assessment I I I  I I I POST-TEST Assessment I I I  Assessment Eight  I I GENERALIZATION  weeks  Assessment Assessment  I I I FOLLOW-UP  68 3. APPARATUS  The but  laboratory  "closet"  well-ventilated f i l i n g  used  cabinet,  s m a l l d a r k room. A f t e r t h e c l o s e t experimenter shut darkness.  light  study  d o o r had been  signalled  ina  locked, the  room l e a v i n g i t i n  came f r o m a s m a l l  i f pressed,  was a s t u r d y  7'x 4'x 2', p l a c e d  the door of the outside  The o n l y  c l o s e t which,  i n this  switch  i n s i d e the  f o r the experimenter to  return.  The clinic  room u s e d  f o r g e n e r a l i z a t i o n was b o r r o w e d  where i t was u s e d a s a m o b i l e h e a r i n g  from a  laboratory. Its  d i m e n s i o n s were 6'x 2'x 2' and t h e s e a t and a l l i t s u s u a l equipment h a d b e e n  The  p u l s e meter used t o assess  HRM-97E. T h i s works clipped both  removed.  r a t e was a Sanyo  through a p h o t o - e l e c t r i c pulse  to the earlobe,  time and p u l s e  heart  yielding  a digital  r a t e . I t s range  a m i n u t e and i t i s a c c u r a t e  i s from  to within  sensor  d i s p l a y showing 38 t o 200  3% on e a c h  beats  beat.  4. PROCEDURE /  Subjects were s c r e e n e d over  responding for certain  the telephone.  t o r a d i o and n e w s p a p e r a d v e r t i s i n g exclusionary c r i t e r i a  Those i n v i t e d  ( s e e above)  t o come t o t h e c l i n i c  were  69  given  the p r e - i n t e r v e n t i o n  interview  and q u e s t i o n n a i r e s ,  the  assessment package which i n c l u d e d  and  a l l subsequent  as  well  as l e a d i n g  testing points, subjects  t h e BAT. A t t h i s  the p r e d i c t i o n s ,  o u t by an e x p e r i m e n t e r b l i n d t o s u b j e c t  and  t o o k no p a r t  The is and in  a f t e r subjects  i t had been e x p l a i n e d i t for a period  "only  illuminated  that  "high  had b r i e f l y  needed t o " should  participate  i f t h e d o o r was  part with both doors  any  way  study  obliged  locked,  consent  to take part,  a t any t i m e . T h o s e  closet  Subjects  who  told  P r a c t i c e use of refused  locked.  and c o u l d who  to  t h e y were n o t i n withdraw from the  d i d not stay  f o r t h e two m i n u t e s were n o t n e c e s s a r i l y  f o r a t l e a s t 30 s e c o n d s a t t h e f i r s t  willing  to stay  i n f o r t h e same l e n g t h  to take  T h e y were  i n the  excluded  f r o m t h e s t u d y . The minimum r e q u i r e m e n t s were t h a t in  that  a button  were e n c o u r a g e d  form t h a t  subjects  to stay  s i g n a l the  shut, but n e i t h e r  a s s u r e d on t h e e t h i c a l  seen t h e c l o s e t  they p r e s s  i n t h e c l o s e t , which would  b u t t o n was d i s c o u r a g e d .  demand". T h a t  t h e y were  e x p e r i m e n t e r t o l e t them o u t i m m e d i a t e l y . the  conditions,  t h e y w o u l d be a s k e d  o f some two m i n u t e s ,  i f they r e a l l y  reports,  i n any o f t h e i n t e r v e n t i o n s .  i n s t r u c t i o n s f o r t h e BAT were  t o say t h a t  first  t o and f r o m t h e c l o s e t , were a l l  carried who  and  they  stay  a s s e s s m e n t , and were of time a t a l l  s u b s e q u e n t BATs. S i m i l a r l y , t h o s e on whom t h e d o o r was n o t locked, all  went  i n t o the c l o s e t under  subsequent  assessments.  identical  conditions at  70  Subjects of  whose r e p o r t e d  more t h a n  0-100) were a s k e d t o p a r t i c i p a t e i n t h e  l o w e r f e a r l e v e l s were t o l d s i t u a t i o n was  own  f e a r s and  the  opportunity  Subjects one  of t h e  that  lower than t h a t  were t h e n g i v e n  to  f e a r was  at  how  least these  t o ask  included  an  their  50  study.  anxiety  currently being  (on Those  in  any  best  be  VAS with  this  studied.  hour's c o u n s e l l i n g about  might  a  They  their  h a n d l e d , as w e l l  as  questions.  i n the  four groups:  study  (a)  (b)  were r a n d o m l y  exteroceptive  assigned  exposure  i n t e r o c e p t i v e exposure  (c) a pure c o g n i t i v e i n t e r v e n t i o n . (d)  I n the explanation be  exteroceptive o f how  particularly  spent  with  light  sessions  appropriate  f o r each less  the  i s a good  d i s c u s s i n g what we  from the  individual  to the  of the  and  s u s c e p t i b l e t o p i c k i n g up  i m p l e m e n t i n g an created  e x p o s u r e g r o u p , t h e r e was  a fear i s learned,  which claustrophobia was  a c o n t r o l group  on,  humans seem  certain fears  example. The  bulk  know a b o u t e x p o s u r e  of  so  t h a t exposure c o u l d  locked  items light  used  for  time  was proceed  (e.g. d o o r wide o f f ) over the  assessment.  of  the  i n t e r v e n t i o n . A l l exposure took p l a c e  same c l o s e t t h a t was  to  and  programme. A h i e r a r c h y  more f e a r e d  to door  how  an  open three in  the  71  In the i n t e r o c e p t i v e group, acquisition  emphasized  merely of s i t u a t i o n s ,  the explanation  how e a s i l y  one c a n p i c k up f e a r n o t  but of sensations  A h i e r a r c h y was f o r m e d  i n a similar  exercises  Subjects  were g i v e n  (some p i o n e e r e d  related  to anxiety.  fashion to the  e x t e r o c e p t i v e group, but of s e n s a t i o n s situations.  of fear  brief  by Z a r a t e ,  rather  than  exposure t o a range of Personal  Communication,  M a r c h 1989) w h i c h b r i n g on t h e p h y s i c a l s e n s a t i o n s be  experienced  (through and  a straw with  running  individual the  another.  resembling  those  and i n c o m b i n a t i o n  sensations, related hyperventilation  by t h e while i n  h i e r a r c h y . T h e y were  t o most a n x i e t y - p r o v o k i n g  To m a i n t a i n  spinning  experienced  f o r i n c r e a s i n g l y extended periods  isolation,  underbreathing  The e x e r c i s e s i d e n t i f i e d  formed t h e s e n s a t i o n s  from l e a s t  practiced  These i n c l u d e d  nose h e l d ) , o v e r b r e a t h i n g ,  on t h e s p o t . as c l o s e l y  closet,  ordered  when a n x i o u s .  l i k e l y to  with  a n d were of time, i n  one c l o s e l y  following  a maximum emphasis on e x p o s u r e t o t h e coping  training  s t r a t e g i e s such as ( w i t h f e a t u r e s such as paced  r e s p i r a t i o n ) were n o t i n c l u d e d . O t h e r t h a n  i n answer t o  direct  m e n t i o n made o f  enquiry,  cognitions, and  n e i t h e r was t h e r e  explicit  nor the c o g n i t i v e l i n k s  between s u c h  sensations  catastrophic misinterpretations.  In t h e c o g n i t i v e group, initial  i t was e m p h a s i z e d  e x p l a n a t i o n how i m p o r t a n t  provocation  of anxiety.  Subjects  i n the  t h o u g h t s c o u l d be i n t h e l e a r n e d how t o i d e n t i f y  72  automatic the  t h o u g h t s , and d i s c u s s e d  those experienced  a s s e s s m e n t and how t h e s e m i g h t have c o n t r i b u t e d  anxiety.  chair  their  own  irrational  thinking),  exposure,  i n thinking  ("links" faint";  t o i d e n t i f y and d e a l  dispute  to help  thoughts r e l a t e d  suffocating")  breathless  as w e l l  took p l a c e  therefore  the p o s t - t e s t  following  as t h o s e w i t h o u t  interventions first an  included  participants while  sensations  i n here"?).  training  the pre-test  took p l a c e  the second  the d i r e c t i v e that  assessment,  A s s e s s m e n t s and three  shorter  v i s i t s , the  at just since  Instructions  over  i t also a t the  as f a r as p o s s i b l e  s h o u l d n o t seek o u t c l a u s t r o p h o b i c  t h e s t u d y was i n p r o g r e s s  session  immediately  a g a i n a b o u t two h o u r s  t h e t e s t of g e n e r a l i z a t i o n .  included  how t o  s u c h an a s s o c i a t i o n  were t h u s c a r r i e d o u t w i t h i n  some two h o u r s l o n g ,  Information  I am l i k e l y t o  the f i r s t  training session.  hour, and the t h i r d  outset  following  assessment  the t h i r d  logical  a n d so I am i n d a n g e r o f  interventions,  immediately  anxiety.  to physical  ("What h a p p e n s i f I am f o r g o t t e n / t r a p p e d  In a l l t h r e e  with  the process of learning  s u c h as " I f e e l d i z z y "I f e e l  out of  t h e a i m was f o r c l i e n t s t o  as a way o f r e d u c i n g  s h e e t s were p r o v i d e d rationally  and t h e  ( t r y i n g t o p e r s u a d e an " i m a g i n e d o t h e r "  learn, without errors  to their  W i t h t h e u s e o f methods s u c h as f l a s h c a r d s  third  and  during  experiences  73  All  three  therapist  who  psychologist, supervised Pilot  had  as w e l l as  every  third  treatment  A d a t e was  the  by  t o an  up  and  s e s s i o n was integrity  asked to  c l o s e t f o r one  therapy.  to  improve  I t was  fill  final  out  questions  that  they  a w r i t t e n and the  should  like  at  that  to  own  time.  subjects re-  followed  preliminary  f e a r s , as w e l l as  to ask.  third  a s s e s s m e n t s and  study,  verbal explanation  study  the  t i m e . T h i s w o u l d be the  could  K).  explained  the  the  study  so t h a t c h e c k s  (see Appendix  hour of d i s c u s s i o n of  of  clinical  extensive  discussed  taped  implications for their  procedures  as a  same  i n t e r v e n t i o n s . Once t h e  findings,  given  the  s e t some s i x t o e i g h t weeks a f t e r  w o u l d be  enter  years  received  f o r a r e t u r n appointment. they  by  in cognitive-behavioural  of a l l three  made on  that  having  s e s s i o n s were a l l t a p e d  started,  visit  worked f o r t h r e e  experience  efficiency  be  i n t e r v e n t i o n s were g i v e n  any  P a r t i c i p a n t s were of the  aims  and  74 HYPOTHESES  EXPERIMENTAL STUDY: HYPOTHESES The  hypotheses  stem f r o m f o u r  questions  which a r e posed  below.  Set  1. Do t h e t h r e e  interventions  differ  from t h e  c o n t r o l group a t p o s t - t e s t ?  I t was t h o u g h t t h a t the of  scores  regression  t h a t may w e l l  likely  avoidance,  as w e l l  as a l l a y i n g etc,),  t o some r e d u c t i o n  i n view o f t h e i r  i n scores  of the seven v a r i a b l e s  reported and  heart  superior  panic, rate)  should  that  a general  cognitions,  rather  i t was t h o u g h t t h a t  i n t e r v e n t i o n was l i k e l y significantly.  interventions  t o be change  fear, reported unpleasant  interventions  only  t h a t on fear,  sensations  w o u l d be  the Anxiety  than a s p e c i f i c  to reduce  Specifically,  l i k e l y to  I t was h y p o t h e s i z e d  (predicted  the three  (distrust  show s i g n i f i c a n t  t o t h e c o n t r o l group. Since  Index r e f l e c t s anxiety,  negative  anxiety  e v e n i n t h e a b s e n c e o f an  f o r these  they  exposure  widespread  of a d d i t i o n a l fears  o v e r and a b o v e s u c h improvement. six  brief  were a l l c o n s i d e r e d  Nevertheless,  shown t o be e f f e c t i v e ,  contact,  n o t be t h e t o p o f t h e i r  overprediction  the experimenter,  intervention.  i n a d d i t i o n to the e f f e c t  t o t h e mean. T h e r a p i s t  hierarchy,  lead  w o u l d be some improvement i n  o f t h e c o n t r o l group,  to a stimulus  of  there  Sensitivity r e a c t i o n to  the i n t e r o c e p t i v e scores  on t h i s  t h e p r e d i c t i o n s were  measure that:  75  The  three  reduction seventh  on  interventions  six variables  (the  Anxiety  group alone would the  control  Set  2  other at  the  the  other.  three  superior  other The  influence  and  two  cognitions In a d d i t i o n  is likely  to reduce,  reports  anxiety  on  usual the  that:  return  o t h e r hand, w i t h w o u l d be  unpleasantness Anxiety  interoceptive  i n scores  compared  with  of  two  groups  on  More i n t e r e s t relate  and  from  each  to  the of  a l l but  i t has  would f o c u s  e x p o s u r e and expected  "sleeper"  each  to panic  The  expected to reduce the and  Index. S p e c i f i c a l l y  and  i n place  interoceptive  focus  on  of  group  physical  reported  scores  the  the  effect,  follow-up period,  sensations  on  been proposed t h a t  constant, predictions  fear.  be the  to reduce r e p o r t e d  i t s exclusive  physical  Sensitivity  differ  exposure group would  t o have a  or h o l d  during  d e g r e e of  sensations,  the  i n t e r v e n t i o n w o u l d be  continuing  the  other  interventions  reported  group  the  Sensitivity.  cognitive  of  Index),  the  follow-up?  to the  even a t p o s t - t e s t . cognitive  c o n t r o l g r o u p . On  interventions  a n t i c i p a t e d that  Index o f A n x i e t y how  Sensitivity  show a r e d u c t i o n  post-test  equal or  than the  a b o u t a more marked  group.  Do  I t was  would b r i n g  on  the  predictions  were  76  The on  e x p o s u r e and c o g n i t i v e  scores  The scores  of reported  panic  and r e p o r t e d  post-test  than the o t h e r  cognitive  group would a l s o  g r o u p on t h e s e  cognitive  group.  the  rate at  be s u p e r i o r  to the interoceptive  groups would  sensations  than the  g r o u p w o u l d show a g r e a t e r  on t h e A n x i e t y  Sensitivity  Index  show more  reduction  than e i t h e r of  o t h e r two g r o u p s .  Set is  reduction i n  two g r o u p s , b u t by f o l l o w - u p t h e  on p h y s i c a l  interoceptive  scores  reduction  cognitions.  f e a r and h e a r t  exposure and i n t e r o c e p t i v e i n scores  in  show  measures.  reduction  The  and n e g a t i v e  e x p o s u r e g r o u p would show g r e a t e r  of p r e d i c t e d  The  groups would  3  reduced  This  a difference  i n the three  third  self-report sessions  Is there  groups  that  become a p p a r e n t .  i s focused  fear  on c h a n g e s i n  o c c u r b e f o r e and a f t e r  of the i n t e r v e n t i o n .  concerns the timing  a t which  (measured a t s i x p o i n t s ) ?  s e t of hypotheses  anxiety  i n the r a t e  individual  The most i m p o r t a n t  a t which the e f f e c t s  I t h a s been a r g u e d t h a t  o f an  question  intervention  t h e c o g n i t i v e and  77  i n t e r o c e p t i v e groups a r e l i k e l y anxiety, out  only  anxiety three  BAT.  that  should  training  gradual  sessions,  hand, l i t t l e  groups u n t i l  have had t h e c h a n c e  i n the p o s t - t e s t  the l a r g e s t decrement coming  (the longest  period  s u c h change s h o u l d  be s e e n i n t h e o t h e r  t h e measure i s taken a f t e r  At  of s i x measuring p o i n t s ,  i n predicted  Set  the p o s t - t e s t  that:  there  w o u l d be a  f e a r i n the exposure group. At the  s i x t h measuring p o i n t , cognitive  during  o f e x p o s u r e ) . On t h e  t h e p r e d i c t i o n s were  reduction  predicted  i n the exposure group over the  Specifically  the t h i r d  t o check  BAT. Thus i t was  changes i n s e l f - r e p o r t  be e v i d e n t  second s e s s i o n  other two  subjects  what t h e y have l e a r n e d  predicted  the  after  t o show a r e d u c t i o n i n  there  w o u l d be a r e d u c t i o n  i n the  and i n t e r o c e p t i v e g r o u p s on t h e same m e a s u r e .  4  Do t h e f o u r  groups d i f f e r  on m e a s u r e s r e l a t e d t o  generalization?  A feature  of t h i s  generalization. participants different  After  rate  conditions,  the  that  i s i t s c o n s i d e r a t i o n of  the p o s t - i n t e r v e n t i o n  a second enclosed  which they would e n t e r predicted  study  assessment  space under s i x  a n d choose one o f s i x " l e v e l s " i t f o r a short  the three  period  of time.  under Iti s  i n t e r v e n t i o n s w o u l d be s u p e r i o r t o  c o n t r o l g r o u p on t h e s e two m e a s u r e s o f g e n e r a l i z a t i o n .  78  A  PHENOMENOLOGICAL STUDY OF  In a d d i t i o n the  emphasis on  to  descriptive  learned  of  n a t u r e of  since  so  preliminary  step,  i t was  of see  the  questionnaires  w h i c h were t h e  moving to included  the  The  s o r t of  s u c h as  events,  of  this  on  as  the  others,  fear.  to  look  cognitions  structured o n s e t of  well  which  security and  taken  to  of  be  this  t o e s t a b l i s h some  s t e p was  both  suffocation  i n agoraphobia,  p r e s e n c e of of  intended  the  part  i s known a b o u t t h i s f e a r . As  as  at  and  the  and  fear  can of  seems t o be  what a r e  the  be  facts  sensations  fear,  a  results to  before  interviews  a r e a s of  that  the  items,  which  likely  current  i l l u m i n a t i o n was  whether t h i s i s a f e a r  between f e a r as  on  as  much c o u l d  from  most commonly e n d o r s e d  r e s u l t s of  issues  also  hoped t h a t  claustrophobia  next on  information  precipitating  I t was  little  sample. The  s t u d y , and  o p p o r t u n i t y was  data.  information  about the  experimental  process,  collect  the  the  CLAUSTROPHOBIA: OUTLINE  avoidance.  sought,  split  were  cleanly  entrapment,  whether,  gained  the  from  major c o g n i t i v e  themes  79  RESULTS  In t h i s main s e c t i o n o f presented  f o r the  four  have been b r i e f l y  Alpha important favoured Since  level  s e t s of  The  setting  of  studies w i l l  be  need n o t  an  be  research,  the  reduced,  important  and  is a risk  duly  followed  that up.  An  is  an  often  justification.  of a s e r i e s of  risk  of  o v e r r i d i n g importance Indeed  noted  issues  however, where  as p a r t  tested again,  have t h e  level  appropriate  t e n t a t i v e and  fully  alpha  assume i n some c i r c u m s t a n c e s . there  are  two  have p e r h a p s t o o  bias without  i s exploratory will  the d a t a  discussed.  a liberal  conclusions  results,  hypotheses a f t e r  decision. Clinicians  this  errors  the  Type I i t must  i f power i s o v e r l y  alpha  threads  of  .05  is  might not  be  considered  appropriate.  Missing  data  session  (one  group).  I n one  postponing it  fell  i n the  outside  subjects  one  only  i n the  the  interoceptive  f o r such a l o n g  time boundaries  offered a  s e t . In the  job o u t s i d e  before  other  departure.  other, did  that the not  about  T h e s e p a r t i c i p a n t s were  replaced.  The  (from  i n t e r o c e p t i v e group) r e f u s e d  the  only  her  the  period  V a n c o u v e r and  to-''delay g e t t i n g a l l p o s s i b l e i n f o r m a t i o n  claustrophobia  first  domestic problems n e c e s s i t a t e d  second v i s i t  the  attended  e x p o s u r e and  case,  of her  i n d i v i d u a l was want  Two  complication  was  that  t o go  one  subject  i n t o the  closet  80  at  follow-up  and  so was  unable  m e a s u r e s a t t h a t p o i n t . The clear  and  trial, in  expressed  her  h e a r t was  again,  and  excellent pointed her  she  article  out  Question the  reduction seventh,  had  no  three on  The  previous of  going  panic.  In  an  i t is omitting  The  duly  s c o r e s w h i c h she  these  followed,  had  endorsed  f o u r measures.  first  q u e s t i o n were  i n t e r v e n t i o n s w o u l d b r i n g a b o u t a more marked  s i x v a r i a b l e s than  (the ASI),  the  the  control  g r o u p . On  the  i n t e r o c e p t i v e group alone would  compared w i t h  the c o n t r o l  ( c o v a r y i n g out  performed  to t e s t  significant  (Pillais)  E  (49,  f o r an 259)  show  group.  the p r e - i n t e r v e n t i o n overall  = 2.35,  £  effect  and  was  <.001. Means  and  d e v i a t i o n s f o r a l l seven v a r i a b l e s are p r e s e n t e d  2 and  c o v a r i a n c e - a d j u s t e d means a r e p r e s e n t e d  in  in  L.  A series the  the  a mean s c o r e o r  quite misleading.  s c o r e s ) was  Appendix  on  (Howard e t a l , 1986)  p r e d i c t i o n s f o r the  A one-way MANCOVA  Table  were  panicked  either  same h i g h  a reduction i n scores  standard  refusal  f o r her  i n s t a n c e , w h i c h was  o c c a s i o n on  1.  the  d e s i r e t o have another  on a t t r i t i o n  the  the p r e v i o u s  had  three of  a l r e a d y r a c i n g a t the p r o s p e c t  for this  to g i v e her  that  She  s t u d y w o u l d be  recommendation  on  reasons  that g i v i n g her  from the  was  fully.  to complete  o f u n i v a r i a t e ANCOVAs were t h e n  p o s t - i n t e r v e n t i o n d i f f e r e n c e s , one  performed  f o r each of  the  on seven  81  dependent covaried of  variables,  o u t . The r e s u l t s  are presented  fear, negative  finely  warranted. For each o f t h e s e  significant,  u s i n g Dunnett's procedure  was  compared w i t h  necessary  the  found t o  were  with the  adjustment f o r the c o v a r i a t e (see K i r k ,  results  i n Table 4 .  o f p r e d i c t e d and r e p o r t e d  cognitions, unpleasant  ( a l l a t c <.01)  sensations  1982,  show t h a t t h e e x p o s u r e g r o u p was l o w e r  heart r a t e , negative  physical  main e f f e c t s  a l l other groups),  c o n t r o l g r o u p on s c o r e s  cognitive  analyses  ( s i n c e the c o n t r o l group  p.735). T h e s e c o m p a r i s o n s a r e p r e s e n t e d  The  physical  grained  follow-up m u l t i p l e comparisons  conducted being  significant:  c o g n i t i o n s , unpleasant  a n d h e a r t r a t e a t £ <.05. More  were t h u s  3. F o r s i x  a t p. <.001, r e p o r t e d f e a r a t £2 <.01 a n d r e p o r t e d  sensations panic  being  i n Table  t h e s e v e n v a r i a b l e s t h e s e ANCOVAs were  predicted  be  the p r e - t e s t s c o r e s again  sensations  on n e g a t i v e  fear,  physical ( B <.05). T h e  and r e p o r t e d p a n i c  group had lower s c o r e s  than  c o g n i t i o n s and  ( b o t h a t £ <.01), a n d r e p o r t e d f e a r a n d  (e <.05). The i n t e r o c e p t i v e g r o u p h a d l o w e r s c o r e s on  panic  negative  c o g n i t i o n s and p h y s i c a l s e n s a t i o n s  (both a t E  <.05).  The  e x p o s u r e g r o u p showed a b r o a d  reduction  i n scores  cognitive  group, i t i s o f note t h a t t h e r e p o r t s o f f e a r ,  rather  than  in relation  and e x p e c t e d  i t sprediction,  t o t h e c o n t r o l group.  were s i g n i f i c a n t l y  In the  reduced and  82  that  heart  rate  r e m a i n e d unchanged.  Changes i n t h e  i n t e r o c e p t i v e g r o u p were more modest, and  only  those i n  reported  the  assessment  reached the  cognitions statistical  prediction  would  that  be r e d u c e d .  and  sensations during  significance. ASI  scores  T h e r e was  no  support f o r  i n the i n t e r o c e p t i v e  group  83  TABLE 2 Means and s t a n d a r d d e v i a t i o n s f o r s e v e n p r e - and p o s t - i n t e r v e n t i o n f q u e s t i o n 11  PREDICTED  FEAR  CONTROL EXPOSURE INTERO COGNITIVE  Pre 87 84 82 83  CONTROL EXPOSURE INTERO COGNITIVE  CONTROL EXPOSURE INTERO COGNITIVE SENSATIONS  MEAN HEART RATE  ASI  /  CONTROL EXPOSURE INTERO COGNITIVE  2) 8) 8) 4)  Pre  . . . .  ( 22 2) (24. 9) ( 26 ,6) (10 7)  (33 ( 20 (32 (12  2) 4) 5) 0)  75 (0 87) 08 (0 29) 50 (0 67) 25 (0 45) Post  (247, 2) ( 215 ,5) (187 , 0) (180 , 6)  Pre  251 18 81 29  00 (244 ,3) 83 ( 32 ,9) 33 (128 5) 50 ( 40 ,7)  Post  396.00 286.92 360.67 386.17  (375.1) (230.7) (233.4) (263.8)  Pre 99.67 93.25 93.58 98.58  33 00 33 83  52 . 59 15.92 34 . 41 21 . 00  (0.79) (0.74) (0.52) (0.62)  42 75 58 25  (23 (23, (20 (24,  259 38 126 69  ,50 (254 2) ( 39 2) ,00 ,83 (135 4) ( 64 6) ,92  Post 4) 9) 3) 9)  Pre 29.58 23.08 24.16 27.16  67 25 51 49  Post  Pre 273 300 187 244  CONTROL EXPOSURE INTERO COGNITIVE  CONTROL EXPOSURE INTERO COGNITIVE  (17 (15 (13 (19  1.92 2.0 0 1.58 2.3 3  NEGATIVE COGNITIONS  2) 5) 1) 7)  Post  50 83 25 33  REPORTED PANIC  PHYSICAL  (17. (14 (21 (22,  Pre 76 78 78 75  CONTROL EXPOSURE INTERO COGNITIVE  Post  .33 . 83 . 58 . 16  REPORTED FEAR  variables  (5.4) (7.2) . (13.0 ) (8.6)  97 79 87 90  08 50 75 83  (18 (12 (11 (23  2) 4) 3) 1)  Post 25 18 20 23  33 (10.6) 67 (5.8) ,41 (10.5) 92 (9.3)  84  Table  3  Univariate the  ANCOVAS on  four groups  post-intervention  fpre-assessment  Dependent v a r i a b l e Predicted  scores  £ value  covaried  43)  between  out)  p.  7.64  <.001  4.82  <.01  Reported panic  3.99  <.05  Negative c o g n i t i o n s  8.81  <.001  6.73  <.001  3.39  <.05  0.26  >.05  Reported  fear  (3,  differences  fear  Unpleasant p h y s i c a l  sensations  Heart Rate Anxiety  Sensitivity  Index  85  Table 4  S i g n i f i c a n c e of the d i f f e r e n c e s interventions adjustment  and t h e c o n t r o l g r o u p  f o r the  t  three  fDunnett's  t values  Cognitive  a  £  1.85  1.66  3.51**  2.94*  1.76  Reported panic  2.93*  2.55*  0.65  Cognitions  4.66**  4.12**  2.76*  Sensations  3.94**  3.81**  2.90*  Heart r a t e  3.17**  1.28  1.35  ASI  0.67  0.15  fear  The c r i t i c a l <.05. **p. < . 01  with  Interoceptive  4.70**  Reported  fear  the  covariate)  Exposure  Predicted  between  t v a l u e s were 3.09 f o r p. <.01 *p_ < . 05  0.32  and 2.44  f o r p.  86  Question differences and  2 The  between t h e  f o l l o w - u p . The  analyses  second  q u e s t i o n focused  c o n t r o l g r o u p was  s i n c e i t d i d not  continue  not  to  included i n these  follow-up.  MANCOVA was  first  p r e - i n t e r v e n t i o n scores are c o v a r i e d out)  g r o u p s a t p o s t - i n t e r v e n t i o n and b e t w e e n - g r o u p s f a c t o r was and  the  three groups at p o s t - i n t e r v e n t i o n  A two-way b e t w e e n - w i t h i n (the  on  the within-groups  levels). p. >.05;  The  f a c t o r was  deviations  £  (7, 27)  = 3.2,  are presented  A series  £  (14,  56)  p. <.05.  i n Table  (14,  time,  results  6.  (two  42)  = 1.97,  f o r g r o u p was  =  p.  Means and  the  and  1.77, <.05;  standard  same b e t w e e n on  f o r time.  each  The  Since the m u l t i v a r i a t e  non-significant  (as n o t e d  none o f t h e g r o u p m a i n e f f e c t s were examined univariate  levels),  a b o v e , were t h e n p e r f o r m e d  i n Table  three  i s the  (three  £  out  5.  d e p e n d e n t measure f o r g r o u p by are presented  the  measurement t i m e  o f u n i v a r i a t e ANCOVAs, w i t h  wi t h i n d e s i g n as n o t e d  main e f f e c t  group  r e s u l t s were G r o u p : P i l l a i s  Time: P i l l a i s  on  follow-up. That  treatment  Group by Time: P i l l a i s  carried  in  above),  these  ANCOVAs.  In^no c a s e  was  x time  interaction.  effect  f o r time.  intervention  there a s t a t i s t i c a l l y For  significant  f o u r of the v a r i a b l e s  Averaged  to follow-up,  a c r o s s groups from s c o r e s were l o w e r  group  t h e r e was  an  post a t the  latter  point  for predicted  higher  on r e p o r t e d  Overall predictions time  fear fear  t h e r e was for this  interactions.  and on t h e A S I , b u t s c o r e s were and h e a r t  no  support  question  rate.  found f o r the  a l l of which  specific  involved  group  88 T a b l e 5. Means and s t a n d a r d d e v i a t i o n s at p r e - i n t e r v e n t i o n . p o s t - i n t e r v e n t i o n ,  PREDICTED  FEAR  Pre  EXPOSURE INTERO COGNITIVE  (14.5) (21.1) (22.7)  Pre  EXPOSURE INTERO COGNITIVE  (15.8) (13.8) (19.4)  Pre 2 00 1 58 2 33  (0.74) (0.52) (0.62)  EXPOSURE INTERO COGNITIVE MEAN HEART RATE EXPOSURE INTERO COGNITIVE AS I EXPOSURE INTERO COGNITIVE  (215.5) (187.0) (180.6)  Pre  286.92 360.67 386.17  15 92 34 41 21 00  1.08 1.5 1.25  (20.4) (32.5) (12.0)  Pre 23 . 08 (7.2) 24.16 (13.0) 27.16 (8.6)  (27.0) (33.8) (30.5)  1.25 (0 45) 1.5 (0 67) 1.25 (0 45 )  (32.9) 57.75 (83.8) (128.5) 99.42 (118) (40.7) 22.16 (27.1)  (230.7) 38.00 (39.2) (233.4) 12 6.83(135.4) (263.8) 69.92 (64.4)  93.25 (23.9) 93 . 58 (20.4) 98.58 (24.9)  27.00 39.08 34.58  Follow-up  Post  Pre  (21.5) (28.7) (22.9)  Follow-up  (0.29) (0.67) (0.45)  18.83 81.33 29.50  22.41 47.50 28.50  Follow-up  Post  300.75 187.58 244.25  PHYSICAL SENSATIONS  (24.9) (26.6) (10.7)  Post  NEGATIVE COGNITIONS P r e EXPOSURE INTERO COGNITIVE  25.00 51.33 49.83  Follow-up  Post  78.83 78.25 75.33  REPORTED PANIC EXPOSURE INTERO COGNITIVE  Post  84.83 82.58 83.16  REPORTED FEAR  f o r seven v a r i a b l e s and a t f o l l o w - u p  Post 79.50 (12.4) 87.75 (11.3) 90.83 (23.1) Post 18.67 ( 5 . 9 ) 20.41 (10.5 23.92 (9.3)  Follow-up 54.20 155.25 55.42  (79.9) (180.8) (80.7)  Follow-up 80.25 98.08 96.33  (13.6) (17.5) (23.2)  Follow-up 17.08 ( 5 . 6 ) 19.25 (11.9) 19.33 (10.9)  Table 6  Univariate between  ANCOVAs  the three  frepeated  m e a s u r e s ) on  intervention  time, at p o s t - i n t e r v e n t i o n  and  groups,  fear  f o r time,  and g r o u p x  follow-up.  F Predicted  differences  TIME (1,33)  GRP X TIME F (2,33)  4.96*  2 .12  Reported  fear  6.16*  0 .45  Reported  panic  0.48  0 . 48  Negative  cognitions  2 .65  1 .73  1. 42  1 . 08  7 . 77*  1 . 95  5.71*  1 .11  Unpleasant Heart  rate  ASI  *p_ < . 05  sensations  90  Question that be  the  3 In  timing  different  a reduction  of  i n the  and  i n the  sixth  time  point.  the  reduction  of  cognitive  time p e r i o d s  Before  day the  hypothesis  interventions.  and  first  the  in fear predictions  the  were as  the  intervention,  Time 2:  three  scores  Time 1 : A f t e r to the  t h i r d question,  between t h e  three,  The  the  was would  There would  exposure group at interoceptive  be  time  groups at  the  follows: assessment, b e f o r e  introduction  1. main s e s s i o n  of  the  intervention,  2.  day  Time 3:  After  Time 4:  Before  the  main s e s s i o n  of  the  intervention,  day  2. day  day  the  final  session  of  the  intervention,  3 . Time 5 :  After  the  final  Time 6:  After  the  post-intervention  session  of  the  intervention,  3  Means and  standard deviations  the  s i x time p o i n t s  are  graphed  The analysis factor  are  in Figure  presented  of  a s s e s s m e n t , day  the  three  in Table  groups  7 and  the  at  means  1.  e x p e r i m e n t a l d e s i g n was  a  of  levels  of  the  between  six levels  of  the  within  variance,  ,3.  with three  ( t r e a t m e n t g r o u p ) and  3 x  6  between-within  factor  91  (time p o i n t ) . been v i o l a t e d , (Chi  square  <.001. The  To  test  i f the assumption  a Mauchly  = 56.84, d f  sphericity = 14  of s p h e r i c i t y  t e s t was  ) and was  carried  was  thus  (hence t h e change i n t h e d e g r e e s o f f r e e d o m )  was  then c a r r i e d  The  results  (6.65,  109.77) = 3.48,  on  were: f o r t h e e x p o s u r e g r o u p £ group E  11.48, f2<.05; f o r t h e i n t e r o c e p t i v e  used  the r e p e a t e d  p. <.01.  out f o r simple main e f f e c t s  28.60, p.<.01; f o r t h e c o g n i t i v e  out  s i g n i f i c a n t a t p_  Greenhouse-Geisser c o r r e c t i o n  m e a s u r e s ANOVA, E  had  f o r each  (3.33,  ( 3.33,  group E  Analysis group.  109.77) =  109.77) =  ( 3.33,  109.77) =  10 . 47, p< . 05 .  S i n c e t h e s e were s i g n i f i c a n t f o r a l l t h r e e g r o u p s , i t was  justified  comparisons  to t e s t  on w h i c h  the s i g n i f i c a n c e the p r e d i c t i o n s  had been  specified  a priori  and t i m e  3 i n the exposure group,  t i m e 6 i n t h e o t h e r two  of s p h e r i c i t y  and  g r o u p s ) and  between t i m e  since  f o r each c o n t r a s t .  presented  i n table  W i t h i n each group  reduction  came a t t h e s e p r e d i c t e d  reached/statistical (1,  11)  significance:  and  error  data are  the l a r g e s t  mean  i n each  case  i n the exposure group  = 20.97, p. <.001; i n t h e c o g n i t i v e  < . 025 .  the  separate  The  points,  27.56, p. <.001; i n t h e i n t e r o c e p t i v e P.  5 and  t h e y were  violated,  terms were c a l c u l a t e d 8.  between time 2  were u s e d . B e c a u s e  had been  pairwise  focused. Since these  (the d i f f e r e n c e  orthogonal, p l a n n e d comparisons assumption  of the three  group E  group E  E  (1, H )  ( 1 , 11)  =  8.94  =  92  The  predictions  predictions as the  further  of t h a t  i n t e r v e n t i o n was  i n the c o g n i t i v e  two m i n u t e s  interoceptive deviation  of these r e d u c t i o n s  i n t h e t e s t - c l o s e t , was  The l o w e r l e v e l group r e f l e c t s  i n that  group.  fear were  after  statistically  and i n t e r o c e p t i v e  a f t e r the second assessment, which  significant.  were  In the exposure group, the r e d u c t i o n  period  significant; reduction  t h u s c o n f i r m e d . Not o n l y  reduced, but the timing  hypothesized. longest  were  groups the  included  a  also  of s i g n i f i c a n c e a t t a i n e d once a g a i n t h e l a r g e r  i n the  standard  93  Table  7  P r e d i c t e d a n x i e t y a t s i x time p o i n t s f r e - t e s t between t i m e 5 and t i m e 6)  Time  Exposure  1  Time  2  Time  3  during  Time  fear  4  reduction  Time  5  Time 6  70.25 (22.27)  57.25 (26.52)  29.00 (24.29)  23.50 (14.07)  16.25 (14.06)  (  9.00 7.86)  Cognitive  60.25 (23.89)  65.75 (21.48)  48.33 (19.92)  49.58 (22.81)  44.17 (15.64)  21.67 (20.15)  Interoceptive  72.42 (15.87)  61.67 (14.82)  50.42 (17.89)  54.17 (20.87)  54.17 (22.42)  28.25 (30.11)  PREDICTIONS OF FEAR AT 6 TIME POINTS  95 Table 8  Planned  comparisons  i n t e r v e n t i o n s  O_Q  f O u e s t i o n  $_h_S  timing  2j  change  in  the  t h r e e  U.  Contrast  Mean Difference  MSres  f_ ( 1 , 11)  p_  Exposure  Time 2-Time 3  28.25  228.38  20.97  p_<.001  Cognitive  Time 5-Time 6  22.50  110.23  27.56  pX.OOl  25.92  450.95  8.94  p_<.025  Interoceptive Time  5-Time 6  96 Question  The three on  4.  p r e d i c t i o n s f o r the f o u r t h question  i n t e r v e n t i o n s w o u l d be s u p e r i o r  were t h a t t h e  t o the c o n t r o l group  t h e two measures o f g e n e r a l i z a t i o n , c a r r i e d o u t u s i n g  second enclosed predictions,  s p a c e . The f i r s t  measure was a sum o f f e a r  the second the h i g h e s t  level  (from  s i x ) a t w h i c h p a r t i c i p a n t s w o u l d be p r e p a r e d enclosed  a  s p a c e . The means and s t a n d a r d  a choice  to enter  deviations  of  this  were as  follows:  FEAR  PREDICTIONS Mean  Cognitive Exposure Interoceptive Control  S t d . dev  124.50 182.67 212.92 281.17  74.99 86.56 141.96 126.52  SITUATION CHOSEN Mean Cognitive Exposure Interoceptive Control  S t d . dev,  4.42 4.8 3 4.42 3.3 3  1.16 0.94 1.38 1.37  A one-way MANOVA was c a r r i e d o u t w i t h v a r i a b l e s n o t e d above C h o s e n ) . The r e s u l t  (Fear  t h e two d e p e n d e n t  P r e d i c t i o n s and S i t u a t i o n  o f t h i s was  significant,  Pillais  £ (6,  88) = 3.85, p. <.01. U n i v a r i a t e ANOVAS were t h e n  conducted:  for  and f o r t h e  Fear P r e d i c t i o n s £  Situation  ( 3 , 44) = 4.14, p. = <.05  Chosen £ ( 3, 44) = 3.29, p_ < .05.  97  In  the subsequent m u l t i p l e  method), largest  statistical  Fear P r e d i c t i o n s cognitive  a o f 3.79 (p  and t h e c o n t r o l  Tukey's f o r the  among t h e means i n b o t h (p  <.05) and 4.7  the l a r g e s t d i f f e r e n c e  largest difference  (using  s i g n i f i c a n c e was r e a c h e d o n l y  pairwise difference  With a c r i t i c a l  comparisons  group, a  cases.  <.01), f o r  was b e t w e e n t h e  = 4.89, p <.01. The n e x t  was between t h e e x p o s u r e a n d c o n t r o l  g r o u p s where a a t 3.08, p >.05. F o r t h e S i t u a t i o n s the  largest difference  and  c o n t r o l where a  difference  =  between means was b e t w e e n 4.29, p <.05. The n e x t  was b e t w e e n t h e c o n t r o l  interoceptive  Overall,  and c o g n i t i v e  was t h a t  predictions  than the c o n t r o l  g r o u p s where a  the cognitive  exposure group chose a h i g h e r  the  control  group.  largest  =  3.11, p  between g r o u p s g r o u p made  group;  the  exposure  and b o t h t h e  the single difference  Predictions  Chosen,  f o r Fear  lower  f o r the S i t u a t i o n  level  >.05.  of d i f f i c u l t y  Chosen than  98 PHENOMENOLOGICAL STUDY: DESCRIPTIVE DATA THE  SAMPLE  Since  so  little  claustrophobic  work has  subjects,  w h i c h t o compare t h i s t h a n two point 34  majority and  the  at  g r o u p who  p a t i e n t s who  there  least  (30),  average d u r a t i o n  the  of  anxiety  elevators  and  toilets".  had  participation,  i n and  since  (of those  I t i s not out  who  had  at  other  great  36  years  16.8  the  earlier  had  the  old,  years  presenting  " c l o s e d spaces  "the  more  Ulleraker  t h e i r major  to encourage  than  Of  the  was  p r e v i o u s l y sought  t h e r e were t r e a t m e n t s ,  with  comparison  c l e a r whether  i t i s stated that  w o u l d have a p p l i e d f o r t r e a t m e n t that  as  against  research.  p h o b i a s was  a v o i d a n c e of  been c a r r i e d  some  a v e r a g e age  had  using  study  (1982),  y e a r s ) . A l l were o u t p a t i e n t s  complaint  majority  other  in this  study  out  yardsticks  provides  their  M e n t a l H o s p i t a l i n Sweden, and  advertising  few only  took p a r t  completed Ost's  were f e m a l e  ( r a n g e 4-54  are  s a m p l e . The  dozen s u b j e c t s  f o r the  been c a r r i e d  such  any  their  overwhelming treatment) they  only  known  pharmacological,  available."  The  subjects  i n the  UBC  outpatients  of a p s y c h i a t r i c  volunteers,  solicited  in  the  with  Swedish study  an a v e r a g e age  claustrophobia h o s p i t a l but  study  were  not  community  through a d v e r t i s i n g i n the media. the m a j o r i t y  of  42  years.  were women (42 This  as  i s again  an  of  48),  older  As  99  sample  t h a n m i g h t have b e e n e x p e c t e d  of  fear described  the  for  this  are  the  are  unclear.  most l i k e l y  time t o  take part  presume t h a t  evidence sample  treatment the  of  had  certainly  some f o r m o f  can  subjects  i n a small  period  two  difference this  the  study  experimental the  and  less fearful Swedish study  s e t t i n g ) was  lit,  UBC  study  increase  of  bpm.  no  this  a  groups  i n to  not  having  in  that  a setting  was  overly and  This  were  locked,  a s m a l l d a r k room f o r a even a l l o w i n g  rate  (from  half  outside  two  for  changes h a r d l y  resting rate  with  the  From t h i s  the  suggest  average h e a r t  highest  t h e mean i n c r e a s e was 82  is  they both l o c k e d  s a m p l e . The  7 bpm,  to  Almost  i n which subjects  heart  of  t e n minute t r i a l .  closet within  i n demand, t h e  i n the  an  UBC  case  there  time. Ost's  i t was  the  the  were c u r r e n t l y  t o go  minutes. N e v e r t h e l e s s ,  i s the  attack  few  were a s k e d  the d o o r d u r i n g  standing, of  although  i n that  have  sought p r o f e s s i o n a l  panic  were s i t t i n g ,  with  highest  group, but  setting for a limited  more b e n i g n  unlock  In  i n any  group  less seriously  f u r t h e r r e l a t e the  subjects  contrasts  bpm.  easy  reasons age  s u c h s t u d i e s and  s i m i l a r proportion  previously  situation,  studies  increase  r e v i e w . The  (psychiatry, psychology, hypnosis).  claustrophobic  that  A  distribution  t h a t women i n t h i s  outpatient  this.  had  s u c h a t t a c k s . One  could  be  sample m i g h t be  48)  claustrophobic  cramped,  I t may  than the  s a m p l e had  i n both  literature  to hear about  to support  (17  i n the  i n them. I t w o u l d be  this  claustrophobic  from t h e  2 5 bpm  rate  to just and  index alone,  15 the it  can  100  be  seen t h a t t h i s  i s a group w i t h  a high  claustrophobic  fear,  with  I t i s proposed t o look  the fear.  questionnaires  they  even i f imbalanced  filled  l e v e l of t o w a r d s o l d e r women  at the results  i n and t h e i r  of the  i n t e r v i e w s i n more  depth.  PRE-INTERVENTION QUESTIONNAIRES  All Anxiety  Sensitivity  Mobility -  subjects f i l l e d  Inventory,  i n three questionnaires - the  I n d e x , t h e Chambless and a p i l o t  t h e means a n d s t a n d a r d  from t h e i n i t i a l The  Anxiety  Set  results  Claustrophobia  pre-intervention interview.  out i n the order 0 = "very  fASIl  of t h e s t r e n g t h of response  little",  (using  up t o 4 = " v e r y much") t h e  were a s f o l l o w s :  ASI It  Questionnaire  d e v i a t i o n s of which are presented  Symptoms Index  a s c a l e where  Agoraphobic  MEAN i s important  STD.DEV.  to stay i n c o n t r o l of  my e m o t i o n s  3.4  0.9  It It  2.8 2.5  1.2 1.0  i s i m p o r t a n t t o me n o t t o a p p e a r n e r v o u s s c a r e s me when I f e e l f a i n t /  It  s c a r e s me when I become s h o r t o f b r e a t h  2.5  1.2  It  s c a r e s me when my h e a r t b e a t s  rapidly  2.4  l . i  It  s c a r e s me when I f e e l  (trembling)  1.8  1.1  shaky  101 It  s c a r e s me when I am n a u s e o u s  U n u s u a l body s e n s a t i o n s It  e m b a r r a s s e s me when my  Other people It  s c a r e me stomach g r o w l s  n o t i c e when I f e e l  shaky  s c a r e s me when I am n e r v o u s  1.6  1.3  1.6  1.2  1.4  1.0  1.1  1.1  1.1  1.0  1.0  1.3  0.9  1.0  0.8  1.1  0.6  0.9  When I n o t i c e t h a t my h e a r t i s b e a t i n g r a p i d l y , I w o r r y t h a t I m i g h t have a heart It  attack.  s c a r e s me when I am u n a b l e t o keep  my m i n d on a t a s k . When my  stomach i s u p s e t ,  I m i g h t be s e r i o u s l y When I c a n n o t  I worry  that  ill.  k e e p my mind on a t a s k , I  w o r r y t h a t I m i g h t be g o i n g  crazy.  When I am n e r v o u s , I w o r r y t h a t I m i g h t be m e nOft a lsymptoms l y i l l . t h a t a r e f o u n d f r i g h t e n i n g ,0.6 i t i s h e a r t0.9 rate,  f a i n t n e s s , and b e c o m i n g s h o r t o f b r e a t h  most p r o m i n e n t . reflect  However, t h e two h i g h e s t  a different  element, namely  scoring  c o n s t r u c t , a n d one w i t h  Agoraphobic  where tfye mean i s above 2 ( w i t h avoid",  a more  social  nervous.  Inventory  Items f r o m t h e A g o r a p h o b i c  "rarely  items  the importance of s t a y i n g i n c o n t r o l of  e m o t i o n and t h e i m p o r t a n c e o f n o t a p p e a r i n g The  that are the  Inventory  1 = "never a v o i d " ,  3 = "avoid about h a l f  most o f t h e t i m e "  are presented  the time",  and 5 = "always a v o i d " ) .  only  2 =  4 = "avoid  102 WHEN ALONE PLACES  (Mean,  Enclosed  spaces  WHEN ACCOMPANIED  S t d dev)  (Mean,  S t d Dev)  3. 4 (1.• 4)  3. 0 (1.4)  Elevators  3. 1 (1.• 4)  2 . 6 (1.4)  Parking  2 .4 (1.• 4)  1. 8 (1.2)  2 .3 (1..4)  2 . 0 (1.1)  Subways  2 .6 (1. 5)  2 . 4 (1.5)  Airplanes  2 .3 (1. 5)  2 . 1 (1.4)  garages  Heights RIDING IN  Though scores,  s e v e r a l o f t h e sample h a d h i g h  this  was uncommon. On o n l y  agoraphobic  the s i x items  above was  t h e r e a mean s c o r e o f above  2.0 a n d , w i t h  heights,  t h a t have c l e a r a s s o c i a t i o n s  with,  these  are the five  o r a r e more a c c u r a t e l y c o n c e i v e d  The C l a u s t r o p h o b i c  The  study  as an o p p o r t u n i t y  to pilot  a scale  and degree o f c l a u s t r o p h o b i c a n x i e t y .  The means a r e f r o m a s c a l e where "slightly  anxious",  anxious",  5 = "extremely  deviations  of as c l a u s t r o p h o b i a .  Inventory  was t a k e n  measuring t h e extent  t h e exception of  1 = "not a n x i o u s " ,  3 = "moderately anxious"  are i n brackets.  anxious",  2=  4 = "very  and t h e s t a n d a r d  103 Alone I n an e l e v a t o r a t a t i m e when there i s a strong l i k e l i h o o d o f a power c u t .  Accompanied  4.6  (0.9)  4.3  (0.9)  A t t h e f u r t h e s t p o i n t f r o m an e x i t on a t o u r o f an u n d e r g r o u n d mineshaft. 4.6  (1.0)  4.4  (1.0)  4.2  (1.0)  3.5(1.4)  4.0  (1.3)  3.8  Locked i n a s m a l l d a r k room w i t h o u t windows f o r 15 m i n s . S t a n d i n g f o r 15 m i n u t e s straitjacket.  in a  S t a n d i n g i n t h e m i d d l e o f t h e t h i r d row a t a p a c k e d c o n c e r t , r e a l i z i n g t h a t you w i l l be u n a b l e t o l e a v e u n t i l t h e end o f t h e show. 3.7 (1 .2) In a p u b l i c t o i l e t  and  the lock  Locked i n a s m a l l w e l l l i t room w i t h o u t windows f o r 15 m i n s .  Back o f a crowded b u s . In the c e n t r e at a cinema.  of a f u l l  In the middle of a l o n g l i n e at a supermarket.  3 ,. 5 ( 1 • 5)  jams 3 .7 (1 • 2)  3 ,. 1 (1..3)  3.5 (1 .3)  2 , 9 (1.• 4)  I n t h e back o f a s m a l l two-door c a r w i t h a p e r s o n e i t h e r s i d e of 3. 5 (1.4) you, and a l l t h e windows f o g g e d up. I n a crowded s k y t r a i n w h i c h between s t a t i o n s .  (1.5)  stops 3.4 (1 • 4)  3 ,, 3 (1.• 5)  3, . 0 (1..4)  2.8 (1 •4)  2 ., 4 (1.•3)  2.5 (1 .4)  2 , 3 (1.•4.)  1.4  1.3  row  (0.9)  (0.7)  In a b a r b e r ' s / hairdresser's chair  It being the  c a n be n o t e d how l i t t l e  accompanied,  in striking  presence of a t r u s t e d  anxiety.  The h i g h e r  e s c a p e w o u l d be  COGNITIONS AND The all  1.3 (0.8)  reassurance contrast  friend  scores  1.2 (0.6)  i s g a i n e d by  t o a g o r a p h o b i a where  can d r a m a t i c a l l y  a r e a l l s i t u a t i o n s from  which  difficult.  PHYSICAL SENSATIONS  mean c o g n i t i o n s  and s e n s a t i o n s  are presented f o r  f o u r g r o u p s a t p r e - and p o s t - i n t e r v e n t i o n  three  reduce  interventions without  the control at  and f o r t h e  follow-up.  COGNITIONS Mean  (max=12)  PRETEST (N=48)  POSTTEST (N=48)  FOLLOW UP (N=36)  DID YOU THINK THAT.... You  were t r a p p e d  You  were g o i n g  You  You  You  9.0  4.75  5.0  control 7.5  3.75  3.67  i n t h e room 6.25  1.5  3.0  were g o i n g t o a c t f o o l i s h l y 5.5  2.25  2.0  might  2 .25  1 . 0  to lose  h a d been f o r g o t t e n  suffocate  5. 5  105  You  were g o i n g  t o run out of a i r to breathe 5.25 2.25  2.0  t o pass  1.0  You  were g o i n g  out  5.25  1.25  The  w a l l s were c l o s i n g  in  4.75  2.5  You  were i n d a n g e r  4.0  1.25  1.33  You  were g o i n g t o f a l l  2.25  1.25  1.33  You  were g o i n g  0.25  0.0  1.0  2.0  0.0  0.0  t o have a h e a r t a t t a c k 1.25  Other ( t y p i c a l l y f i r e , earthquake or c o n c e r n a b o u t demands b e i n g s e c r e t l y increased) 1.0 You  were g o i n g t o c h o k e t o d e a t h 0.25 One  can note  most common w i t h  t h a t t h e c o g n i t i o n o f e n t r a p m e n t was t h e s u f f o c a t i o n being present  frequently.  The f e a r s o f l o s i n g  highlighted  i n the ASI, are a g a i n  PHYSICAL SENSATIONS  Palpitations heart rate  .67  control  Mean(max=12) PRETEST (N=48)  v e r y much  or acting  less  foolishly,  prominent.  POSTTEST (N=48)  FOLLOW UP (N=36)  or a c c e l e r a t e d 9.0  5.75  5.67  /  Shortness  of breath  8.25  4.25  4.67  Trembling  or shaking  7.0  2.75  2. 0  106  D i z z i n e s s , l i g h t headedness, unsteady f e e l i n g s  or 6.5  3 .25  2 .33  5. 0  4. 0  3. 0  Sweating  4.75  3 .25  1. 67  Too  4 . 25  3 . 25  3. 0  Flushes, hot flashes or c h i l l s  4.25  0.75  0 . 33  Faintness  3.75  1. 0  0. 5  Dry  3. 5  2. 0  1 . 33  Depersonalization or d e r e a l i s a t i o n  2. 5  1 . 25  1. 0  Tearful  2 . 25  1.0  0.33  1. 0  0. 0  Tightening  muscles  warm  mouth  F e e l i n g s i c k , abdominal o r a n y f o r m o f nausea  distress, 2.0  Numbness o r t i n g l i n g sensations  2. 0  0. 5  0. 0  Choking o r smothering sensations  1. 5  1.75  1 . 33  Headache  1. 5  1 . 25  0.33  Chest p a i n o r discomfort  1.25  0. 5  0.33  The  most common  shortness of breath, characteristic they  sensations trembling  not only  a r e symptoms  of increased heart  rate,  and d i z z i n e s s a r e s i g n s  of anxiety  but panic  d i s o r d e r , where  t h a t a r e commonly m i s i n t e r p r e t e d .  107  STRUCTURED INTERVIEWS  Structured protocol) three of  interviews  provided  (see  important m a t e r i a l  g r o u p s . They a l s o p r o v i d e d  the  f e a r . Some o f t h e  (see  table  that  allows  a rather  9).  responses are  However most a r e  most  f o r therapy  not  of and  the so  points.  in a l l  in a  s o r t or are  complete  on many  presented  commentary t h a n w o u l d be salient  f o r the  information  f o r such p r e s e n t a t i o n ,  fuller  convey the  Appendix A  to  table  length  s e t out  usual,  aspects  with  help  108 Table  9  Selected  f i n d i n g s from t h e s t r u c t u r e d  interview  The q u e s t i o n s a s k e d d u r i n g t h e s t r u c t u r e d i n t e r v i e w a r e p r e s e n t e d i n A p p e n d i x A. Many o f t h e q u e s t i o n s r e q u i r e d p a r t i c i p a n t s t o g i v e d e t a i l e d a n s w e r s . T e n o f t h o s e t h a t do not r e q u i r e such e l a b o r a t i o n s a r e presented here.  1. Do you remember childhood ? Yes 30  any c l a u s t r o p h o b i c  2. Do you remember adolescent ? Yes 16  being  experiences No  from  18  claustrophobically fearful No  your  as an  32  3. Do you f e e l t h a t t h e r e was a s i n g l e e v e n t i n y o u r a d u l t l i f e which p r e c i p i t a t e d your c u r r e n t c l a u s t r o p h o b i a ? Yes 28 No 20 4. Have y o u h a d p a n i c setting Yes 21  attacks  other  than i n a No  claustrophobic  27  5. I s t h e f e a r g e t t i n g b e t t e r o r w o r s e ? Better 11 Stable 22  Worse  6. Have you h a d c l a u s t r o p h o b i c dreams ? Yes 16 No  32  15  7. Have you u s e d a l c o h o l o r m e d i c a t i o n on a r e g u l a r b a s i s as a means o f c o p i n g w i t h y o u r f e a r ? Alcohol 4 M e d i c a t i o n 13 Both 4 N e i t h e r 27 8. Do you know o t h e r s Yes 30  who  have t h i s  9. Have you p r e v i o u s l y s o u g h t Yes 17  fear ? No 18  treatment f o r claustrophobia No 31  10. Do you t h i n k t h a t s u f f o c a t i o n / a c c e s s t o a i r to your f e a r of e n c l o s e d spaces ? Major 23 M i n o r 17 No 8  contributes  ?  109 AVOIDANCE  The  two  most f r e q u e n t l y r e p o r t e d a r e a s  claustrophobic flying,  avoidance  reflecting  type of avoidance attention.  Both  of  i n t h e p a s t have b e e n e l e v a t o r s and  presumably not most l i k e l y  were h e a v i l y  o n l y p r e v a l e n c e but  to lead  to  professional  endorsed  by  this  s u b s t a n t i a l m i n o r i t y would n o t use  sample.  e l e v a t o r s under  c i r c u m s t a n c e s . A g r e a t e r number were p r e p a r e d under c e r t a i n  conditions:  company o f p a r t i c u l a r been s e e n would  by  some as  particular  people  fear,  often reported either  t o use  but  times. in this  landed  opened. B e i n g  i n the a i r , or concerns  flying,  and  as t h e d o o r  t h e p l a n e had  the doors  were f a r l e s s p r o m i n e n t  interesting  of f l y i n g  subgroup w i t h c l e a r  Other  had  about  responses.  commonly  phobics  them  Flying  clothing  sitting  access  i n the m i d d l e  t h e back o f a two  door  been safety  I t would  o f a row  of  be  a  characteristics.  underground  to fresh  or jewelry, g e t t i n g  after  c l a u s t r o p h o b i c s are  underground p a r k i n g or a t o u r of a w i n e r y ) , or without  the  Peak  or  s e t t i n g s were c a r w a s h e s ,  one's h e a d u n d e r w a t e r , a c t i v i t i e s  the dark  shut  not  has  sample i t  as a w h o l e , o r a r e  distinguishing  avoided  was  still  t o i n v e s t i g a t e whether these  representative  tight  any  seem c o n s i s t e n t w i t h o t h e r c l a u s t r o p h o b i c f e a r s .  f e a r was  in  A  e l e v a t o r s i n the  at p a r t i c u l a r  a distinct  the  (such  crowds,  a i r , locking  stuck  putting as sleeping doors,  in a traffic  jam,  i n a t h e a t r e o r cinema, or i n  c a r . Some o f t h e r e a s o n s  that  these  110  particular reviewed  s i t u a t i o n s may  be  less  commonly r e p o r t e d  f e a r s w h i c h have h e a l t h o r sample r e p o r t e d  u n d e r g o i n g a CAT sedated  about  with  Personal 5% o f  even i f the their  that  scan,  at  they  reports  recommended  f e a r o f w a k i n g up  and  being  removed d r i p s  " i f they  had  a whole range  being  refuse  i n the so  that  now  that there  r o u t i n e use  The  p r e s e n c e of  equipment only  i n t h e mouth t h a t  prevents  difficult,  a hasty  a subject  exit,  c a n n o t be but  c a n make  common r e f u s a l  seat  implications.  belt,  f e a r was  could of  i s more dental  are  not  breathing  c a s t o f f a limb,  i n which t h i s  two  they  a d d r e s s e d below. A r e p o r t o f  t o 'wear a  the  q u i c k l y removed  premature removal of the  instances  bed,  d e n t i s t i s another area  r u b b e r dam.  option,  because of  c o n c e r n f o r some, p a r t i c u l a r l y of the  the  that  implications for  down s u r g e r y  arm  is  Hospital  1989,) w h i c h s u g g e s t  constrained  of  strongly  Sciences  f o r a scan  of  of  procedure. This  Health  from t h e i r  t o " . The  Some 40%  conceive  r e s u l t s m i g h t have i m p o r t a n t turned  leave  for this  f r o m UBC  had  had  c o u l d not  Communication,  those  to date are  l e a s t without  h e a l t h . Two  others  are  safety repercussions.  which i s discouraged  consistent (Paty,  so u n p l e a s a n t  i n the d i s c u s s i o n .  Far  this  found  and  just  the two  shown t o have  the alarmingly further  health  Ill  ONSET  In many c a s e s at  w h i c h any  exception. clear they  In t h i s  saw  as  starts, sample, event  However, t h e r e  vivid,  access  claustrophobia  t h e r e were t h o s e late  in their  were a g r e a t e r  to  information  c o m p a r i s o n . The  sample  at  some c h i l d h o o d  just  t o have had,  the  a  which their  impact,  even i f  help i f  some p o i n t  i n the  30  from  of  this  some f o r m  game o r p r a n k .  a feeling  for  Others  great  blankets  t o wear a gas  pulled  mask  during  war.  Infrequently in  of  I t might  f o r example, t h e  o v e r t h e i r h e a d , o r t o have had  reported  memories was  reported  i n c i d e n t s but  no  have memories  least  experience  a childhood  discomfort  start  age  such e a r l y memories from a  of p a r e n t a l punishment, or not  the  life  number who  to provide  most t y p i c a l  did report  on  is  who  adult  e a s y f o r them t o a s s e s s .  non-claustrophobic  sample who  and  i n c i d e n t s whose i m p o r t a n c e and  were n o t  had  p o s s i b l e to determine  i n c o n t r o v e r t i b l y marking the  childhood  one  phobia  precipitating  fear. of  i t i s not  later  life.  embarrassing only  fitfe,  t h e r e were s i g n s o f  "I c a n  s i g h t of  variations  seeing  I determined  door to ensure t h a t attention  still  that  recall  t h o u g h t s more common  the  a child  hideously  v o m i t . Though  I would always  I would never a t t r a c t  t h e woman who  recalled  was  t r y t o be  that  sort  i n p u b l i c " . E a r l y m i s i n t e r p r e t a t i o n s had s u c h as  I  wondering  near a  of their  own  i f her  112  lungs  had holes  when s h e was the  anxious.  It will  be f o r l a t e r  d i f f e r e n c e s and s i m i l a r i t i e s  claustrophobia, age  i n them so i n e f f e c t u a l was h e r b r e a t h i n g to  between c h i l d h o o d  and t o answer s p e c i f i c  a t w h i c h one d e v e l o p s  study  questions  analyze  and a d u l t  s u c h as t h e  the c a p a c i t y to m i s i n t e r p r e t  sensations catastrophically.  It  i s striking  t h a t more t h a n h a l f o f t h i s  reporting  childhood  the  of the f e a r , i n s o f a r as they  of  start  i t during  their  claustrophobia  childhood  early as  i n adult  as  being  were r e l a t i v e l y  free  adolescence.  It  seen t o d e v e l o p s e r i o u s l y  and t h e c h i l d h o o d  a t most a v u l n e r a b i l i t y  appeared who  life,  d i d n o t see t h i s  and i n t o t h e i r  was more common t h a t t h e f e a r was  group  experience  was  seen  f a c t o r . Adult p r e c i p i t a n t s  t o be i n d i s t i n g u i s h a b l e between t h o s e  h a d n o t had c l a u s t r o p h o b i c memories o r  who  had and  concerns.  ADULT PRECIPITATING EVENT  The  d e s c r i p t i o n s o f what was  precipitating  event  arousal during detail./Examples categories.  for their  s e e n by many as t h e  claustrophobia  e v o k e d t h e most  t h e i n t e r v i e w and were n a r r a t e d give  i n t h e most  some f l a v o u r o f t h e d i f f e r e n t  113  T h e r e were, f i r s t l y , people, likely  whether or not t o have f o u n d  some i n c i d e n t s w h i c h v e r y many  predisposed  very  to c l a u s t r o p h o b i a , are  frightening.  One  f r o m an  a n a e s t h e t i c came t o c o n s c i o u s n e s s  bed  and  i n a l l s o r t s of r e s t r i c t i v e  The  first  was  a c r y of  t h i n g she  delirious the  heard,  "fire"  and  d i s c o m f o r t of the  her.  occasions.  this  P a s s e n g e r s had  with  The  initial  situation elevator  the engine  a frightening  then  a Turkish airlines  to  on h e r  own.  remained reasonably buttons this  and  was  s t a y on  p o i n t she was  Included  here  a l s o are  t h r e a t e n i n g but situations. got  on  "I was  until  k n e e s ) and  those not  who  t h e i r way  had  to get  out  of t h a t  again.  unpleasant  then  went t o p r e s s  the  themselves  in  game. A f t e r  crowd".  out to  the  an  She  started  objectively  in  went o u t .  that  at  panic.  dangerous  e i g h t months p r e g n a n t and  t o watch a b a l l  as  confidence,  yet  ( i t turned  found  a subway a l o n g w i t h a b o u t h a l f  on  light  she  t o l o c a t e them  probably  the p l a n e  to i n s p i r e  the  with  flight  A subject reported being  controlled  on h e r  a  successive  i t t a x i e d out  I t jammed and  unable  three  o f o t h e r s made an  one.  plaster.  t r a n s p i r e d t o be  t a k e - o f f on  before  response  the  i n t h e dead o f n i g h t ,  m e c h a n i c s , whose demeanour d i d l i t t l e tinkered  to  Many m i g h t a l s o e m p a t h i z e  s u b j e c t on  from I s t a n b u l which aborted  strapped  bandages and  f r o m what l a t e r  p a t i e n t beside  woman r e c o v e r i n g  i n New  rest  of  York.  the  f i v e minutes  I  city I  just  114  The doing  third  group  something  occasions,  that  fitting  c a n be d i s t i n g u i s h e d t h e y h a d done on many  i n t o Barlow's  n e v e r minded b e i n g i n e l e v a t o r s  one  d a y I g o t on one i n E a t o n s  alarm. "I  i n t h e s l i g h t e s t . But  and j u s t  out of a c l e a r  suddenly  blue sky". Another  someone who h a d f l o w n f r e q u e n t l y and w i t h no a n t i c i p a t o r y holiday  i n Europe.  had t o g e t  a n x i e t y , she b o a r d e d  a glimpse  (what s h e d e s c r i b e d a s t h a t  And  there i s , f i n a l l y ,  all.  can i d e n t i f y  support,  I started  stress,  of the plane  crept  incident at  b u t one t h a t h a d a  "At t h e t i m e my h u s b a n d t o f i n d my own c a r f e e l  withdrew very t i g h t ,  i n t h e bathroom, m i l d l y  I  bothered  t i m e o f j u s t how s m a l l  were".  Through a l l these groupings fir^t  fora  on whom t h e f e a r  no p r e c i p i t a t i n g  by b r i d g e s , and aware f o r t h e f i r s t elevators  a plane  of the i n s i d e  a precipitant  became a b i t u n c o m f o r t a b l e  later  i t h i t her l i k e a  the group  Some c a n i d e n t i f y  slow-acting e f f e c t .  Years  "no way o u t " l o o k ) .  up q u i e t l y . Others  i t  example i s  i n the f o r c e s .  She r e p o r t e d t h a t  hammer when she c a u g h t  i s one n o t e d  r u n some common t h r e a d s .  i n t h e g e n e s i s o f many  which i s c e r t a i n l y  was m e n t i o n e d "The  previous  I was amazed as t h e r e was n o t h i n g l e a d i n g up t o i t ;  came r i g h t  The  t h e y were  category of f a l s e  had  off.  i n that  evident here.  fears,  L o s s , f o r example,  commonly a l t h o u g h i n some q u i t e u n u s u a l  day I h e a r d  t h a t my m o t h e r ' s i l l n e s s  namely  forms.  was t e r m i n a l ,  my  115  bedroom seemed so s m a l l and s t u f f y stressors  have s u c h c l e a r l y  their  first  panic  while  pregnant.  was w h i l e  pregnant had  I just  felt  t o g e t out".  top  Cathedral and  period  the reason  speculate  i n a tent or i n a c l i m b i n g to the  p a t t e r n of onset  i s not clear  of p o s s i b l e  about these  "critical  dangerous  •  situations:  i n a packed Further, the  short. T h i r d l y , the  h a s much i n common w i t h  agoraphobia o r f o r the onset  incidents" are,  between s t a t i o n s .  i s o f t e n very  although  explanations.  o f one's v u l n e r a b i l i t y  stopping  be t a k e n  of breathlessness  t o be i m p l i c a t e d i n t h e  f o r the former  a variety  of entrapment  points w i l l  I knew t h a t I  are p a r t i c u l a r l y  t h a t most a r e n o t o b j e c t i v e l y  or a train  /  s e v e n months  i s while  o f e s c a p e seem l i k e l y  a sudden r e a l i z a t i o n theatre  o f t e n before but  Suddenly  i s camping, e i t h e r  Some o b s e r v a t i o n s firstly,  crowded, and b e i n g  i t was  b u i l d i n g such as t h e V a t i c a n o r S t Paul's  difficulty  could  that mall  so v u l n e r a b l e .  F o r many  f o r others  i n London. While t h e c o m b i n a t i o n  second case, one  on h o l i d a y ,  v e h i c l e . The s e c o n d  of a t a l l  overtones.  Two h o l i d a y l o c a l e s  common. The f i r s t recreational  negative  " I had been i n t o  n e v e r had i t been t h i s  and c l o s e " . Not a l l t h e  of panic  that f o r  d i s o r d e r . A l l three  up i n t h e d i s c u s s i o n .  116  TYPICAL SUBSEQUENT CLAUSTROPHOBIC EVENTS  Though a v o i d a n c e all  fears, i t i s striking  carried be  i s the strategy of choice how s u c c e s s f u l l y t h i s  out f o r c l a u s t r o p h o b i a .  on t h e a i s l e  One c a n i n s i s t  s e a t , w a l k up s t a i r s  f o r almost c a n be or arrange to  i n s t e a d o f u s i n g an  e l e v a t o r , m i s s o u t on u n d e r g r o u n d t o u r s . However,  i t i s not  a l w a y s p o s s i b l e t o a n t i c i p a t e how a s i t u a t i o n w i l l  develop  (notably  on a h o l i d a y where a c c u r a t e  much more d i f f i c u l t ) , pressured  by o t h e r s  situation.  and there  p r e d i c t i o n c a n become  are occasions  o r i n some way c a n n o t a v o i d  Most p e o p l e  can thus r e a d i l y  come up  examples o f s u b s e q u e n t  t i m e s on w h i c h t h e y  trapped.  these  I n many c a s e s  described  as f i r s t  With r e g a r d it  has a l r e a d y  when one f e e l s  felt  i n c i d e n t s , but i n v i t e  out that anxiety  a situation,  they  been s u r p r i s e d by t h e s p e e d a t w h i c h t h e i r  Where p e o p l e  have g e n e r a l l y anxiety  down. T h e r e a r e however some s t a r k e x c e p t i o n s . hardly  12 h o u r / f l i g h t , d u r i n g  trapped crouched  abated  which  throughout  i n the corner  h a s gone  One woman  the course  of a  she d i d n o t e a t o r e v e n d a r e go  The s u b j e c t m e n t i o n e d a l r e a d y  i n an e l e v a t o r  can l a s t ,  i s usually  have been u n a b l e t o l e a v e  that her panic  those  f u r t h e r comment.  from t h e s i t u a t i o n .  to the t o i l e t .  i n some way  t o t h e l e n g t h o f time t h e a n x i e t y  been p o i n t e d  enclosed  with  events f o l l o w c l o s e l y  r e d u c e d q u i c k l y by e s c a p e  felt  an  i n which the l i g h t motionless  who h a d been  h a d gone o u t ,  f o r an h o u r .  In both  cases  117  t h e y were i n a s t a t e o f  shock  This  The  r a i s e s two  points.  w o r s t does happen,  freeze, of  p h y s i c a l l y and  c o n t r o l as  they would  i t t e n d s t o be  locked  i n the  tossed  in a screwdriver  toilet  sought h e l p .  removed t h e  s e c o n d p o i n t was  fear.  rather  goal  from  like rusty they  i s taken at  directed.  me  "When I  rivets  while  and  had  with assistance".  The  study r e p o r t e d  a  delayed  I t w o u l d be  mistake to underestimate  the  rather way.  "I knew i f I went  shattered it  f o r the  g r a v i t y of  i n some f a u l t y o r  i n that  r e s t of  closet that  t h a t day;  and  a  reactions;  c o r r e c t l y p r e d i c t i n g severe  than c a t a s t r o p h i z i n g  within  out,  shock of q u i t e d i s t r e s s i n g p r o p o r t i o n s . the  out  and  s o m e t h i n g t o do  returned  they  got  desperation  s c r e w s and  that  this  a p e r s o n p o s s e s s e d , and  t h a t many i n t h e  many c a s e s p e o p l e a r e  the  t h a n b l i n d l y go  If action  to give  door before  e v e n when  d i f f e r e n t form  someone s e n s e d my  the  later.  a n t i c i p a t e d : most commonly  highly  I was  f i v e m i n u t e s I had  i s that  a very  mentally,  point,  they  first  i t takes  w h i c h most c l a u s t r o p h o b i c s  f o r more t h a n a day  reactions  exaggerated  I would  that  in  be  is exactly  how  comes a c r o s s  two  was".  Sifting themes not  through the  d e s c r i p t i o n s , one  common i n o t h e r  disorientation.  A r e a s o n why  f e a r s . The  night-time  panics  occur i s that  a p e r s o n may  and  be  unable to  e i t h e r where he  out  where t h e  see  e x i t s are.  As  first  of  claustrophobic  wake up or  i s that  i n a strange  she  place  i s or  to  work  with entrapment, t h i s  is  the  118  sort  of  instance  i n which  i t is difficult  whether r e l a t e d c a t a s t r o p h i c  cognitions  t o work  are  out  causal  or  epiphenomenal.  A  second  i s an  increase  to p a r t i c u l a r c o g n i t i o n s , t o be  associated  subjects as  the  take short  fainting,  most  the  theme t h a t  i n t r i g u i n g of  Fear of S u f f o c a t i o n " , s p e c u l a t i o n was  that  has  quite  seems  also  unease they  feel  accompanying  this  and  fear,  suffocation.  i s that of  p r o m i n e n t was  study  these  the  lines.  being  the most common b u t f o r those  uncomfortable. particular  no  I t i s important  cognition  should  mentioned  be  t h o s e who  been c l e a r  but  can  to consider  to  latter  exclusive become why  so  this  prominent.  v u l n e r a b i l i t y to t h i s  i n the  be  fear  s u f f o c a t i o n , the  means the  so  One  i t i s more a c c u r a t e  f o r whom b r e a t h i n g  reason f o r the  previously  by  could  of  "The  cognition.  d i c h o t o m y has  to entrapment w i t h or w i t h o u t  cognition  this  claustrophobia  Instead  i s one  claustrophobia  f e a r e n t r a p m e n t and  In t h i s  along  so  refer  One  lead  b e e n t o u c h e d on,  those with  i n t o t h o s e who  suffocation. not  can  some  without reporting  Rachman (1989) s u b t i t l e d h i s c h a p t e r on  split  but  discomfort:  showers b e c a u s e of increases,  This  thoughts.  A third the  notably  with non-cognitive  temperature  anxious  i n temperature.  l i t e r a t u r e was  f e e l i n g not  a sensitivity  to  119  air  and  breathing,  even o u t s i d e  Some h a l f d o z e n had started  or exacerbated  observation that the  had  the  not  probability  breathing,  claustrophobic  accidents their  of  their  their  the  t o t h e i r nose which e i t h e r  sensitivity  allergies  having  feeling  f o r those  with  of  breathing  to avoid.  i t s most e x t r e m e , a n d  individuals will  not  windows c a n n o t be time  "stale" c r a n e my  stay  i n p l a c e s where t h e y  "In crowded e l e v a t o r s talking air  t o o much as  quicker."  The  I can  I feel  who  always c a r r i e s  so  she  can  she  the  are  get that of  is a  very  keen  cases, the  f o r a minimum  a i r could  i n the  the  importance  smell  they  this  in several  stay  feel  get  subject that  this  will  "When I am  neck t o t r y and  one  the  their  difficulties  and  increase  W h i l e many i n  i n h o t e l rooms i n w h i c h  o p e n e d , and  or l i m i t e d .  reported  could greatly  a r a p i d change i n  frightening feeling  of  t o a i r , an  a panic.  particularly At  situation.  p r e v i o u s l y n o t e d . A f u r t h e r seven  presence of  group d i s l i k e d  a  length  either  skytrain I  be  literally  a i r above e v e r y o n e e l s e " . a g i t a t e d i f people they  are  are  just using  up  the  " f r e s h " a i r i s shown by  around  "freshness"  a Vicks  inhalant with  around her  the her  nose whenever  needs i t .  It  may  be  amount, and  shown t h a t  r a t e of  s h o w i n g up  i n C0  breathing.  But  contributory  2  such  intake  of  sensitivity  a i r is biologically  t e s t s as w e l l  c o g n i t i o n s , too,  role  f o r those  to the q u a l i t y ,  who  as  exercises  may  play  may  be  based,  s u c h as  at the  very  biologically  straw least  a  120  vulnerable.  I t i s suggested  generated the f i r s t easily  that  specific  o c c a s i o n an i n d i v i d u a l  a c c e s s e d , and f o u n d d i f f i c u l t  subsequent  c o g n i t i o n s may be  high levels  p a n i c s and a r e  to dispute at  of a n x i e t y . There  do seem t o be  e x a m p l e s where p e o p l e  initially,  that  o f r u n n i n g o u t o f a i r . An example i s  the  t h e r e was a r i s k  s u b j e c t who f o u n d h e r s e l f  safe  landing  captain  took  that  this  to their  erroneously, f e l t  on a f l i g h t ,  some t i m e t o t a x i  announced t h a t  should return  i fquite  which  t o t h e t e r m i n a l . The  both passengers  and stewardesses  s e a t s . As a r e g u l a r  was n o t n o r m a l  after a  procedure.  flier  She s u d d e n l y  she knew sensed  that  t h e r e was no a i r coming o u t o f t h e v e n t s . H e r mind t u r n e d immediately  t o the p o s s i b i l i t y  to h y p e r v e n t i l a t e , be g e t t i n g  of s u f f o c a t i o n  d e s p e r a t e l y concerned  that  as she s t a r t e d she m i g h t n o t  enough a i r . When t h e d o o r was opened a  later  she f e l t  since  this  fine  event,  s u f f o c a t i o n which claustrophobic of  this  fear  be  prominent  and t h o u g h t  i t i s thoughts  no more a b o u t relating  a r e t h e most l i k e l y  setting.  it.  minute However,  t o a i r and  t o be summoned i n any  The p r o g r e s s i o n i n t h e d e v e l o p m e n t  t h u s t a k e s i n many o f t h e s t a g e s t h a t i n many c a s e s  vulnerabilities  i n that  in this  s t u d y : T h e r e were  certain  i t was a t i m e o f h i g h s t r e s s ( h e r  husband had a t e r m i n a l d i s e a s e ) ;  a situation  of the shutting  was  misinterpreted  ( t h e sound  pressurization  s y s t e m ) and e x a c e r b a t e d by h e r own  hyperventilation;  appear t o  she t h e n d e v e l o p e d  c o g n i t i o n was t h e most l i k e l y  o f f of the  a fear  i n which  t o be a c c e s s e d when a  this certain  121  level of  of  anxiety  avoidance  felt  of  a i r might  and  that  she  a problem.  still  fits  knows t h a t  she  will  reassurance nor guarantee f o r  she  developed  not  the  Yet,  and  i n t o the  the  places  this  strict  p r o v i s i o n of  out  of  pattern where  i s perhaps definition  fear i s quite without  a c t u a l l y run  a  she  why of  a  foundation  a i r . Neither  information  are  thus  any  improvement.  There are structured  been r e a c h e d ;  entrapment c o n s i s t e n t w i t h be  claustrophobia phobia,  had  further points  interviews,  but  t o be  considered  these are  observations  f r o m a l l f o u r g r o u p s and  experimental  data  i n the  following  tied the  in  from  the  with  d i s c u s s i o n of  section.  the  DISCUSSION A main, a i m interventions,  of t h i s pared  t o a pure  a d d i t i o n of exposure, phobia  t o see  i f two  form and w i t h o u t  c o u l d produce  the usual  a reduction in a  even s e v e r a l  the a f f i r m a t i v e ,  and  y e a r s ago.  The  a n s w e r was  g i v e s encouragement  broadly  to t r y i n g  t h e t e c h n i q u e s t h a t h a v e worked so w e l l w i t h p a n i c i n other anxiety d i s o r d e r s , t h i s main o b j e c t i v e was w h i c h change was control  and  an  the wish  brought  exposure  including  about group  w i t h such harvest, aim was  one  to f i n d  qualification,  o u t more about  Since t h i s the r e s u l t s  areas of change.  success r a t e  Cerny,  of exposure  panic attacks,  major t r i a l  as  interest.  Barlow  on p a n i c 1989)  treatment  to somatic  as w e l l  catastrophic  study  & Klosko,  for his central  (1990) r e p o r t i n g  A  second without  has p u b l i s h e d disorder  which found approach.  80%  This  sensations associated  some c o g n i t i v e  thoughts.  a more meagre  quest.  initiated,  of h i s treatment  Inevitably  c l a u s t r o p h o b i a and,  a fruitful  s t u d y was  Craske,  consisted  these methods, u s i n g a  by no means w i t h o u t  t h i s was  Within  t h e mechanism w i t h  s m a l l numbers, s u c h a s e a r c h y i e l d e d though  (Barlow,  by  disorder  simple phobias.  to study  out  t o p r o v i d e b e n c h marks a g a i n s t  w h i c h t o a s s e s s t h e t i m i n g and  salient  simple  i n ways t h a t w o u l d have been t h o u g h t d e c i d e d l y  unpromising in  s t u d y was  C l a r k has  therapy d i r e c t e d also  even s l i g h t l y  s u c c e s s w i t h v e r y much more emphasis  on  with at  finished his  higher  correcting  treatment cognitive  123  misinterpretations no  doubt t h a t  alone  the a d d i t i o n of these techniques  h a s done much t o i m p r o v e t r e a t m e n t  been p r e d i c t e d , on  t h a n on i n t e r o c e p t i v e e x p o s u r e . T h e r e i s  the e f f e c t  there  that  example, w i t h i n  outcome. As had  i s now i n c r e a s i n g t h e o r e t i c a l i n t e r e s t  either is likely  the realm of panic  t o have on i t s own. F o r disorder,  have r e c e n t l y b e e n s e t u n d e r way t o a s s e s s purely  cognitive  i n t e r v e n t i o n ( J . Magraf,  Salkovskis,  communication, A p r i l ,  1990) w i t h  promising  intensive  sessions  sensations  very  similar to their  panic  attacks.  about  the i n d u c t i o n ,  naturally  While  they  the effect  occurring panic,  what a r e t h e l i k e l y treatment.  over  Van den  eight  subjects to occurring  much l e s s  anxious  d i d not g e n e r a l i z e to  o p e n i n g up some s p e c u l a t i o n as t o  strengths  It is certainly  2  own n a t u r a l l y  became v e r y  of a  personal  results.  i n h a l a t i o n of C0  a s a way o f e x p o s i n g  studies  personal  1990; P.M.  (1989) h a s a l s o u s e d  two  the e f f e c t  communication, March,  Hout  t o exposure  and l i m i t a t i o n s o f s u c h a  no l e s s t i m e l y  t i m e t h e s t u d y was i n i t i a t e d ,  to consider  form o f these  two a p p r o a c h e s w o u l d  situationally  cued p a n i c  than  how a n  fare with  and a n x i e t y  i t was a t t h e abbreviated  t h e more  evident i n  claustrophobia.  The cognitive effects.  main focus approaches  i s i n e v i t a b l y on t h e i n t e r o c e p t i v e and since  so l i t t l e  I t w o u l d go a g a i n s t  i s known a b o u t  the g r a i n adopted  their  i n this  t o t r y and work o u t w h e t h e r t h e c o g n i t i v e o r t h e  study  124  interoceptive in  any c a s e  tested, an  start  after  I t would  from  seem j u d i c i o u s emphasis.  the  90 m i n u t e s  exposure  reduction  group  in their  Without, examining sensations, on  reduction  fear  to at least  thoughts  significantly  review,  this  will  that  which that  situation.  or decreasing s e n s i t i v i t y to to bring  about  a clear  reduction  m e a s u r e s , as compared w i t h t h e  relatively were t h u s  reported fear  r e d u c e d by e n t i r e l y  t h e r e was some but f o r a g r e a t e r  u n c h a n g e d . The r e s u l t s o f  v e r y much a s e x p e c t e d .  and p a n i c were  both  cognitive procedures i s  o f a m i l e s t o n e . As r e c e n t l y  L a s t was w r i t i n g  clear  enclosed  i n t h e f e a r o f some i n d i v i d u a l s ,  fact  something  speed w i t h  In the case o f the l a t t e r ,  "benchmark" g r o u p s  The  Discussion  s h o u l d have undergone such a  number, s c o r e s r e m a i n e d the  t o keep t h e  o f e x p l a n a t i o n and e x p e r i e n c e , t h o s e i n  of assessment  c o n t r o l group.  showing  o u t . I t i s thus n o t s u r p r i s i n g ,  i t was p o s s i b l e  a battery  t o be  of the treatment of  ( O s t , 1989) i s t h e i n c r e a s i n g  under  have n o t b e e n  of q u e s t i o n 1 s e t the foundation f o r the  treatments are c a r r i e d in  would  the four experimental questions.  s t u d y . One o f t h e r e c e n t f e a t u r e s phobias  This  o f i n t e r v e n t i o n and a f t e r so  o f f such a comparative  results  that  b o t h w o u l d be as l i k e l y  with the r e s u l t s  The  of assumptions  t h e same l e n g t h  a time p e r i o d .  spotlight  was t h e more s u c c e s s f u l .  imply a range  s u c h as t h a t  effect  short  approach  o f f the role  a s 1987, i n a m a j o r of c o g n i t i o n s  i n the  125  treatment this  of  i s too  reports  any  p h o b i a s . These r e s u l t s would  hasty  a judgment. Not  reduced, but  stimulus,  confidence  a f t e r only i n that  assured predictions being closet, it  was  from the  striking  effect to  evident  on  that  reducing  assume t h a t  among o t h e r s ,  has  free  as  be  of panic  an  overly  exposure  to  feature  i n the  the  lack  will  of  one a  may  cognitive  Factors  the  (1990),  percentage  a r e s u l t of a  cautious  from the  t h a t make t h i s  can  be  to  to  or  to  but  the  disappointing  notion  of  continued  cognitive  d a t a on  question the  i n v a r i a b l y improve  more and  used  established,  i n assuming t h a t  intervention w i l l  prove  c e r t a i n phobias,  f o r the  wrong  success".  f i r m l y opened. A  support  It i s evident  have t o be  of  h a v e t o be  i s now  improvement o v e r t i m e as intervention.  treatment  treatment  such r e s e a r c h was  Barlow  therapeutic  though  anticipated  i t w o u l d be  "measures o f  components t o  with  Thus,  c e n t r a l m e a s u r e o f outcome may  make i t more e f f i c i e n t , door  panic,  4.  the  isolated effect.  o p t i m i s t i c gauge o f  Whether c o g n i t i v e speed  an  the  generalization  i n t e r v e n t i o n had of  with  running high,  the  that  fear  contact  r e s u l t s of q u e s t i o n  warned t h a t the  were t h e s e  brief  g r o u p was  reports  t h i s was  this  made a b o u t  this  the  only  suggest  less likely  will  2  that  effects over  of  time.  have t o  be  isolated.  It the on  i s important  cognitive  to note  the  measures n o t  intervention d i d exert  which i t d i d not.  T h e r e has  an  j u s t on  effect,  which  but  on  those  b e e n much d i s c u s s i o n  as  to  126  whether s u c c e s s f u l c o g n i t i v e p r o c e d u r e s would r e s u l t better  coping  anxiety  even  c h a n g e on  i n the  face of a s t r e s s o r , or very  i n i t s a n t i c i p a t i o n and  question  1 on b o t h h e a r t  fear,  would  suggest that  their  improvement d i d n o t  exposure, at heart  during  in their  their  the  own  high.  the  significant  decrements  in reported  on  1 were n o t  m a t c h e d by  r e p o r t s and large  standard  deviations  t h i s was  some but  f o r o t h e r s ; more t h a n  hot  some p e o p l e r e s p o n d e d intervention. 1990)  and  written  inefficient is  little  of  at  way  of changing  In p a r t i c u l a r , will  i t may  prove  have more  Study of a  other  a l l to  a and  longer  in the  likely  intervention for two  groups,  this April, have  decidedly so a n x i e t y ,  f o r i t to warrant  effect.  cognitions  c o g n i t i v e approach  thoughts  that  and  communication  i n t e r o c e p t i v e e x p o s u r e as  enough change shown h e r e  sensations  the  of  i n the  or not  links  reductions  panic.  style  (personal  supporters  which  statistically  and  effective  While C l a r k  other  off  an  t h u s made  group provides  explanation:  as  below.  equivalent  in this  and  at l e a s t  sensations  p r e d i c t i o n s of a n x i e t y  second  stimulus,  3 discussed  of  subjects,  fear levels  f e a r , was  feared  i n t e r o c e p t i v e group,  question  the  Their progress,  from q u e s t i o n  lack  a number o f  p r e d i c t i o n s of  less  p r e d i c t i o n of  come a b o u t b e f o r e  re-exposure to the  results  In the  least  approach to which t h e i r  r a t e were s t i l l  expressed  with  the  for at  much  a p p r o a c h . The  r a t e and  in  further  exposure  to  there study.  127  While little  the r e s u l t s  of question  emerges f r o m q u e s t i o n  1 are quite  2. The r e d u c t i o n i n t h e t o t a l  f r o m 48 t o 36 e f f e c t e d by t h e e t h i c a l l y of  the c o n t r o l group a t follow-up,  statistical searching  power. T h i s  necessary  has s e v e r e  i s t h e more n o t a b l e  i n t h e same d i r e c t i o n .  particularly  wary o f making any d e d u c t i o n s  negative  however, it  results.  important  t h a t much w i l l  effect  sizes  f a r from  at follow-up  as r e p o r t e d  than  fear.  "return of fear"  the  over  expected  rate.  i n reported  during  of feared settings,  on b o t h illustrative  high proportion of  W h i l e one m i g h t  fear,  this  a l l groups,  post-  These p o i n t s a r e  expect  a  would u s u a l l y a l s o A combination  of  t h e i n t e r v e n t i o n and a t t h e  s e c o n d a s s e s s m e n t , f o l l o w e d b y , i n most c a s e s , avoidance  had h i g h e r  across  s c o r e s were h i g h e r  at follow-up.  gained  i s that the  between  i n scores of p r e d i c t e d f e a r .  confidence  since  interactions  time,  averaged  t h a t t h e r e was an u n u s u a l l y  "underpredictions"  be  data a r e ,  a t p o s t - i n t e r v e n t i o n on measures  Secondly,  f e a r and h e a r t  the f a c t  from these  The f i r s t  improving  i n t e r v e n t i o n and f o l l o w - u p ,  of  from the p l e t h o r a  of group x time  p r e d i c t i o n s o f f e a r were r e d u c e d  reported  when one i s  be l e a r n e d . T h e r e a r e , t o o , s e v e r a l p o i n t s  c o g n i t i v e group,  while  e f f e c t s on  f o r future research,  w h i c h emerge w h i c h c a n be l i n k e d .  such  exclusion  One must, t h e n , be  What one c a n t a k e  i s from the f u r t h e r study  scores  N  f o r d i f f e r e n c e s between t h e t h r e e g r o u p s as t h e y  move b r o a d l y  of  clearcut,  continued  l e d to inaccurate predictions  128  of  f e a r . A way  boosting an  area  appears  t o have been a c c i d e n t a l l y f o u n d o f  the n a t u r a l incidence o f some t h e o r e t i c a l  of u n d e r p r e d i c t i o n s .  interest,  and may  This i s  encourage  s p e c u l a t i o n as t o what makes u n d e r p r e d i c t i o n s  more  since  t h a t the  there  clinician Bichard,  i s i n c r e a s i n g evidence  should  t r y to avoid  1988; Rachman  This  leaves  discussed.  & Eyrl,  the r e s u l t s  These f e l l  very  hypothesized,  with  group f a l l i n g  gradually,  at  the longest  it  was n e c e s s a r y  their  to suggest occurrence  likely,  (Rachman &  1990).  from q u e s t i o n  much a c c o r d i n g  3 t o be t o what h a d been  the f e a r p r e d i c t i o n s i n the exposure the l a r g e s t r e d u c t i o n  s e s s i o n o f exposure.  taking  place  In the c o g n i t i v e group  to have the experience  of the second  exposure b e f o r e  p r e d i c t i o n s of anxiety  raises  o f i s s u e s . Though i t i s n o t r e f l e c t e d i n  a number  reduced to  scores,  allow  learning  there  i s clearly  were r e d u c e d .  some l e a r n i n g t a k i n g  such a r a p i d r e a p p r a i s a l . I t . i s i s , and p r e c i s e l y how  this  information  experience  the  amount o f e x p o s u r e r e q u i r e d c o u l d be g r e a t l y a suitable cognitive preparation.  particularly takes  o f e x p o s u r e . An o b v i o u s  T h i s may  u s e f u l where i t i s d i f f i c u l t ,  of a n x i e t y cognitive  Of i n t e r e s t ,  too, i s that  i s linked to  reduced be  expensive,  the p a t t e r n  i n the i n t e r o c e p t i v e group i s s i m i l a r r a t h e r than  this  i m p l i c a t i o n i s that  t o o much t h e r a p i s t t i m e t o s e t up f r e q u e n t  sessions.  place  n o t c l e a r what  the  with  This  or  exposure of reduction t o the  t h e exposure group. These p o i n t s  will  129  be  f u r t h e r d i s c u s s e d and l i n k e d  after  to the q u a l i t a t i v e  some o b s e r v a t i o n s have been made a b o u t  during  the running  of the four  results  what t o o k  place  groups.  CONTROL F o r t h e most p a r t , anxious to  the second  them t h a t  into  by did  as the f i r s t .  this  implications,  it two  a n d s c o r e s on a v a r i e t y o f  on t h e s e c o n d  In t h i s  case a  social  was e r a d i c a t e d by t h e f o u r m i n u t e s o f s u b j e c t even had t h e c o u r t e s y t o  t o s a y what a n e n o r m o u s l y  and s h e h a d c o u n t e d thought  successful  intervention.  o c c a s i o n she h a d s p e n t  minutes w i t h h e r hand d i r e c t l y  nagging  o c c a s i o n . The most  years d u r a t i o n , with profound  h a d been! On t h e f i r s t  shut,  one i n  e x p e r i e n c e was n o t n e a r l y a s  a s s e s s m e n t . The p a r t i c u l a r telephone  participants  cases,  change i s w o r t h r e c o r d i n g i n d e t a i l .  of t h i r t y  out the  out the p r e l i m i n a r y  In several  as h a d b e e n a n t i c i p a t e d ,  dramatic  t o go  and t o g e t the s o u g h t - a f t e r  the i n i t i a l  m e a s u r e s were r e d u c e d  clear  as p o s s i b l e ,  i n which  e i g h t weeks t o f i n d  information a t the d e b r i e f i n g .  phobia  t h e y w o u l d be a s k e d  was t h e o n l y g r o u p  of the study,  aversive  I t h a d b e e n made  T h i s was f r a m e d as p o s i t i v e l y  n o t have t o w a i t  particular,  g r o u p were as  on two s e p a r a t e o c c a s i o n s a n d f i l l  forms.  saying that  findings  i n the c o n t r o l  as p a r t o f t h e study  the c l o s e t  necessary  time  those  slowly  over  (trying  the buzzer, to blot  o f what w o u l d h a p p e n i f s h e was  c o u n t i n g a t t h e e n d o f two m i n u t e s ) .  the entire  She a r r i v e d  h e r eyes  out the still on t h e  130  second o c c a s i o n with g r e a t e r d e t e r m i n a t i o n confidence. count,  As she e n t e r e d  deliberately exit  turned  she began t o f e e l  not to  more d i f f i c u l t .  When t h e t r i a l  engineer  atypical their  t h e w a l l s and  ended s h e was  and s e t o f f a f t e r  o u t a number o f l o n g - a v o i d e d  from t h i s  After  h e r back t o t h e d o o r , m a k i n g any c h a n c e  brimming w i t h c o n f i d e n c e , carry  she d e c i d e d  t o keep h e r e y e s open a n d t o i g n o r e t h e b u z z e r .  some s e c o n d s h a d p a s s e d ,  of  the c l o s e t ,  b u t no more  example t h a t  the s e s s i o n t o  activities.  It i s clear  i t i s p o s s i b l e f o r people to  own f e a r r e d u c t i o n w i t h m i n i m a l a s s i s t a n c e .  EXPOSURE This out w i t h  i n t e r v e n t i o n was t h e most the l e a s t  v e r b a l i n p u t . Most p a r t i c i p a n t s  s u r p r i s e d a t the speed a t which needed  little  pursue. while  that  i f they  t h i s was a u s e f u l p a t h t o were t h e common ones  c o u l d make s i m i l a r  t o p o n d e r on t h e i m p l i c a t i o n s o f t h i s .  closet  who a d j u s t e d  very  that  they  at higher  points  t o note the  i n speed a t which i n d i v i d u a l s '  that those  level,  progress  t h e i r h i e r a r c h y . I t was i n t e r e s t i n g  indication  were  f e a r was r e d u c e d a n d  t h e y m i g h t be p r o g r e s s i n g a t a g i v e n  difference and  encouragement  their  The o n l y d o u b t s e x p r e s s e d  doubted on  straightforward to carry  f e a r was  reduced  T h e r e was some  quickly tothe  may have shown l e s s g e n e r a l i z e d improvement,  appearing  not to process  effectively. thoughts  their  f e a r r e d u c t i o n as  T h e r e were a l s o two i n s t a n c e s where  not evident  i n the i n i t i a l  assessment  frightening  emerged  131  during  the intervention. Neither  weakly  evident  however, without say  a t the second  i t was s t r i k i n g being  they  were s i m p l y  a s s e s s m e n t . F o r t h e most,  how t h e c o g n i t i o n s  specifically  whether evidence  likely  r e d u c e d . The q u e s t i o n  to challenge  to arise  them, o r w h e t h e r  once a n x i e t y h a d b e e n  r e m a i n s an open one, t o o , a s t o  w h e t h e r e x p o s u r e works s o l e l y Clark  disappeared  examined. I t i s not p o s s i b l e t o  was f o u n d  less  c o u l d be t a c k l e d and were  t h r o u g h c o g n i t i v e means a s  has p r o v o c a t i v e l y suggested  (1990).  COGNITIVE The  major anxious  c o g n i t i o n o f t h e t h e r a p i s t was  p a r t i c i p a n t s would r e p o r t h i g h obvious  supporting  unnecessarily reported, the  role  creating, out  with  belief  turned  but p a r t i c i p a n t s had l i t t l e they  played  their  in fuelling,  fears. Pilot  students  similarity  was e v i d e n c e these  cognitions. This  of anxiety  without  o u t t o be  c a t a s t r o p h i c . Not o n l y were c o g n i t i o n s  some p o i n t s t h a t  A  levels  difficulty  duly  i n seeing  i f not n e c e s s a r i l y  work h a d l a r g e l y  been  w h i c h was a d e q u a t e p r e p a r a t i o n  carried  f o r only  arose.  with  the student  of a c l e a r dual  clinical  that  volunteers  i n the thoughts  was g r o s s l y i n f l a t e d  p o p u l a t i o n was t h a t  belief  recognized  system. Almost  there  a l l of  that the degree of  t h a t h a d come t o mind i n t h e c l o s e t ,  i n comparison with  i n d i s c u s s i o n o r on r e f e c t i o n  later.  what t h e y  believed  The d i f f i c u l t y  was i n  132  getting anxiety.  t h e same r e a s o n i n g t o o p e r a t e T h i s t a s k was s p l i t  were r e l a t i v e l y not.  easy  In the f i r s t  based  clearly  a t the higher l e v e l of between t h o u g h t s  t o c h a l l e n g e and t h o u g h t s  c a t e g o r y were t h o u g h t s  on m i s i n f o r m a t i o n . P a r t i c i p a n t s  which  w h i c h were  w h i c h were  had never  largely  considered  how much a i r one w o u l d n e e d t o s u r v i v e i n a n e n c l o s e d and  were i n t e r e s t e d  the r e a l i t y  t o make a n e s t i m a t e b e f o r e  (a rough  hundred times  e s t i m a t e was t h a t  out i n their  t o work o u t i f a s p a c e fainting  results  from  was a i r t i g h t .  and q u i c k l y  They d i d n o t know  n o t been a n t i c i p a t e d was t h a t  set  o f c o g n i t i o n s i n some i n d i v i d u a l s  from  that  I n many c a s e s  but  personal experience  "idiosyncratic significance  evidence",  subjects to r e c a l l the p r o b a b i l i t y basis  t o be v e r y  that  one must  random,  of others tackle  underplayed the  u n d e r w h i c h t h i s may  have  i t came a s a s u r p r i s e t o  of a certain  o c c u r r e n c e . To u n d e r s t a n d the  was h e l p f u l  t o them.  p o i n t was t h a t w h i l e  straightforward  proved  second  i n c i d e n t s w h i c h h a d l e d them t o b e l i e v e  f o r the b e l i e f  A second  cases,  r e c e i v e d . What  or that  b u t has perhaps  of the circumstances  been l e a r n e d . I n s e v e r a l  a n x i e t y . Such  t h e y were f a r f r o m  t o them. C l a r k h a s s u g g e s t e d  that  and so c o u l d  t h e r e w o u l d be a  much more s t u b b o r n .  close  slower  and e a s i l y  had  their  over a  e s t i m a t e s ) . T h e y d i d n o t know how  n o t happen i f o n e ' s h e a r t was pumping  came f r o m  calculating  t h e y were w e l l  one's h e a r t g o i n g  i n f o r m a t i o n was u s e f u l  space,  i t was  relatively  t o h e l p them t o come up w i t h c o n v i n c i n g  133  counterarguments  during the i n t e r v e n t i o n ,  w h e t h e r t h e y w o u l d be a b l e t o summon s u c h were back  i n the c l o s e t .  The t h i r d  their  concern  was  t h o u g h t s when t h e y  s e s s i o n was  spent  s p e e d i n g up t h e i r r e s p o n s e s and m a k i n g them e a s i e r t o access.  However, a t h e r a p e u t i c  cases,  the f r i g h t e n i n g  coping  statements  seemed u s e f u l beneficial might that  c o n c e r n was  that  t h o u g h t s were n e v e r  were u s e d - a l m o s t  like  i n some  accessed at  a mantra.  While  i n t h e s h o r t - t e r m , i t seemed u n l i k e l y  i n t h e l o n g - t e r m . The c l i n i c i a n  have e n c o u r a g e d  at this  subjects during training  t h e y were i n t h e s i t u a t i o n ,  to bring  all; this  t o be point  t o imagine  on t h e f r i g h t e n i n g  thoughts  and t h e n , and o n l y t h e n , t o t r y a n d d i s p u t e them.  However,  i t was  conflict  with the i n t e g r i t y  felt  t o be c o n d u c t e d . t h i s manner, typical  i m a g i n a l exposure  o f t h e way  thoughts,  the intervention  t h e n t h i s may  d i d n o t c o n t i n u e t o improve from t h e i r  t h e i r more u s u a l ,  p a t t e r n s , would  return.  from  h e l p t o e x p l a i n why  was  key c o g n i t i o n s  even  almost  their this  over time:  t o c h a l l e n g e them. I t w o u l d be e x p e c t e d  point,  c o u l d be i n  I f c o p i n g s t a t e m e n t s were b e i n g u s e d i n  were b e i n g d i s t r a c t e d  later  such  a n d s u b j e c t s were b e i n g d i s t r a c t e d  c o g n i t i v e group  learning  that  rather that  automatic  they than at a  thought  134  INTEROCEPTIVE T h e r e has  been almost n o t h i n g w r i t t e n  problems of g i v i n g  interoceptive  points  the  most d i f f i c u l t  it  not  hard  was  felt  to  comfortable  example, efforts  exposure.  intervention  convey t h e  engaging  closet,  was  to b r i n g  some  administer.  While  a l l individuals  i n these e x e r c i s e s ,  main e x e r c i s e  hyperventilation, to  at  and,  embarrassment  for  despite  them a t t h e i r e a s e .  Though t h e  similar  to  the p r a c t i c a l  I t was  r a t i o n a l e , not  e x p r e s s e d awkwardness o r t o put  on  breathing  sensations easier  that  used  through the had  t o b u i l d up  disorder  a tolerance  i n panic  may  to,  out  of  in  the  and  mean t h a t  i n and  is  s t r a w p r o v e d more  been e x p e r i e n c e d  a b o u t more change. T h i s  qualitative difference  i n panic  appeared  there an  is a  enclosed  space.  It  is still  change m i g h t be. something not  that in  the  about  It could  I t could  be  that  tried, be  as  that  exercises theory  panic  t r i g g e r i n g sensations  them. I t i s s t i l l  interoceptive  an  i s at  one  is getting  or  change.  open q u e s t i o n operate,  appears  less It could  It is  r e d u c e d by  changing  doing  least  sensation.  be  mechanism  least  which a t  can  i n t e r v e n t i o n might  the  and  foster cognitive that  t o what  one  to a p a r t i c u l a r p h y s i c a l  cognitive  reducing  uncertain  previously  t o make s e n s e . sensitive  quite  be  implicit either  interpretations  as at  to whether  the  l e a s t i n some  of  135  cases,  by t h e f o r m e r mechanism, i n s t i t u t i n g  reducing  anxiety  without  accessing  T h i s would need t o be e s t a b l i s h e d , w o u l d be a l e s s p o w e r f u l ,  change and  or changing  cognitions.  as i t w o u l d w h e t h e r  or at l e a s t l e s s  generalizable,  way o f change. I t r e m a i n s an i n t r i g u i n g p o s s i b i l i t y interoceptive  techniques  this  that the  a r e n o t j u s t a d i f f e r e n t method t o  c o g n i t i v e ones, but o p e r a t e  t h r o u g h d i f f e r e n t mechanisms.  CLAUSTROPHOBIA AND THE CLARK MODEL  A s t a r t i n g point psychological  interventions  model o f t r e a t m e n t attention, could  research  with panic  was t h e s u c c e s s o f disorder.  (1987) has a r o u s e d much  At expect  i t should  a mirror-image definition,  be s a i d t h a t  t r a n s f e r . Panic  involves  obvious cause. T h i s  that  c a n be  one w o u l d n o t  disorder,  a state of anxiety  makes f o r a g r o u p t h a t  by i t s DSM-  without  have p r o v e n  t o be  s u i t e d t o t r a i n i n g on r e i n t e r p r e t a t i o n o f t h e i r  sensations.  I t h a s n o t , a n d w o u l d n o t , be c l a i m e d  claustrophobic  or s i m i l a r l y  cued p a n i c  mechanism. T h e r e a r e i n s t a n c e s overlap,  professional  i n claustrophobia.  the outset  ideally  Clark's  and i t was o f i n t e r e s t t o n o t e how e a s i l y i t  be t r a n s f e r r e d t o t h e s o r t o f p a n i c  observed  III-R  f o r this  that a  occurs using  where t h e r e  t h e same  i s complete  b u t t h e s e a r e n o t t h e r u l e . F o r example,  arousal  136  brought about can  indeed  losing  of reasons  a i r , or  some o t h e r  frightening  trapped,  of e x t e r n a l cues.  triggering  anxiety  sensations.  are u n l i k e l y  less  However,  likely  o r m i g h t be t o be  f o r the  so  paper,  of the  important  Lopatka  secondary  and  phase of  associated with crushed  fear,  fearing  a fear.  might  there  Clark sticks  must be  continued  which there i s a  f r o m some  internal  the  p o s e s no  conceptual  i s evidence  play a  that  they  role may  unpublished  (1988) p r o p o s e d t h e  n o t i o n of a  the d i s c o m f o r t  t h a t has  Thus, f o r example, w h i l e  initiate  the  resolutely  first  found to the  m i s i n t e r p r e t a t i o n on panic.  at r i s k  be  I n an  be m i s i n t e r p r e t e d t o be  present  might  c o g n i t i o n s may  a high degree of a r o u s a l i n other  need not  than  common  t r i g g e r e d by  i n i t s maintenance. Levitt  to  theory.  A second p o i n t i s t h a t w h i l e the g e n e s i s  that  t h a t one  of e x t e r n a l t r i g g e r s  leap or d i f f i c u l t y  be  as  S u c h a c h a n g e i n emphasis t o  misinterpretation  off  control,  catastrophe.  It is clear  such  m i g h t become c r u s h e d ,  natural disaster  being  space  from the m i s i n t e r p r e t a t i o n of p h y s i c a l s e n s a t i o n s  cognitions  not  enclosed  losing  of t h r e a t i n c l a u s t r o p h o b i a are  the misreading  in  i n an  be m i s i n t e r p r e t e d as a s i g n o f  perceptions arise  for a variety  panic,  very  the  this  enclosed  f e a r of  might  spaces  At  there  occasion  set  which  unpleasant.  notion that every  become  on  137  Whether c l a u s t r o p h o b i a c o g n i t i v e panic said  provides  opens more c o n t r o v e r s i a l a r e a s .  i s that c o n d i t i o n i n g a t t h e very  much more p r o m i n e n t p a r t  initially  subject  least  i n this  study  became v e r y  finally in  strong  was b r e a t h i n g She f e l t  cognitions  terrible  her wearing seemed a s  i f  a n d w o n d e r e d i f she w o u l d t h r o w u p , a n d l e a v i n g . The s m e l l  i s now s u f f i c i e n t  even t h o u g h t h e r e  itself  i s now no r e p o r t e d  c o n c e r n when she c o n s i d e r e d the study,  One  p e r f u m e a n d was n o t g e t t i n g enough  becoming p a n i c k y  followed  i n panic  uncomfortable a t a packed  perfume, and i t suddenly  just  a n y crowded p l a c e  panic,  a very  a p p a r e n t b u t t h e n weaken o r d i s a p p e a r .  overpoweringly  air.  plays  a n example i n w h i c h  f o o t b a l l game. A woman s a t down b e s i d e  she  f o r nonWhat c a n be  t h a n h a s been a p p a r e n t  d i s o r d e r . One c a n s t a r t w i t h are  the grounds  joining  o f perfume  t o b r i n g on a  c o g n i t i o n . Her  a treatment group  was n o t o f t h e a c t i v i t i e s  that  t h a t m i g h t be  demanded, b u t w h e t h e r any o f t h e o t h e r women m i g h t be wearing  perfume.  Consistent  with  the role  of conditioning i s that i t  seems a s i f i n t e r n a l  scanning  plays  claustrophobia situation, brings  prominent r o l e i n  I t i s the e x t e r n a l  whether o r n o t c o g n i t i v e l y i n t e r p r e t e d , t h a t  on t h e s e n s a t i o n s  misinterpreted. it  than i n uncued p a n i c .  a less  which  i n their  Though some s u b j e c t s  have h i g h  i s much more r e m a r k a b l e t o n o t e t h e i r  e x t e r n a l cues: t h e n o i s e  t u r n c a n a l s o be ASI s c o r e s ,  vigilance f o r  from above i n t h e e l e v a t o r , t h e  138  change  i n engine  conditioned  tone  triggers  i n a p l a n e , which are e i t h e r o r open t h e d o o r  t o unwelcome  cognitions.  One c o u l d go a s t a g e  further  and s p e c u l a t e t h a t  instances  t h e r e may have n e v e r  certainly  does seem t o be a n i n t r i g u i n g  to  been a c o g n i t i o n .  f r o m many was b e i n g  i n a straitjacket.  w e r e a c c o m p a n i e d by a t r u s t e d restricted they  that  they would  neat  An  invited  Even i f they  their  safety,  very uncomfortable.  t h e y have i n e x p r e s s i n g t h e f o u n d a t i o n s  d i s c o m f o r t make i t d i f f i c u l t into  feel  cognitive  important  t o s e e how t h i s  The  for this  c a n be  fitted  terms.  observation i n this  interestingly  Clark  agoraphobics,  i s that  study, however, and  (1990) h a s r e p o r t e d t h e same w i t h the thoughts  so p r o m i n e n t  i n panic  disorder,  a r e o f t e n f l e e t i n g when t h e r e i s t h e d e g r e e  avoidance  as i s e v i d e n t h e r e .  were s o c l e a r l y  nature  who was n o t so  and who c o u l d h a v e l o o k e d a f t e r  predict  difficulty  friend  There  non-cognitive  e n t r a p m e n t . An i t e m on one q u e s t i o n n a i r e t h a t  horror  i n some  The f a c t  that  reported i n the c o g n i t i v e  a misleading impression of t h e i r  salience.  of  the thoughts  checklist  may  give  Attention f o r the  m o s t p a r t was v e r y o f t e n n o t on t h e s e b a r e l y c o n s c i o u s thoughts, the  but i n s t e a d  situation.  mental  on w a n t i n g  d e s p e r a t e l y t o g e t out of  S u b j e c t s have t o engage a l m o s t  s e t i f t h e y a r e t o f o c u s n o t on t h e i r  i n a change o f anxious  139  feelings,  but  on  the  underlying  a b o u t w h i c h t h e y m i g h t be can  be  posed  fuelling on  that  their  which the  faced  its  c l e a r data  e f f e c t and  What one  is left  from t h i s  secondly,  study  likely will  they are  may  i s to  very  specifically  to negative  i t s e m p h a s i s on  t o be  appropriate  Clark  cognitions  for getting  that  beliefs.  These  i t is useful  in this  phobia.  elements  model f o r  longer  m o d e l . One  to the  of  negative periods  thoughts, would  in  panic at  that  beliefs.  root  of  comes which If  exposure  then C l a r k ' s  i n d e e d be  least  the  exposure  of  is  this  f e a r and,  provide  periods  was  reduction.  behaviours  the  well  to  firstly,  cognitive  to t e s t c r i t i c a l to  of  to t h i s  may  short  superior  tied  purely  administered  their  A v a r i a n t of  transferable  provide  is  t o mere e x p o s u r e , b u t  claustrophobia  opportunities  a  are,  evident  addressing  t h e s e p r o v e t o be  and  that  i n t e r v e n t i o n and  a t e s t i n g ground f o r the  t o mind give  tested.  w e l l be  importantly,  hand, one  time p e r i o d ,  there  sets  clearly  a useful adjunct  need t o be  disorder  so  suggests that  t o be  future  study  i n d i v i d u a l s f r o m t e s t i n g out  requisites for a cognitive  This  other  short  i s that  question  t o what i s  s u b s t a n t i a l e f f e c t i n anxiety  with  and  seem an u n l i k e l y r o c k  the  f o r a very  t h o u g h t s and,  t o know t h a t  as  i s f o u n d e d . On  about  prevent are  fear  to b r i n g  negative  t o e d u c a t e p e o p l e as  i n t e r v e n t i o n , w i t h o u t doubt not  optimal  able  has  them  much l e s s aware. The  f e a r , then t h i s would  with the  cognitive  i f one  very  thoughts which f u e l  not  model  demonstrated  this  fear.  140 CLAUSTROPHOBIA AND THE BARLOW MODEL  It  would  opposition  be m i s l e a d i n g  to Clark,  since  t o s e t B a r l o w up a s b e i n g i n the s i m i l a r i t i e s  a p p r o a c h e s a r e more s t r i k i n g most o f t h e i r and  recent  i ti s I, rather  approaches  provide  One  questions  t h a n t h e y , who have  a slightly  a different  slant  their  the fact  emphasis  that  i n h i s work  a p p r o a c h h a s been h i s Though a l o t o f  e x e r c i s e s d i d make a n i m p r e s s i o n  aspects of t h i s argue  effective  that  this  phobia. Cognitive effect that  At t h i s  theorists  will  through  t h e s t r a w was by f a r t h e most  t h e one w h i c h was most l i k e l y change.  on some  was b r o u g h t a b o u t  o f t h e s e t of e x e r c i s e s , would  being  answered  disorder  for discussion.  of Barlow's  c o g n i t i v e means. The f a c t  cognitive  on p a n i c  r e m a i n as t o t h e mechanism o f i t s e f f e c t , t h e  important  this  different  Moreover,  transferred  f o r t h e i n t e r o c e p t i v e model.  interoceptive  no d o u b t  a t t e n t i o n has f o c u s e d  characteristic  enthusiasm  than the d i f f e r e n c e s .  t o a simple phobia. N e v e r t h e l e s s ,  Barlow has g i v e n does  i n their  point,  be e x p l a i n e d as to bring  the question  w i t h any d e g r e e o f c e r t a i n t y .  about  c a n n o t be  B u t even  i fthis i s  t h e mechanism o f change,  t h e n i t must be s e e n a s a n e x e r c i s e  likely  for at least  t o p r o d u c e change  many a r e a s i n w h i c h exposure  (flying,  i t i sdifficult  some p e o p l e . T h e r e a r e  or expensive to get  underground mines), and i n c r e a s i n g  treatment g e n e r a l i z a t i o n  has always been  a problem. At t h e  141  very  least  gaps;  these e x e r c i s e s  are l i k e l y  to help p l u g  i f t h e y work t h r o u g h mechanisms o t h e r t h a n  cognitive,  t h e n a w h o l e new  approach  will  such  the  h a v e b e e n opened  up.  I t was  of note  panic disorder each group  false  learned  a l a r m s was  categorizing  could  and  learned.  The  interoceptive  open up new  numbers i n  treatment  that  the experience an  open t h e d o o r  o t h e r f e a r s n o t by  on  avenues of  of s u c c e s s from  then i t might  f e a r e d , b u t by how,  described i n  s u g g e s t i v e of trends,  If i t transpired  predictive  treatment, phobias  as B a r l o w  occur i n claustrophobia.  assessment.  interoceptive  object  alarms  t h e s u c c e s s o f an  t h e f e a r was  therapeutic of  false  a r e t o o s m a l l t o be even  but p r e d i c t i n g how  also  that  the  f o r example, t h e f e a r  to  specific was  142  AN  ANALYSIS OF  A model s p e c i f i c a l l y from borrowing  ideas  CLAUSTROPHOBIA  addressing  f r o m t h e o r i s t s s u c h as  B a r l o w . However, i n t h e  final  this  around the  f e a r must be  There are other  built  points  about  f e a r s , and  anxiety  have  s i n g l e most  themes i n p a r t  and  understanding  in parallel  t h a t make i t s t a n d  alone.  i m p l i c a t i o n s f o r the  important  of  with  Elements  study  of  other  relating  t o a i r , such as  when e x i t s  characteristic Since  entrapment,  of  they  i t may  Little  light  this  study.  The  that  this  be  best  since  they  concerning  f e a r , but occur  or without  the  by  i n the  to think  i s s h e d on  element which are  no  to  Other  be  include  thoughts  s u f f o c a t i o n , which means  absence  always of as  a  suffocation.  notion  of  only  entrapment served  f e a r does seem t o h a v e a i s not  fear.  enclosed  of. c l a u s t r o p h o b i a  structured interviews the  tend  cut o f f . These  those  rarely  element of  claustrophobics  are  this  entrapment w i t h  cognitive  theme i s e s c a p e f r o m a n  stem f r o m t h i s ,  only  present.  t o what c o n s t i t u t e s t h i s  predominant c o g n i t i o n of entrapment.  reported  f e a r of  gain  f a c t s p e c u l i a r to i t .  fear that run  become c l e a r e r as  space, hence the  are  a n a l y s i s an  Clark  can  disorders.  I t has The  the  others  of both c a t e g o r i e s  claustrophobia  easily  explained.  to  in confirm  nonWhen  a s k e d about p h y s i c a l r e s t r i c t i o n ,  or  143  even f a c t o r s t h a t  induce discomfort  underground p a r k i n g , fear  unable to l i n k  of being  catastrophic  notion  outcome t h a t  t h a t h a s been a d v a n c e d  represent trapped, little  another  i s that  such f e e l i n g i n their  this.  one member  of the c o n t r o l group  debriefing)  settlement  very  when a d i v o r c e  i n d e p e n d e n c e . Though she r e p o r t e d  much l e s s t r a p p e d  on h e a r i n g  of the  a t t r i b u t e d her reduced  avoidance to t h i s  are  alternate explanations  s u c h as a r e d u c t i o n  more l i k e l y ,  gave  t h a t she settlement,  feeling,  there  i n her  explanations  e n t r a p m e n t t h a n some f o r m o f s y m b o l i c i s that  i t i s , at least i n part,  P r e p a r e d n e s s , as d i s c u s s e d is  that  l e v e l s of s t r e s s .  There a r e o t h e r ,  first  lost  before  was r e a c h e d  and  general  could  The s i n g l e r e l a t e d f i n d i n g  ( a f t e r the study but  felt  One  lives:  much o f h e r c l a u s t r o p h o b i a  financial  i s no  i n a job or i n a marriage. There i s  t o support  s t u d y was t h a t  clothing  there  they can i d e n t i f y .  form o f entrapment  f o r example,  evidence  this  her  their  u n a b l e t o remove t i g h t  r i n g s w h i c h a r e s i m i l a r , i n as f a r as t h a t  clear  in  are quite  t o any p a r t i c u l a r t h o u g h t . T h e r e a r e , t o o , m u l t i p l e  examples o f r e p o r t s or  they  s u c h a s low c e i l i n g s i n  s i g n i f i c a n c e . The a vestigial  fear.  i n the review of the l i t e r a t u r e ,  c e r t a i n l y a f a c t o r i n other  claustrophobia  of  common p h o b i a s ,  w o u l d n o t be i n c o n s i s t e n t  and a l i n k t o  i n that  t o e a r l y man:  entrapment  could  a l s o be s e e n a s a t h r e a t  a mechanism t o  avoid  s i t u a t i o n s f r o m w h i c h e s c a p e w o u l d be d i f f i c u l t  would  144  certainly of  have had  preparedness  understanding fear.  survival  seems t h e most l i k e l y  of  this  apparently  A second p o s s i b i l i t y  entrappedness experience.  is easily  In three  their  parents  as  their  own,  fearing  like  f o r them t o be  understanding o f an  non-cognitive  the  feeling  feeling  The  of  had  panic  emotional  been s e p a r a t e d  from  of b e i n g u t t e r l y  feeling  the  of  what  o r may  on  it  I t i s u n c e r t a i n whether  a r e merely d e s c r i b i n g a s i m i l a r  to  entrapment  o n e s e l f abandoned, was  trapped.  improved  aspect  to e a r l y negative  o f when t h e y  children.  route  i s t h a t the  linked  cases  reminded p a r t i c i p a n t s  of  value. A clearer  be  was they  pointing  t o a p o s s i b l e mechanism o f l e a r n i n g .  A theme t h a t had in  c l a u s t r o p h o b i a , was  control  to t h i s  structured  the  f e a r of b e i n g  there  are  the  important  role.  presence  of others  offers  indeed,  expressed  own  i f they  With r e g a r d a host  were t o  t o who  experiences, a concern  stress, about  find  so  from both i t may  fear,  and  the play why  why  to being  some on  trapped.  t h e r e do  including  to breathing  control  lose  means  support  themselves  factors  prominent  help to e x p l a i n  little  the  as  to  no  a preference  sensitivity losing  i s by  indications  T h i s may  p i c k s up  of v u l n e r a b i l i t y  this  seen  Inventories, that  unusually  their  and  fear,  i n t e r v i e w s and  participants,  be  the  b e e n p a i n t e d as b e i n g  of one's e m o t i o n s . W h i l e  peculiar  an  not  seem  to  childhood difficulties,  particularly  in front  of  145  other  p e o p l e . These t y p i c a l l y  salient  experience. This  entrapment  period of  i s n o t o b j e c t i v e l y dangerous  jamming o r an e l e v a t o r  stopping  between  A r e s u l t of the b r e v i t y o f such experiences  many c l a u s t r o p h o b i c s claustrophobic "just  i s most commonly a s h o r t  i n a s i t u a t i o n that  such as a door floors.  i n t e r a c t with a p a r t i c u l a r  i s that  have n e v e r a c t u a l l y h a d a  panic.  They have a l w a y s managed t o g e t o u t  i n t i m e " , and so a r e l e f t  with  this  n a g g i n g and  f e a r s o m e d o u b t o f what w o u l d have h a p p e n e d h a d t h e y n o t b e e n able  to leave.  sensations that if  leading  they h o l d  they c o u l d  may be t i e d to  to a panic,  assumptions  n o t make g o o d t h e i r  experience but t h i s  that  with panic  disorder.  heart  of f a m i l i a r i t y  There  started  Apart  apart  isa  from  those  that  this  i n neither  does  intense.  that  the core  an i n c r e a s e  to a belief  attack.  with panic  i s no r e a s o n t o s u g g e s t  i n a physical sensation  overinterpreted: leading  happen  assumptions  t h e y have a l r e a d y  t h e two d i s o r d e r s  now a p p e a r l i k e l y change  that  appears t o s e t c l a u s t r o p h o b i a  What may l i n k  a  escape. These  would  i s not n e c e s s a r i l y the case,  lack  makes t h e f e a r any l e s s  it  feel  t o say  i n t h o s e who h a v e h a d t h e b r i e f e s t e x p e r i e n c e  entrapment. This  feature  i t seems more a c c u r a t e  a b o u t what t h e y  to the sensations  particularly of  Rather than a h a b i t u a l m i s i n t e r p r e t a t i o n o f  i s that  i s as s i m p l e  being  i n heart  such as t h a t from t h e f a c t  a m a t t e r as  greatly beat,  f o r example,  one may be a b o u t t o have a that  this  i s an e x t r e m e l y  146  uncommon a s s o c i a t i o n , i t i g n o r e s m i s i n t e r p r e t a t i o n s are this  study  that  the  stubborn because The  nature  of  discussion, individual past,  situation.  for  to  experience  explained  one  can  experiences  as  yet  l e a d to  an  a i d t o s e t t i n g up  clients  to  test  belief  to  their  t o be  f r o m an  in  the  their  current  particularly  anxiety,  the  reasons  speculate.  personal  i d i o s y n c r a t i c negative appropriate  the  While  conditions  beliefs,  experiments  for  i t i s important under which  been g i v e n  to  mechanism t h r o u g h which such t h o u g h t s  come t o be  held.  can  often  advantage some way  of  that  first she  child.  straightforward  clear personal  to take  seem more l i k e l y  place. might  An  had,  not  on  c l e a r why  occasion,  i n c i d e n t and  to  see  how  certain  i t influenced  in  feared  f a i n t e d as  I t d i d prove t h e r a p e u t i c a l l y u s e f u l f o r her  examine t h i s  in  influential  a p a r t i c i p a n t who one  While  therapeutic  t o h a v e been so  example was  f a i n t who  the  e x a m p l e s whose m e a n i n g has  been d i s t o r t e d , i t i s s t i l l  experiences the  be  for  any  f o r m e d , l e s s a t t e n t i o n has  it  was  of  often  or  terms, but event  in  experience.  interpret their  assumptions.  aware o f  are  after reflection  a p p e a r s t o be  only  as  client  been s t r i k i n g  h a v e , f o r t h e most, e x p l o r e d  t h a t may  such  b a s e d on  i n other  cognitive link  Therapists  the  may,  a r i s e at a c e r t a i n l e v e l  which  only  they are  consciously,  This  that  catastrophic beliefs  u s e s some i n f o r m a t i o n  o f t e n not  likely  critical  easily  fact  random. I t has  i n some way  that  be  not  the  to her  a  147  present  concerns  i n anxiety-provoking  o t h e r hand, much l e s s seem t o t r i g g e r topic  i s known a b o u t why  beliefs.  This  felt  i s s u r e l y no  t h a t she was  losing  i n t o a s t a t e o f madness e v e r y claustrophobic  experiences.  why  experience  moderate l e v e l s  progress  t r a c e d to  at  treatment  o n l y on  the  place after  they  of  the  short  fear,  a l l the  i n the  three  strands  of therapy  exclusively.  As  dramatic  durable  and  much s l o w e r  one  progress. itself  those  f o r s i x weeks. A t  unable  to face the i n an  between f l o o r s . cognitive  and  who  on  had  had  made  f o l l o w i n g the of therapy  r a t h e r than  the  initially  T h e r e was  an  E i g h t of these  weekly  n a m e l y t o be  study  using  one  w o u l d have p r e d i c t e d , most made r a p i d ,  progress,  investigation.  this  r e l e v a n t data  hour  together,  even  i n t e r v e n t i o n s , but  s u b j e c t s , and  wanted  clear  situations.  i n t e r v e n t i o n , were o f f e r e d f u r t h e r p e r i o d s all  particular  effect  in particular  a  a  s h o u l d have a c e r t a i n  A l l control  than  had  as  drifting  not  a b l e t o draw n o t  been c o l l e c t e d . less  t h a t she  and  such  i t was  to the  t h a t took  examples  though,  of a n x i e t y  With r e g a r d  treatment  Here a g a i n ,  the  l e s s worthy a  control  p a n i c , c o u l d o f t e n be  personal this  time  On  certain incidents  o f r e s e a r c h . Even some more complex  s u b j e c t who  was  situations.  interesting  s u b g r o u p who area  end  of  this  unthinkable the  from t h i s  time,  o n l y one  g o a l of the  power t u r n e d  once was  group,  o f f , stuck  g r o u p were t h a t  i n t e r o c e p t i v e elements d i d indeed  made  for  f o r m e d a g r o u p w h i c h met  elevator with  Impressions  a  hasten  148  progress,  and  o f f e r e d u s e f u l o p t i o n s when t h e  exposure alone  One  issue raised  signals; fear the  appeared  perhaps  from the first  day,  many o f whom h a d  carrying fear  i s so v e r y  and  so many o f t h e  some o t h e r i t was  likely  medication,  or  not  to  some o t h e r  as  s a f e t y , and  apart  vigilance clear  to  secreted in  the  group  most  Perhaps because  does n o t less  for help with  coping  the  h a v e t o make commonly  used  somewhat  but was  travel  sedative.  at  sickness  Other  orientation  ease o f b r e a t h i n g  insistence  larger  r a n g e , h o w e v e r , was  such m i l d  looked  (such  (decongestant  strategies  on open d o o r s ,  such  as  o p e n windows  a and  exits.  /  Though i t i s n o t individualized breadth  and  unusual  f o r phobias  p a t t e r n s , there  variety  i n the case  a  to a range  to t r a z n q u i l l i z e r s  from p a r t i c u l a r  f o r and  access  The  of  a g a i n s t i t . On  include sleeping tablets,  commonly  sprays)  nature  a i d s . The  a p p e a r e d t o be  limited  participants a torch),  the  anxiety disorders, i s  p r e d i c t a b l e t h a t one  fears.  as  of  some f o r m o f m e d i c a t i o n .  than  least  to defend  characteristic  they  as  about  even s c r e w d r i v e r s  so many p r e c a u t i o n s ,  greater  used  said  reported using similar  as w i t h  around  with  be  t h a t of s a f e t y  g r o u p members s h e e p i s h l y a d m i t t e d  h a n d b a g s . T h i s was  common one,  g r o u p was  s o m e t h i n g can  torches  of  faltering.  in this  safety signals  of m e d i c a t i o n , their  t o be  effects  seems t o be  to  have  particular  o f c l a u s t r o p h o b i a . Whereas  149  in  panic  disorder, recent  cognitions this  i n general  i s only  emphasis has b e e n on t h e r o l e o f  and m i s i n t e r p r e t a t i o n s  one p a r t  of claustrophobia.  misinterpretations  of sensations,  cognitive  such as f e a r of l o s i n g  elements  foolishly. and  There  but there  c a n be s u c h  are also  Entrapment and d i s o r i e n t a t i o n a r e l e s s  there  conditioned  clearly,  of the fear.  i s t h e much more p r o m i n e n t r o l e o f  features  i n c l u d i n g s i g h t s , sounds, and s m e l l s .  Indeed i t i s o f t e n d i f f i c u l t disorientation  other  control or acting  sometimes n o t a t a l l , c o g n i t i v e f e a t u r e s  Further,  in.particular,  to categorize  something  as c o g n i t i v e o r c o n d i t i o n e d ,  since  s u c h as  i t may  have e l e m e n t s o f b o t h .  One f i n a l recent  clinical  that panic has  emphasis  i s between p a n i c  on p a n i c  i s not a necessary  already  actually  should  panicked  a n d , f o r some, t h i s  The s h e e r  not cloud  discomfort  t h e f e a r have i s not t h e i r  of anxiety  be m i n i m i z e d and may w e l l be s u f f i c i e n t  perpetuate  avoidance.  examining panic, claustrophobia occur  and a n x i e t y .  Claustrophobia  b u t t h e two s h o u l d  i s .primarily a phobia  under c e r t a i n c o n d i t i o n s .  may  alone  The  the fact  feature of claustrophobia.  been m e n t i o n e d , many w i t h  catastrophe. not  distinction  As  never worst should  t o c a u s e and  be a u s e f u l way o f  n o t be e q u a t e d : i n which p a n i c can  150  DIRECTIONS FOR FURTHER  It  seems a l m o s t  RESEARCH  i n e v i t a b l e i n such p r e l i m i n a r y  t h a t many more q u e s t i o n s  have been r a i s e d t h a n  research  answered.  T h e r e a r e no f e w e r a v e n u e s w h i c h now b e c k o n f o r a t t e n t i o n . One c o u l d about  choose t o f i n d  the i n t e r v e n t i o n s and i n s t r u m e n t s  research,  intriguing  left  does  unsolved  differentiates  interoceptive  seem t o be much v a l u e  techniques  on a g r e a t e r  o f what  v a r i e t y of anxiety  cognitive  techniques  r e h e a r s a l . There  The  utility.  i s considerable  The  f o r example,  e x p o s u r e t o g e t more  more e x p e r i e n t i a l l y  longer  disorders, to  as t o t h e i r  c o g n i t i v e techniques  against  study.  c o u l d be expanded w i t h ,  i n t r o d u c t i o n of imaginal  different  i n this  in investigating  c o u l d be u s e d f o r a much  clearer conclusions  information  between  l e a d t o an i m p r o v e d u n d e r s t a n d i n g  establish  testing  i s the i s s u e o f entrapment.  f e a r s , and f u r t h e r e x p l o r a t i o n  the i n t e r v e n t i o n s used  cognitive  t o f i n d out  t h e two.  There would  the  in this  p e r h a p s one o f t h e most  seem t o be on t h e b r i d g e  and n o n - c o g n i t i v e  e n t r a p m e n t may  period  to claustrophobia  aspects  Claustrophobia  further  more  fear.  With r e g a r d  cognitive  used  o r use the model of c l a u s t r o p h o b i a  more a b o u t  of  o u t more a b o u t c l a u s t r o p h o b i a ,  effective  scope a l s o i n  ( p r o v i s i o n of oriented  techniques,  151  for  example) t o e x p l o r e B a r n a r d  on  levels  o f meaning. A t  i n v e s t i g a t i n g how techniques from  interact  t h e d a t a on  treatment, addition  with exposure.  in light  at  implication  speeded  exposure up by  the  t h o s e most u r g e n t l y i n n e e d  might  compare w i t h t h e most  single  similar  I f ways c o u l d be d e v e l o p e d  the frequency  critical  how  belief,  or other  to those  and  of  scores  adopted  t o measure c o g n i t i o n s  anxiety-provoking situations,  useful.  be  a  they are b e l i e v e d ,  d u r a t i o n of b e l i e f s ,  h a v e been u s e d w i t h s c a l e s  must  population. L i t t l e  of combining  to which  of  pschometric  Cognitions Checklist  t h a n an a g o r a p h o b i c  w i t h the degree  least  clear  f o r d e v e l o p i n g the measures  the e f f e c t  frequency of b e l i e f s ,  very  worth  cognitive  o f t h e c h a n g e s made t o s u i t  rather  y e t known a b o u t  outside  The  c o u l d be  study. Perhaps  claustrophobic  here.  and  be w e l l  the t i m i n g of change i s t h a t  of the N e g a t i v e  established  that  (1990) work  i t will  a r e t h e c o g n i t i v e m e a s u r e s . The  properties  this  point  interoceptive  i s a l s o much s c o p e  i n this  beliefs  Teasdale's  of these methods.  attention  is  a later  even i n p h o b i a s ,  There used  both  and  this,  t o o , would  be  C l a r k ' s I n t e r p r e t a t i o n s Q u e s t i o n n a i r e (1990) i s  a start  in this  measurement must be  direction.  taken  into  Even t h e t i m i n g o f  consideration.  The g r e a t e s t  / impact One, to  of the assessment  f o r example, had  stop herself  was  to turn  shaking  delayed i n four on  participants.  the h e a t e r i n the c a r  i n a warm summer day,  while  park  another  152  had  to p u l l  are  just  o f f the road  questions  our o v e r a l l  little  study  that this  t o do t h i n g s ,  about s o c i a l  adulthood.  often  embarrassment.  Whether t h i s  o r whether t h e two a r e d i s t i n c t  these  data.  belief  system  (the fact  Medical  particular what was  found  and t h e n a g a i n i n  i s uncertain  from  why  and t h e p r e d i c t i o n o f  t o what s o r t s o f the claustrophobic  to the l a b o r a t o r y  techniques  a r e so d i f f e r e n t  t o f a r removed f r o m i t ) ,  respond  i s no r e a s o n  study.  Instead,  beliefs  to treatment,  what g r o u p s o f p e o p l e w i l l  be c o n f i n e d  that  as opposed  slow and non-responders  should  i n t h e absence of  a l s o seems a good way o f s t u d y i n g t h e  when i n t h e s i t u a t i o n  t r e a t m e n t . There  have  i s a re-emergence of t h e e a r l i e r  fear,  dual  t h a t so  when one m i g h t  m i g h t be v e r y  of the f e a r i n c h i l d h o o d  Claustrophobia  the l i f e -  One w o u l d  time of l i f e  s i g n a l s , and when t h e r e  was e v i d e n c e  of f e a r through  i n adolescence.  i s the very  w e l l be p r e s s e d  concerns  of f e a r . T h e r e a r e  i t was s u r p r i s i n g , f o r example,  f e a r was r e p o r t e d  thought  seems a u s e f u l one f o r  understanding  r e l a t e d t o the t i m i n g  In this  safety  I t w o u l d be  t o know, t o o , o f t h e c o g n i t i v e r e a c t i o n s on a  model o f c l a u s t r o p h o b i a  increasing  very  These  time-scale.  The  span.  herself trembling.  the p h y s i c a l r e a c t i o n s r e p o r t e d .  interesting longer  to stop  format used  model  i n this  such as magnetic resonance  imaging  153  (Quirk this  e t a l , 1989)  fear,  and  investigation.  /  allow a broad  f o r use  of the  fear  scope for  f o r research further  into  154  CONCLUSION  One on  task  of a c o n c l u s i o n i s to put  to a set of data.  fear  t r y t o do  must be too,  on  with  guard  the  items  discounted,  of  is precisely  what t h o s e  path  is a risk  can  be  f o r the  meaning  with  the  f o l l o w e d on w h i c h  same t i m e one  One  researcher,  i n f o r m a t i o n are used, o t h e r s  a t the  and  information at t h e i r d i s p o s a l .  f o r there  that a s i m i l a r  certain  This  patterns  i s unaware o f  only  are yet  other  factors.  The  first  important screened is  step  exclusionary  of  f a t e f o r example  were n o t likely  c l a u s t r o p h o b i c s who  included i n this  in their  research  study.  sample  p o s s i b l e that have been  They a r e and  there  excluded, who  s u r e l y e v e n more  t o be  sensitive  p h y s i c a l s e n s a t i o n s . They a r e  this  v o l u n t e e r s may  to  a group  any  that  i s a p r e - s e l e c t e d sample,  Firstly,  detail  our  t h e r e were t h e r e s u l t s  phenomenological  study.  and  have c e r t a i n d i s t i n g u i s h i n g  from the w i d e r c l a u s t r o p h o b i c p o p u l a t i o n ,  p o s s i b l e t o b r o a d e n and  fear.  is a  study.  features yet  major  of t h r e e w i t h Meuniere's d i s e a s e  Acknowledging t h a t that  sample. A  i s that this  to m i s i n t e r p r e t sensations  changes merit  criterion  the  f o r i t s good h e a l t h . I t i s very  a whole s u b s e t  the  i s to consider  I t i s unusual  it  understanding of  was  of  the  the  to give  s o much  focus  to d e s c r i p t i v e data,  but this  l e a r n i n g more a b o u t t h i s b e e n s e e n as t r i v i a l  f e a r . Though i t may  from a c l i n i c a l  f e a r w h i c h c a n have p r o f o u n d occupational nuisance  ruled the  social,  this  that  b u t , i n t h e more e x t r e m e c a s e s ,  o p p o r t u n i t i e s , and i n some c a s e s  o u t , b u t many p a r t i c i p a n t s i n t h i s on mood a n d s e l f - e s t e e m  been a t t h e i r  i t isa  even  many  when t h e i r  travel  jobs, are  a r e many study  and p l a n  options  p o i n t e d out fears  have  worst.  Claustrophobia  i s n o t a simple  seems t o be g r e a t  experience  isa  h e a l t h and e v e n  down b e c a u s e o f t h e f e a r . Not o n l y  effect  There  sometimes have  t o have t o c o n t i n u a l l y m o n i t o r o n e ' s e x i t s  social  turned  step i n  perspective,  i m p l i c a t i o n s . I t i s not merely  one's i t i n e r a r y , and  seems an i m p o r t a n t  of being  variability  trapped  accompanying s e n s a t i o n s .  fear to categorize. to the  emotional  and i n some c a s e s  I t s nature  to the  i s not easy  W i t h a wide r a n g e o f c o n d i t i o n i n g h i s t o r i e s  and a c c o m p a n y i n g  cognitions,  there  are  and i n o u t c o m e s t h a t a r e f e a r e d . What i t does  avoided  i s huge v a r i a b i l i t y  t o p i n down.  h a v e i n common w i t h predictable,  unlike panic  agoraphobia. This powerful phobia.  other  phobias  i n the s i t u a t i o n s that  i s that  i t i s at least  d i s o r d e r and t o a l e s s e r  c a n be a t t r i b u t e d t o t h e v e r y  conditioned  extent  much more  f a c t o r s which a r e such a f e a t u r e  of the  156  With regard was  to the  experimental study,  that  a purely  cognitive  reported  f e a r and  panic,  predictions control  of  a  and  e f f e c t on  of p a r t i c i p a n t s  period and  change was  intervention of  interoceptive  interest  will  i n that  f r o m the  profitable necessary with  other  even t h e  data  of  t h i s study  i f t h i s i s an  phobias.  power  of  that  There that  of  cognitive much  gained  from  quicker  i s ample  t h i s would  further research avenue t h a t  the  briefest  making them b o t h  such a d d i t i o n s .  with claustrophobia; t o see  the  seem much t o be and  as  group. N e v e r t h e l e s s ,  techniques w i t h exposure  l i e . There would  not  a  smaller  I t i s i n t h i s combination  more e f f e c t i v e by  evidence  a  s i m i l a r i n both groups,  broadening exposure techniques and  an  b e i n g m a x i m i z e d by  exposure.  i n r e l a t i o n to  i t exerted  proportion  each  space,  confident  i n t e r v e n t i o n was  in that  of  l e d t o more  finding  both  interoceptive  successful  timing  procedure d i d reduce  second e n c l o s e d  g r o u p . The  a major  be  will  w o u l d be  be  useful  157 REFERENCES A g r a s , W.S., S y l v e s t e r , D., & O l i v e a u , D. ( 1 9 6 9 ) . The e p i d e m i o l o g y o f common f e a r s and p h o b i a . C o m p r e h e n s i v e P s y c h i a t r y . 10, 151-156. American P s y c h i a t r i c A s s o c i a t i o n . s t a t i s t i c a l manual o f m e n t a l W a s h i n g t o n . DC: A u t h o r .  (1987). D i a g n o s t i c and d i s o r d e r s (3rd ed.. r e v ) .  B a n d u r a , A. ( 1 9 7 7 ) . 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The i m p o r t a n c e o f a s s e s s i n g t r e a t m e n t i n t e g r i t y : An example in the anxiety d i s o r d e r s . Journal of Behavioral Assessment, £, l - l l . V e r m i l y e a , J.A., B o i c e , R., & B a r l o w , D.H. ( 1 9 8 4 ) . Rachman and Hodgson (1974) a d e c a d e l a t e r : How do d e s y n c h r o n o u s response systems r e l a t e to the treatment o f agoraphobia? B e h a v i o r R e s e a r c h and T h e r a p y . £1, 615621. W i l l i a m s , S.L., & R a p p o p o r t , J.A. ( 1 9 8 3 ) . treatment i n t h e n a t u r a l environment B e h a v i o r T h e r a p y . 1 1 , 299-313.  Cognitive f o r agoraphobics.  W i l s o n , G.T. ( 1 9 8 6 ) . P s y c h o s o c i a l t r e a t m e n t o f a n x i e t y d i s o r d e r s . I n B.F. Shaw: A n x i e t y D i s o r d e r s . P s y c h o l o g i c a l a n d B i o l o g i c a l P e r s p e c t i v e s . New York and London: Plenum P r e s s . Wolpe, J . ( 1 9 5 8 ) . P s y c h o t h e r a p y bv r e c i p r o c a l S t a n f o r d , CA: S t a n f o r d U n i v e r s i t y P r e s s .  inhibition.  Wolpe, J . ( 1 9 8 1 ) . T h e d i c h o t o m y between c l a s s i c a l c o n d i t i o n e d and c o g n i t i v e l y l e a r n e d a n x i e t y . J o u r n a l of B e h a v i o r T h e r a p y and E x p e r i m e n t a l P s y c h i a t r y . 1 2 , 3542 . Zajonc, no  R.B. ( 1 9 8 0 ) . F e e l i n g and t h i n k i n g : P r e f e r e n c e s need i n f e r e n c e s . A m e r i c a n P s y c h o l o g i s t , 25_, 151-175. /  168 APPENDIX A:  STRUCTURED INTERVIEW  1. Do you remember any c l a u s t r o p h o b i c e x p e r i e n c e s f r o m c h i l d h o o d ? Can you d e s c r i b e i t / t h e m i n as much d e t a i l possible ? 2. Do you remember b e i n g adolescent ?  fearfully  3. What has been t h e c o u r s e o f t h i s s t a b l e , spread, reduced e t c . ?  claustrophobic  f e a r : Has  as  your as  an  i t remained  4. Do you f e e l t h a t t h e r e was a s i n g l e e v e n t i n y o u r a d u l t l i f e which p r e c i p i t a t e d your c u r r e n t c l a u s t r o p h o b i a ? 5.  Have you had r e c e n t c l a u s t r o p h o b i c e x p e r i e n c e s ? I f y e s , c h o o s e a r e p r e s e n t a t i v e one and ask f o r r e c a l l of s e n s a t i o n s what went t h r o u g h y o u r mind a t y o u r most a n x i o u s , what was t h e w o r s t you m i g h t happen 6. C u r r e n t l y what do you a v o i d d o i n g / w h e r e do you g o i n g ? ( S p e c i f i c a l l y ask a b o u t e l e v a t o r s , p l a n e s water) . 7. Do you have o r have you claustrophobia ?  had  dreams/nightmares  8. What i s t h e most f r i g h t e n i n g s i t u a t i o n r e a l i s t i c a l l y envisage ?  that  thought  avoid and u n d e r about  you  could  10. I n g e n e r a l , what a r e t h e c o n d i t i o n s t h a t i n c r e a s e y o u r f e a r s i n e n c l o s e d s p a c e s (prompt: t i m e , r e s t r i c t i o n o f movement, o t h e r s p r e s e n t , l i g h t / d a r k . . . . ) . 11. I n t h e helpful?  past  have you  f o u n d any  coping  strategies  12. Have you/do you use o r c a r r y m e d i c a t i o n i n c e r t a i n s i t u a t i o n s ? Have you u s e d a l c o h o l o r m e d i c a t i o n on a r e g u l a r b a s i s as a means o f c o p i n g w i t h y o u r f e a r ? 13. When you a r e i n an e n c l o s e d s p a c e do you r e a c h y o u r peak l e v e l o f f e a r i m m e d i a t e l y o r does i t t a k e some t i m e ? ( I f n o t i m m e d i a t e l y ) How l o n g ? 14. Do y^ou know anyone e l s e who f a m i l y members/friends) ?  has  these  fears  (prompt:  15. Do you see a common theme ( f o r e x a m p l e , a p a r t i c u l a r f e a r ) running through your c l a u s t r o p h o b i c e x p e r i e n c e s ?  169 16. Which t e r m w o u l d you see as a c c u r a t e l y d e s c r i b i n g y o u r f e a r , e n t r a p m e n t o r s u f f o c a t i o n , o r b o t h ? Do you t h i n k t h a t s u f f o c a t i o n / a c c e s s t o a i r c o n t r i b u t e s to your f e a r of e n c l o s e d s p a c e s ? I f y e s , ask f o r e l a b o r a t i o n . 17. I am u n c e r t a i n w h e t h e r l o o k i n g back you see t h e s o r t of s i t u a t i o n s you have d e s c r i b e d as b e i n g g e n u i n e l y d a n g e r o u s or j u s t that they are very unpleasant ? 18. Do you have y o u r own claustrophobic fears ? 19. I s t h e stable?  theory  which e x p l a i n s  your  f e a r g e t t i n g b e t t e r , worse o r r e m a i n i n g  20. Do you t h i n k t h a t t h i s o r i s i t w i t h you f o r l i f e  i s a fear that ?  could  be  about changed,  21. Have you e v e r s o u g h t t r e a t m e n t f o r c l a u s t r o p h o b i a ? ( I f y e s w i t h what r e s u l t ; i f no, was i t e v e r c o n s i d e r e d ?; what s p a r k e d the c u r r e n t e n q u i r y ?) 22. What a r e t h e s o r t o f t h i n g s you w o u l d most a b l e t o do i f t h i s f e a r was r e d u c e d ? 23. P a n i c : How f r e q u e n t l y h a v e you e x p e r i e n c e d c l a u s t r o p h o b i c s i t u a t i o n ? How f r e q u e n t l y have e x p e r i e n c e d p a n i c i n any o t h e r s i t u a t i o n ? How h a v e you e x p e r i e n c e d p a n i c o u t o f the b l u e ? 24. yet  Are there discussed  points ?  you  would  like  like  to  be  panic i n a you frequently  t o make t h a t we  have  not  170  APPENDIX B: ANXIETY SENSITIVITY INDEX ASI Instructions. Please respond to each statement by circling the number that opplin to you. Try to be ss accurate as possible. There are no right or wrong answers.  very little 0  a little  some  much  very much  4  2  3  ... 4  2. When I cannot keep my mind on a task, I worry that I might be going crazy. •- 0 — -  2-  3 •  --4  3. It scares me when I feel "shaky" (trembling). —  0  2-  3-  ... 4  4. It scares me when I feel faint.  0-  2-  3-  ... 4  2-  3  ... 4  2-  •3-  ... 4  2  •3-  ... 4  2  •3  ... 4  •2  •3  --- 4  •2  •3  --- 4  2  3  4  I. It is important to me not to appear nervous.  0  5. It is important to me to stay in control of my emotions.  0  6. It scares me when my heart beats r a p i d l y . — . - - 0 7. It embarrasses me when my stomach growls.  0  8. It scares me when I em nauseous.  0  9. When I notice that my heart is beating rapidly, I worry that I might have a heart attack.  0  10. It scares me when I become short of b r e a t h . — 0 11. When my stomach is upset, I worry that I might be seriously ill. I am unable to keep my 0 12. It scores me when mind on a task.  0  13. Other people notice when I feel shaky.  0  14. Unusual body sensations scare me.  0  15. When I am nervous, I worry that I might be mentally ill. - 16. It scares me when I am nervous.  - 0--0---  171  APPENDIX C: PREDICTION OF FEAR  INITIALS  TRIAL* DATE  1.  A t i t s peak, how f e a r f u l do y o u t h i n k you w i l l t e s t room? ( p l a c e a mark on t h e l i n e below)  Extremely fearful  be i n t h e  Not a t a l l fearful  172  APPENDIX  D: REPORT OF FEAR/REPORT  OF PANIC  INITIALS  TRIAL#  POST-TRIAL  ESTIMATES  1. A t i t s p e a k , how f e a r f u l were you i n t h e t e s t ( p l a c e a mark on t h e l i n e b e l o w )  room?  Extremely fearful  Not a t a l l fearful  2.  D i d you p a n i c ?  •  Yes  No IF  Did  NO  you come c l o s e t o p a n i c k i n g ?  Yes_  No.  173 APPENDIX E: NEGATIVE  COGNITIONS  CHECKLIST  INITIALS  TRIAL*  P l e a s e c h e c k o f f any o f t h e f o l l o w i n g e x p e r i e n c e d w h i l e i n t h e t e s t room.  t h o u g h t s o r i d e a s you  DID YOU THINK THAT  % BELIEVED  1.  ...you were g o i n g  2.  ...you were g o i n g t o a c t f o o l i s h l y ?  3.  ... y o u were g o i n g  4.  ...you had been  5.  . . . t h e w a l l s were c l o s i n g i n ?  6.  ...you m i g h t  7.  ...you were i n d a n g e r ?  8.  ...you were g o i n g t o l o s e  9.  ...you were g o i n g t o choke  10.  to pass out?  t o have a h e a r t  forgotten  attack?  i n t h e room?  suffocate?  control? to death?  ...you were g o i n g t o r u n o u t o f a i r to breathe?  11.  ...you were g o i n g t o f a l l ?  12.  ...you were t r a p p e d ?  13.  . . . D i d you t h i n k o f u n r e l a t e d f r i g h t e n i n g e v e n t s ( s u c h as h o r r o r s t o r i e s ) ? Describe b r i e f l y . . . .  14.  ...Other thoughts ( p l e a s e  indicate)  174 APPENDIX  F: PHYSICAL SENSATIONS  CHECKLIST  INITIALS  TRIAL #  P l e a s e c h e c k o f f any o f t h e i t e m s w h i l e you were i n t h e t e s t room.  t h a t d e s c r i b e how  % 1.  Shortness  -  Choking  2  of breath  o r smothering  sensations  3.  Too warm  4.  Tightening  5.  P a l p i t a t i o n s or accelerated heart  muscles  rate  6.  Dry mouth  7.  Relaxed  8.  Tearful  9.  Headache  10-  Chest  pain or discomfort  11. 12.  Sweating Faintness  13.  D i z z i n e s s , l i g h t headedness, or unsteady f e e l i n g s  1*.  F e e l i n g s i c k , abdominal o r any f o r m o f n a u s e a  15.  Depersonalization or d e r e a l i z a t i o n  16.  Numbness  17.  _ Flushes,  18.  Trembling  19.  Other  or tingling  sensations  hot flashes or or  distress,  shaking  (please indicate)  chills  you  felt  Unpleasant  175  APPENDIX G: GENERALIZATION TEST GENERALIZATION  Instructions for t h i s part of the assessment should be c l e a r l y presented i n the following order: 1) The subject i s invited t o make a set of predictions about how anxious they think they would feel i f they were to stay in the generalization closet. It i s emphasized 2) that this closet i s soundproof (in answer to any queries state only that there i s enough a i r for t h e i r needs, rather than getting drawn i n t o discussion of whether i t i s a i r t i g h t or not); 3 ) that the time period i s no longer exactly two minutes but can now be between two and four minutes, t h i s number being randomly drawn from a set of ten second i n t e r v a l s ; 4) that there i s no longer a buzzer and that any cry for assistance would not be heard; 5) that they are encouraged to try each situation as i t i s presented for a very short period (in the order of two seconds) to help them make accurate predictions. (When the sixth scenario i s presented, explain that the door w i l l not be locked i n these practices since no difference w i l l be f e l t or heard). The predictions should be made on a scale from 0 - 100 where 0 denotes no fear and 100 s i g n i f i e s t e r r i f y i n g fear. The situations are as follows: 1. Outer door open, inner door open , l i g h t i n room on. 2. Outer door closed, inner door open, l i g h t i n room on. 3. Outer door closed, inner door open, l i g h t o f f . 4 . Outer door closed, inner door closed, l i g h t i n room on. 5. Outer door closed, inner door closed, l i g h t i n room o f f . 6 . Outer door closed, inner door locked, l i g h t i n room o f f . Fear predictions  Willing to experience for two seconds (Y/N)  1.  2. 3.  4-. _/  5. 6.  No of s i t u a t i o n chosen  N/A  179  APPENDIX K  : TREATMENT  INTEGRITY  In any c o m p a r a t i v e t r e a t m e n t s t u d y , t h e q u e s t i o n o f t r e a t m e n t i n t e g r i t y looms l a r g e . In many s i m i l a r s t u d i e s t h e r e has b e e n a g r a v e r i s k o f c o n f u s i n g t h e d i f f e r e n t s t r a t e g i e s , and i t has been i m p e r a t i v e t o show t h a t no s u c h b l u r r i n g t o o k p l a c e . I n p r a c t i c e , i t d i d n o t t u r n o u t t o be d i f f i c u l t t o d e m o n s t r a t e i n t h i s s t u d y . The t h r e e i n t e r v e n t i o n s were q u i t e d i s t i n c t , and t h i s i s c l e a r f r o m l i s t e n i n g t o t h e t a p e s . I n o n l y t h e e x p o s u r e g r o u p were p a r t i c i p a n t s t a k e n back t o t h e a s s e s s m e n t c l o s e t t o work t h o u g h a h i e r a r c h y o f e l e m e n t s t h e y f e a r e d . In o n l y t h e i n t e r o c e p t i v e g r o u p were p a r t i c i p a n t s t a k e n t h r o u g h a r a n g e o f e x e r c i s e s t o b r i n g on s e n s a t i o n s s i m i l a r t o t h o s e t h e y experienced while anxious. In only the c o g n i t i v e group d i d t h e y examine f e a r f u l t h o u g h t s and l e a r n how t h e s e c o u l d be d i s p u t e d . The o n l y a m b i g u i t y t h a t a r o s e was when t h o s e n o t i n t h e c o g n i t i v e g r o u p e x p r e s s e d c o g n i t i v e change and s o u g h t d i s c u s s i o n or support. In these i n s t a n c e s , t h e i r o b s e r v a t i o n s were n o t i g n o r e d o r d i s m i s s e d , b u t n e i t h e r were they encouraged or taken f u r t h e r . What seems t o have been a more i m p o r t a n t i s s u e i s one t h a t c a n n o t y e t be answered: t r e a t m e n t e f f i c a c y . At t h i s p o i n t i t i s n o t known w h e t h e r i n a c o g n i t i v e i n t e r v e n t i o n one s h o u l d encourage c l i e n t s to d i s p r o v e c o g n i t i o n s f o r themselves, how i m p o r t a n t i t i s t h a t t h e y examine t h e i r own e x p e r i e n c e s w h i c h may h a v e c o n t r i b u t e d t o some o f t h e i r common c o g n i t i o n s , and how i m p o r t a n t a f f e c t may be i n c o g n i t i v e change. T h e r e a r e s i m i l a r g r e y a r e a s i n r e l a t i o n t o t h e i n t e r o c e p t i v e t e c h n i q u e s . I t i s s i m p l y n o t y e t known w h e t h e r t h e e x e r c i s e s s h o u l d be p r a c t i c e d i n s h o r t o r l o n g p e r i o d s , i n i s o l a t i o n or i n combination, with or without modelling. Much i s l i k e l y t o emerge o v e r t h e n e x t y e a r s t h a t w i l l h e l p t o e v a l u a t e t h e e x t e n t t o w h i c h t h e s e i n t e r v e n t i o n s were optimally administered.  /  180 APPENDIX  L  : ADJUSTED MEANS AT POST-TEST OUT) FOR QUESTION 1 O b s e r v e d mean  (PRE-TEST COVARIED  Adjusted  PREDICT FEAR Cognitive Exposure Interoceptive Control  49.83 2 5.00 51.33 67 .33  50 . 18 24 . 91 51.83 66 . 58  REPORTED FEAR Cognitive Exposure Interoceptive Control  21.00 15 . 92 34.42 52.58  21.52 15 . 48 34 . 14 52 . 78  REPORTED PANIC Cognitive Exposure Interoceptive Control  2 .75 2.92 2.50 2.25  2 .85 2 . 94 2.39 2 . 24  NEGATIVE COGNITIONS Cognitive Exposure Interoceptive Control  29 . 50 18 .83 81.33 251.00  31.79 3 .29 101.51 244.08  UNPLEASANT SENSATIONS Cognitive Exposure Interoceptive Control  58.33 34 . 67 106.17 284.92  54 . 37 46 . 37 107.44 275.91  HEART RATE Cognitive Exposure Interoceptive Control  90.83 79 . 50 87.75 97 . 08  89 . 56 81 . 16 89.23 95.21  PREDICT FEAR Cognitive Exposure Interoceptive Control  23.92 18 . 67 20.42 25.33  23 . 04 20 . 86 21.80 22 . 64  

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