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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 of S t r a t h c l y d e , Glasgow, 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.Psych.Sc., 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 i n THE FACULTY OF GRADUATE STUDIES (Department of Psychology) We accept t h i s t h e s i s as conforming to the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA / August 1990 © R i c h a r d Booth, 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 V K r%C,V!>T mo DE-6 (2/88) ABSTRACT The purpose of t h i s study was to i n v e s t i g a t e the process of change d u r i n g three i n t e r v e n t i o n s f o r c l a u s t r o p h o b i a , and to prov i d e d e s c r i p t i v e data about t h i s f e a r . F o r t y - e i g h t p a r t i c i p a n t s , r e c r u i t e d from the community through the l o c a l media, were randomly a s s i g n e d to one of f o u r groups: exposure to the locked t e s t c l o s e t used f o r assessment, exposure to the s e n s a t i o n s of a n x i e t y ( i n t e r o c e p t i v e exposure), m o d i f i c a t i o n of u n d e r l y i n g n e g a t i v e c o g n i t i o n s , or a c o n t r o l group. A l l i n t e r v e n t i o n s were g i v e n over three s e s s i o n s . The exposure group proved s u p e r i o r to the c o n t r o l on a wide range of measures. In the c o g n i t i v e group, scores of r e p o r t e d f e a r and p a n i c , but not p r e d i c t i o n s of f e a r or heart r a t e , were lowered, an important f i n d i n g s i n c e t h i s group had no exposure to the c l o s e t d u r i n g t r a i n i n g . The i n t e r o c e p t i v e group made some modest g a i n s , but these d i d not t r a n s l a t e i n t o r e d u c t i o n i n f e a r s c o r e s . An a n a l y s i s of the t i m i n g of f e a r r e d u c t i o n , and of treatment g e n e r a l i z a t i o n , p r o v i d e d some c l u e s as t o the mechanism of change. S t r u c t u r e d i n t e r v i e w s p r o v i d e d data on a s p e c t s of the f e a r i n c l u d i n g i t s onset, p a t t e r n s of c u r r e n t avoidance, and common s a l i e n t c o g n i t i o n s . The r e s u l t s are d i s c u s s e d i n the l i g h t of r e c e n t f i n d i n g s on panic d i s o r d e r . i i i TABLE OF CONTENTS Abstract i i Table of contents i i i L i s t of tables v L i s t of figures v Acknowledgements v i INTRODUCTION • • • • 1 APPROACHES TO ANXIETY 4 Exposure 11 Cognitive approaches 19 Interoceptive exposure 25 METHODOLOGIES 28 CLAUSTROPHOBIA 3 5 THE PRESENT STUDY 4 6 METHOD 6 0 SAMPLE SELECTION 6 0 MEASURES 61 APPARATUS 68 PROCEDURE 6 8 HYPOTHESES 74 EXPERIMENTAL STUDY:* HYPOTHESES 7 4 A PHENOMENOLOGICAL STUDY OF CLAUSTROPHOBIA: OUTLINE. 78 RESULTS 79 EXPERIMENTAL STUDY 7 9 PHENOMENOLOGICAL STUDY 98 The Sample 9 8 Pre-Interview Questionnaires 100 Cognitions and Physical Sensations. 104 , Structured Interviews 107 DISCUSSION , 122 DIRECTIONS FOR FURTHER RESEARCH 150 CONCLUSION 154 i v REFERENCES 157 APPENDICES 168 Appendix A : Structured interview 168 Appendix B : Anxiety Sens i t i v i t y Index 170 Appendix C : Prediction of fear 171 Appendix D : Report of fear/Report of panic 172 Appendix E : Negative Cognitions Checklist 173 Appendix F : Physical Sensations Checklist 174 Appendix G : Generalization Test 175 Appendix H : Consent Form 176 Appendix I : Consent Form (Control Group) 177 Appendix J : Debriefing Report 178 Appendix K : Treatment Integr ity 179 Appendix L : Adjusted means for question 1 180 / V LIST OF TABLES TABLE 1 Summary and timing of assessment 67 TABLE 2 Means and standard deviations for seven variables pre- and post- intervention 83 TABLE 3 Univariate ANCOVAs on post-intervention differences between the four groups 84 TABLE 4 Significance of the differences between the three interventions and the control group 85 TABLE 5 Means and standard deviations for seven variables at pre-intervention, post- intervention, and at follow-up 88 TABLE 6 Univariate ANCOVAs on differences between the three intervention groups, for time, and group x time, at post-intervention and follow-up 89 TABLE 7 Predicted anxiety at six time points during fear reduction 93 TABLE 8 Planned comparisons on the timing of change in the three interventions 95 TABLE 9 Selected findings from the structured interview.... 109 LIST OF FIGURES FIGURE 1 Predicted anxiety at six time points during fear reduction. . . . 94 ACKNOWLEDGEMENTS I take p l e a s u r e i n acknowledging the h e l p of a v a r i e t y of people. The 48 p a r t i c i p a n t s o f t e n showed gre a t courage i n t a k i n g p a r t , and t h e i r i n t e r e s t i n the study at times r e v i v e d a sagging s p i r i t . I a p p r e c i a t e d the he l p and support of my c o l l e a g u e s Debbie Sansom, L o r i T a y l o r , Cindy Lopatka, and Steve T a y l o r . The a s s i s t a n c e of Maureen W h i t t a l was i n v a l u a b l e . D i m i t r i Papageorgis was p a i n s t a k i n g i n h i s e d i t o r i a l a d v i c e . But, above a l l , I wish to express my g r a t i t u d e to my s u p e r v i s o r Jack Rachman who, i n many ways, made the years d u r i n g which t h i s was w r i t t e n both happy and memorable. 1 INTRODUCTION In 1980 a conference was h e l d i n Albany, New York, to d i s c u s s the most promising d i r e c t i o n s f o r b e h a v i o u r a l approaches to a n x i e t y d i s o r d e r s (see Barlow & Wolfe 1981). One of the main recommendations was t h a t t h e r e should be f a r l e s s emphasis on s t r a i g h t f o r w a r d outcome s t u d i e s , which have done l i t t l e to enhance our knowledge of why c e r t a i n treatments appear to be more e f f e c t i v e than o t h e r s . T h i s c a l l f o r a g r e a t e r emphasis on process v a r i a b l e s has been l e s s heeded i n s t u d i e s of simple phobias than other a n x i e t y d i s o r d e r s . I f i t was f e l t t h a t at l e a s t i n t h i s area an e f f i c a c i o u s treatment had been developed, and t h a t such work would consequently be of l i t t l e v alue, then such a c o n c l u s i o n would have been premature indeed. Not only are there s e r i o u s l i m i t a t i o n s to our knowledge of what u n d e r l i e s performance-based procedures, but there i s c o n t r o v e r s y over how such techniques can be f u r t h e r developed. Even at the time of t h a t conference i n Albany, i t was r e c o g n i z e d that improvement r a t e s i n the treatment of simple phobia had been overestimated. M a v i s s a k a l i a n and Barlow (1981) p o i n t e d out that i f one takes account of those u n w i l l i n g or unable to complete treatment ( t h e i r estimate i s 25%), as w e l l as those who are'unimproved as a r e s u l t of treatment, s u c c e s s f u l i n t e r v e n t i o n s number l e s s than one i n two, h a r d l y a s t a t i s t i c to encourage complacency. There i s no evidence to suggest more o p t i m i s t i c c u r r e n t f i g u r e s . 2 T h i s study s t a r t s w i t h the premise that p r o c e s s r e s e a r c h i s c a l l e d f o r i n the study of simple phobias f o r both p r a c t i c a l and t h e o r e t i c a l reasons. The focus w i l l be on c l a u s t r o p h o b i a , a simple phobia yet s h a r i n g common f e a t u r e s with some of the more widespread a n x i e t y d i s o r d e r s . Though the former are g e n e r a l l y c o n s i d e r e d to be impervious to c o g n i t i v e i n t e r v e n t i o n , c l a u s t r o p h o b i a may be unusual i n the s t r e n g t h with which a s s o c i a t e d c o g n i t i o n s are h e l d (see Rachman, Booth, & W h i t t a l , 1988), and so may be l e s s r e s i s t a n t to c o g n i t i v e m o d i f i c a t i o n . Barlow (1988) has even s t a t e d that c l a u s t r o p h o b i a may be a case of p a n i c d i s o r d e r with more l i m i t e d avoidance, a suggestion which opens up i n t r i g u i n g p o s s i b i l i t i e s . In p a r t i c u l a r , i t h e i g h t e n s c u r i o s i t y about the r o l e of c o g n i t i o n s i n simple phobias as opposed to p a n i c d i s o r d e r , where they have been more commonly i m p l i c a t e d (see Beck 1987, C l a r k 1987). No l e s s i s the i n t e r e s t i n the p h y s i c a l s e n s a t i o n s of a n x i e t y , p a r t i c u l a r l y w i t h the s u g g e s t i o n t h a t exposure t o such sensa t i o n s can add much to p s y c h o l o g i c a l treatments of panic d i s o r d e r (Barlow & Cerny, 1988). ( In c o n t r a s t to treatment outcome s t u d i e s , the i n t e n t i o n w i l l be'to look a t s h o r t e r i n t e r v e n t i o n s and study change at a v a r i e t y of p o i n t s . In t h i s study one of t h r e e i n t e r v e n t i o n s i s g i v e n to v o l u n t e e r p a r t i c i p a n t s , two of which, i n i s o l a t i o n , a r e f a r from what a c l i n i c i a n would u s u a l l y propose, and about whose e f f e c t one can as yet o n l y s p e c u l a t e . The f i r s t i s one which focuses e x c l u s i v e l y on c o g n i t i o n s , c h a l l e n g i n g and attempting to change the f r i g h t e n i n g thoughts which the s u b j e c t s r e p o r t , but without the u s u a l accompanying exposure and b e h a v i o u r a l assignments. The second i s i n t e r o c e p t i v e exposure i n which the s u b j e c t s are exposed to t h e i r f e a r e d s e n s a t i o n s of a n x i e t y (such as h e a r t r a c i n g and d i z z i n e s s brought on by o v e r b r e a t h i n g ) , a g a i n without c o n t a c t with the feared s t i m u l u s . The t h i r d i n t e r v e n t i o n , and the only one which i n v o l v e s c o n t a c t w i t h a c l a u s t r o p h o b i c s i t u a t i o n , i s the standard p r o t o c o l f o r exposure i n which the s u b j e c t i s exposed to i n c r e a s i n g l y a n x i e t y - p r o v o k i n g cues ordered on an i n d i v i d u a l i z e d 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 s u b j e c t s are assessed at two p o i n t s , but without any i n t e r v e n t i o n . While the l a t t e r two groups o f f e r a base from which to gauge change, i t i s emphasized t h a t the study aims not to focus on which of the three i s the most e f f e c t i v e , but on the changes t h a t take p l a c e i n each of the groups. By m o n i t o r i n g change at d i f f e r e n t p o i n t s and with d i f f e r e n t methods d u r i n g the i n t e r v e n t i o n s , and, i n a d d i t i o n , through the i n c l u s i o n of d e s c r i p t i v e data, i t i s hoped to b e t t e r understand what u n d e r l i e s the f e a r , what c o n t r i b u t e s to i t s m o d i f i c a t i o n , and the manner i n which f e a r r e d u c t i o n o c c u r s . 4 APPROACHES TO ANXIETY A s t r i k i n g f e a t u r e of the p s y c h o l o g i c a l l i t e r a t u r e on a n x i e t y i s the s t r e n g t h of the t h e o r e t i c a l approaches which are o f t e n d a r i n g , i m a g i n a t i v e , and s t i m u l a t i n g . A l a s , the s t u d i e s s t i m u l a t e d by such t h e o r i e s have not been s i m i l a r l y i m a g i n a t i v e and, more s e r i o u s l y , the r e s u l t i n g data have too seldom been s u p p o r t i v e , a not i n c o n s i d e r a b l e drawback t o any theory. T h i s review of p s y c h o l o g i c a l approaches does not s e t out to be exhaustive, but r a t h e r aims to i n t r o d u c e concepts t h a t w i l l be d i s c u s s e d throughout the study. A good example, though not one o f t e n mentioned, i s Easterbrook's (1959) concept of "narrowing of a t t e n t i o n " d u r i n g emotional a r o u s a l . He proposed not only t h a t a t t e n t i o n narrowed as emotion became more i n t e n s e , but that cues r e l e v a n t to the emotion became more s a l i e n t a t the expense of co n c u r r e n t a t t e n t i o n to i r r e l e v a n t s t i m u l i . I t i s not u n c h a r a c t e r i s t i c i n the f i e l d t h a t some 30 years l a t e r , there i s s t i l l r e l a t i v e l y l i t t l e known about the r e l a t i o n s h i p between the i n t e n s i t y of emotion and c o g n i t i o n . The common c l i n i c a l o b s e r v a t i o n t h a t severe a n x i e t y and panic seem to e x e r t a numbing e f f e c t on competing r a t i o n a l c o g n i t i v e a c t i v i t y i s beyond d i s p u t e but, f u r t h e r than t h i s , more c o m p l e x i t i e s have been noted 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 ( G i l l i g a n & Bower, 1984). 5 A l i n k from t h i s to more contemporary t h e o r i z i n g can be found i n the work of Barlow whose o u t s t a n d i n g r e c e n t work (1988) w i l l be f r e q u e n t l y r e f e r r e d to i n t h i s study. An important c o n s t r u c t i n h i s approach i s that of "anxious apprehension" which i s not u n r e l a t e d to Easterbrook's o b s e r v a t i o n s . Barlow suggests t h a t the p e r c e p t i o n of p h y s i o l o g i c a l sensations i s a cue to s e l f - f o c u s e d a t t e n t i o n , p a r t i c u l a r l y of a s e l f - e v a l u a t i v e nature. He goes f u r t h e r by s u g g e s t i n g that these concerns are almost always n e g a t i v e , t h a t they are matched by an i n c r e a s e i n the i n t e n s i t y of the p r e v a i l i n g emotion, and that there i s a f a i l u r e to h a b i t u a t e to e x t e r n a l s t i m u l i i n t h i s a t t e n t i o n a l mode (see a l s o S c h e i e r , Carver & Matthews, 1983). A second h i s t o r i c a l landmark a f t e r Easterbrook was a p p r a i s a l theory o u t l i n e d by Schachter and Singer i n 1962. They proposed that g e n e r a l i z e d a r o u s a l would be a p p r a i s e d depending on the context i n which i t occurred. T h e i r s has been an i n f l u e n t i a l t r a i n of thought, though the theory as a whole has been h e a v i l y c r i t i c i z e d . The o r i g i n a l experiment has never been s u c c e s s f u l l y r e p l i c a t e d (e.g. M a r s h a l l & Zimbardo, 1979); unexplained a r o u s a l tends to be always r e p o r t e d n e g a t i v e l y ; and, most damaging of a l l , r e p o r t s and behaviour a s s o c i a t e d w i t h a n x i e t y can c l e a r l y occur i n the absence of a r o u s a l (Barlow & M a v i s s a k a l i a n , 1981). 6 There i s , n e v e r t h e l e s s , a l i n k between a p p r a i s a l theory and the work of Aaron Beck (e.g. Beck & Emery, 1985), although the l a t t e r i s more a c c u r a t e l y seen as a theory of a n x i e t y d i s o r d e r s r a t h e r than a theory of a n x i e t y . His t h e o r i z i n g i s c o n f i n e d l a r g e l y to i n s t a n c e s where danger i s m i s p e r c e i v e d or exaggerated. He has taken the s t r u c t u r e from h i s very s u c c e s s f u l work on d e p r e s s i o n , and f o r the most i t appears to t r a n s f e r w e l l . The problems are seen as being focused on hypervalent c o g n i t i v e schemata where r e a l i t y i s c o n t i n u a l l y i n t e r p r e t e d as dangerous. States of a n x i e t y are thus a s s o c i a t e d with thoughts and images r e l e v a n t to danger. Therapy i s d i r e c t e d a t f i n d i n g and c o r r e c t i n g the d i s t o r t i o n s i n the p r o c e s s i n g of t h i s i n f o r m a t i o n . A weakness of the model i s not t h a t c l i e n t s have to be t r a i n e d to f i n d t h e i r automatic thoughts (a not unreasonable assumption) but that i t can be d i f f i c u l t to "disprove" t h a t there are u n d e r l y i n g c o g n i t i o n s - at what p o i n t can i t be accepted t h a t a c l i e n t c o u l d e x p e r i e n c e n o n - c o g n i t i v e a n x i e t y ? While i t i s a l r e a d y c l e a r t h a t anxious p a t i e n t s do s e l e c t i v e l y p e r c e i v e t h r e a t more o f t e n than nonanxious p a t i e n t s , and that automatic thoughts of t h r e a t are o f t e n r e p o r t e d , two p o i n t s o f t e n r a i s e d i n r e l a t i o n to the theory are a l s o l i k e l y to be important i s s u e s here. The f i r s t i s whether anxious c o g n i t i o n s always do precede the a n x i e t y . Evidence i s by no means c l e a r and the argument t h a t the p r e c e d i n g automatic thoughts or schemata have simply not been d i s c o v e r e d i s , as mentioned, l e s s 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 merel epiphenomena, and that both they and the a n x i e t y response have a cause t h a t l i e s elsewhere ( B e i d e l & Turner, 1986; Hallam, 1985). S e l f e f f i c a c y , one of the c e n t r a l t e n e t s of Bandura (1977), shows the importance which he a l s o p l a c e s on the r o l e of c o g n i t i o n s i n a n x i e t y . He has t h e o r i z e d that i n c r e a s i n g one's sense of s e l f e f f i c a c y or competence i n mastering a f e a r e d s i t u a t i o n leads to s u c c e s s f u l a n x i e t y r e d u c t i o n treatments. He observed t h a t d i r e c t b e h a v i o u r a l experience and accomplishments probably c o n s t i t u t e the most powerful means of i n c r e a s i n g one's sense of s e l f confidence and e f f i c a c y , but that other procedures ( i n f o r m a t i o n , watching others perform s u c c e s s f u l l y ) can c o n t r i b u t e to the p e r c e p t i o n . A l l of these v a r i o u s i n p u t s then summate to produce s e l f e f f i c a c y . Barlow (1988) p o i n t s out that the c o n s t r u c t i s l i m i t e d i n that i t o n l y p r e d i c t s performance. Others have been r a t h e r harsher, n o t a b l y Borkovec (1978), who suggested t h a t s e l f e f f i c a c y i s more a r e f l e c t i o n of change than i t s mediator. However i t i s a concept that has s t i m u l a t e d a g r e a t d e a l of r e s e a r c h , much of i t s u p p o r t i v e (Williams & Rappoport, 1983). Lang's (1985) " b i o i n f o r m a t i o n a l approach" i s r a t h e r harder to e v a l u a t e s i n c e i t has not yet generated much data At t h i s p o i n t , at l e a s t i t can be s a i d t h a t i t numbers some 8 important admirers (Barlow, 1988; P r i t c h a r d , 1990; Seligman, 1987). Emotion i s c o n c e p t u a l i z e d as " a c t i o n t e n d e n c i e s " s t o r e d i n memory and accessed i n a v a r i e t y of ways, a l l of which i n v o l v e the p r o c e s s i n g of i n f o r m a t i o n . I t c l e v e r l y bypasses the requirement of an i n t e r v e n i n g c o g n i t i v e a p p r a i s a l s i n c e "meaning p r o p o s i t i o n s " (which are b a s i c a l l y c o g n i t i v e i n t e r p r e t a t i o n s ) are only one type of p r o p o s i t i o n among many, none of which are seen as e s s e n t i a l antecedents. Meaning, cont e x t , a r o u s a l and a host of other p r o p o s i t i o n s a l l c o n t r i b u t e to the l i k e l i h o o d t h a t an emotion w i l l be accessed. Weak or incomplete matching of p r o p o s i t i o n s may only l e a d to p a r t of the response, but i f most p r o p o s i t i o n s are matched then an emotion can be accessed a t a strong l e v e l , even i f one p r o p o s i t i o n i s completely m i s s i n g . I t i s a theory i n c o n s t r u c t i o n and, as s t a t e d , as y e t only weakly supported. A f u r t h e r shortcoming i s an o v e r r e l i a n c e on p s y c h o p h y s i o l o g i c a l r e c o r d i n g as the primary dependent v a r i a b l e . I t i s , though, h i g h l y c r e a t i v e and i m a g i n a t i v e and another theory to which I w i l l have cause to r e f e r . There i s l i k e l y to be more i n t e r e s t i n Lang's work with the i n t e r e s t being generated by Barnard and Teasdale's l a t e s t paper (1990) which analyzes the r e l a t i o n s h i p between c o g n i t i d n and a f f e c t u s i n g s i m i l a r r e p r e s e n t a t i o n a l and i n f o r m a t i o n p r o c e s s i n g c o n s t r u c t s . In t h i s framework, too, there i s an emphasis on d i f f e r e n t forms of mental r e p r e s e n t a t i o n encoding i n f o r m a t i o n : nine d i f f e r e n t types of 9 i n f o r m a t i o n are s p e c i f i e d which can c o n t r i b u t e to the p r o d u c t i o n of emotion. A major i m p l i c a t i o n of such a system i s that there i s a d i s t i n c t i o n between two l e v e l s of meaning. The f i r s t 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 be expressed i n the form of statements t h a t can be e v a l u a t e d as t r u e or f a l s e . The second i s termed " i m p l i c a t i o n a l " , where code p a t t e r n s a l s o i n c l u d e elements d e r i v e d d i r e c t l y from sensory sources. While the former i s o f t e n the focus of a t t e n t i o n i n c o g n i t i v e therapy, Barnard and Teasdale argue t h a t attempts to modify the l a t t e r are l i k e l y to be more s u c c e s s f u l , and c a l l on c o g n i t i v e t h e r a p i s t s to i n c o r p o r a t e some of the more e x p e r i e n t i a l l y o r i e n t e d p s y c h o t h e r a p e u t i c s t r a t e g i e s (Greenberg & S a f r a n , 1987). These are a l l , at l e a s t i n a l o o s e sense, c o g n i t i v e t h e o r i e s of a n x i e t y , c e r t a i n l y the most popu l a r c u r r e n t f o c u s . I t should not be thought that c o g n i t i o n s are thus the accepted core of a n x i e t y . On the c o n t r a r y , as s h a l l be seen i n a l a t e r s e c t i o n , experimental attempts to i s o l a t e the c o n t r i b u t i o n of c o g n i t i v e procedures have almost i n v a r i a b l y been d i s a p p o i n t i n g . There are a l s o many t h e o r i e s which ignore or downplay the c o g n i t i v e r o l e , n o t a b l y Zajonc's (1980) n o n - c o g n i t i v e view of a r o u s a l . / The only such theory to be o u t l i n e d here i s the work of Seligman on "preparedness". Seligman and Hager i n 1972 put forward the i n t e r e s t i n g n o t i o n that g e n e t i c endowment 10 p r o v i d e s a s p e c i a l i z e d a s s o c i a t i v e apparatus t h a t determines how r e a d i l y an organism can be i n f l u e n c e d by e x p e r i e n c e . A c c o r d i n g to the p r i n c i p l e of preparedness, organisms are b i o l o g i c a l l y c o n s t r u c t e d , through e v o l u t i o n a r y s e l e c t i o n , to a s s o c i a t e c e r t a i n events more e a s i l y than o t h e r s . They l e a r n b i o l o g i c a l l y primed a s s o c i a t i o n s with minimal output, but the unprepared a s s o c i a t i o n s p a i n s t a k i n g l y i f at a l l . While s u b s t a n t i a l evidence can be m a r s h a l l e d to support b i o l o g i c a l preprogramming i n subhuman s p e c i e s , v e r i f i c a t i o n of i n n a t e preparedness i n humans i s much more complicated than i t might at f i r s t appear. The t h e o r y , while s t i m u l a t i n g , i s undergoing e l a b o r a t i o n (see McNally, 1987) but i t i s s t i l l w i d e l y h e l d t h a t at l e a s t some p a r t of the f e a r response may be i n n a t e . The purpose of t h i s s e l e c t i v e overview has been to i n t r o d u c e concepts t h a t w i l l be used i n t h i s study. Others w i l l a l s o be i n t r o d u c e d but i n the context of the t h r e e major approaches to a n x i e t y : exposure to the f e a r e d s i t u a t i o n , c o g n i t i v e therapy and, most r e c e n t l y , exposure to the f e a r e d s e n s a t i o n s . Exposure In t r y i n g to convey the c u r r e n t s t a t u s of what i s understood about exposure, I am reminded of a r e c e n t I r i s h Prime M i n i s t e r noted as an academic, r a t h e r than w e l l s u i t e d to the cut and t h r u s t of p o l i t i c s . He used to be r e g u l a r l y lampooned f o r d i s m i s s i n g p r a c t i c a l ideas because he was u n c e r t a i n how they would work i n theory. A s i m i l a r problem a r i s e s with exposure. No one doubts that i t works, but i t i s s t i l l not c l e a r how i t s e f f e c t s are achieved (Foa & Kozak, 1986). I t had seemed q u i t e s t r a i g h t f o r w a r d f o r a p e r i o d of time, both how f e a r was l e a r n e d and how i t c o u l d best be reduced. In the 1950s i t was very s t r o n g l y argued t h a t a l l phobias were learned simply through traumatic c o n d i t i o n i n g (e.g. Wolpe, 1958). The success of behaviour therapy with phobias strengthened t h i s assumption about e t i o l o g y . By the l a t e 1960s, however, i t was becoming c l e a r that t r a u m a t i c c o n d i t i o n i n g alone c o u l d not account f o r the g e n e s i s of phobic r e a c t i o n , s i n c e c o n d i t i o n i n g c o u l d not accommodate s e v e r a l f a c t s about c l i n i c a l phobias. Among other o b j e c t i o n s , these were the s e l e c t i v i t y of phobias, the f a i l u r e of phobias to e x t i n g u i s h d e s p i t e repeated exposure to the CS, and the f a c t t h a t f e a r s and phobias can be a c q u i r e d through simple p r o v i s i o n of i n f o r m a t i o n as w e l l as v i c a r i o u s l y (Rachman 1977, 1978). 12 The e x p l a n a t i o n s f o r why exposure should work seemed to be s i m i l a r l y s t r a i g h t f o r w a r d . The p r i n c i p l e s of both h a b i t u a t i o n and e x t i n c t i o n each appeared to have s t r o n g cases. However among a host of o t h e r shortcomings, the theory of h a b i t u a t i o n cannot account f o r much of the data on the r e t u r n of f e a r (e.g., see Craske & Rachman, 1987). S i m i l a r l y , proponents of " e x t i n c t i o n " have d i f f i c u l t y i n e x p l a i n i n g a s e r i e s of p o i n t s , such as a n x i e t y r e d u c t i o n o c c u r r i n g even though s u b j e c t s are allowed to escape from the f e a r e d s i t u a t i o n before maximum a n x i e t y has been reached (Rachman e t a l , 1986). N e i t h e r have more r e c e n t t h e o r i e s proved more s a t i s f a c t o r y . Barlow i s perhaps being u n n e c e s s a r i l y harsh when he says of "toughening up", a b i o l o g i c a l model of f e a r r e d u c t i o n , t h a t " i t has l i t t l e t h e o r e t i c a l meat" and i s no more than a " d e s c r i p t i o n of p r o c e s s e s " . However he has more grounds to say of a l l three t h e o r i e s : "In a d d i t i o n to poor s p e c i f i c a t i o n of what i s "learned" d u r i n g exposure, none e a s i l y accommodates the n o t i o n af a n x i e t y as a c o n s t r u c t of three r e l a t i v e l y independent response systems". I t must then be asked what has become of the n o t i o n t h a t f e a r can be l e a r n e d by process of a s s o c i a t i o n . In c e r t a i n c i r c l e s i t appears to have become almost u n f a s h i o n a b l e to acknowledge t h a t f e a r can be l e a r n e d i n such a way. Bandura (1986), n o t a b l y , g i v e s i t scant 13 a t t e n t i o n . T h i s seems u n f o r t u n a t e , f o r w i t h i n a remarkably short space of time a v a r i e t y of techniques based on t h i s p r i n c i p l e have hel p e d l a r g e numbers of people. (Just how recent a phenomenon i t i s , i s i l l u s t r a t e d i n the f a c t t h a t one of i t s most v o c i f e r o u s proponents, Isaac Marks, d i d not even l i s t exposure i n the index of h i s major book i n 1969). A f t e r t e n t a t i v e beginnings with Meyer i n London i n 1963, and a f u r t h e r decade c h a r a c t e r i z e d by l i m i t e d enthusiasm, exposure has achieved broad acceptance as a powerful technique. Rather than t e d i o u s l y o u t l i n i n g the paradigm of c l a s s i c a l f e a r c o n d i t i o n i n g , I favour Barlow's approach i n which he g i v e s an example to r e f r e s h i t i n memory, namely the widespread a c q u i s i t i o n of c o n d i t i o n e d nausea i n cancer p a t i e n t s undergoing chemotherapy (e.g., Redd & Andrykowski, 1982). That these p a t i e n t s develop moderate to severe nausea r e a c t i o n s t o " n e u t r a l s t i m u l i " a s s o c i a t e d w i t h n u r s i n g s t a f f a d m i n i s t e r i n g the therapy, i s an e x c e l l e n t example of t h i s fundamental law of l e a r n i n g . Among f a c t o r s t h a t seem to account 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 i s the st r e n g t h of the nausea-producing p r o p e r t i e s of the drug (the DCS) and the i n t e n s i t y of the i n i t i a l r e a c t i o n . But g i v e n an a p p r o p r i a t e l y powerful combination, an i n t e n s e f e a r can be c o n d i t i o n e d i n j u s t a s i n g l e t r i a l . 14 However, a common f i n d i n g on q u e s t i o n i n g phobic i n d i v i d u a l s i s t h a t , p a r t i c u l a r l y with more simple f e a r s , i t i s q u i t e unusual f o r them to have had such a c l e a r l e a r n i n g experience. T h i s poses a problem u n l e s s one i s to adopt an extreme p o s i t i o n such as that phobics p r i m a r i l y p i c k up t h e i r f e a r s v i c a r i o u s l y . The d i s c r e p a n c y has been i n g e n i o u s l y e x p l a i n e d by Barlow (1988). He argues that the f e a r s are c o n d i t i o n e d not by a traumatic event but by a " f a l s e alarm". An example i s p r o v i d e d i n a r e t r o s p e c t i v e study of d r i v i n g phobics by Munjack (1984). Though s i x of h i s 30 s u b j e c t s r e p o r t e d a traumatic i n c i d e n t , such as a c o l l i s i o n , t h a t appeared to cause t h e i r f e a r , twice t h a t number r e p o r t e d no such i n c i d e n t . For no reason that they c o u l d i d e n t i f y , they had "panicked" while d r i v i n g and now f e a r e d d r i v i n g a g a i n because of the p o s s i b i l i t y of having f u r t h e r unexpected panic a t t a c k s . I t i s e x a c t l y t h i s s o r t of f a l s e alarm, when of a s u f f i c i e n t i n t e n s i t y , t h at causes l e a r n i n g t o occur and causes the i n d i v i d u a l to be anxious i n the presence of the (or a s i m i l a r ) o b j e c t or s i t u a t i o n i n which the f i r s t f a l s e alarm o c c u r r e d . The model has not been f u l l y worked through by Barlow, but he does b e l i e v e that a f a l s e alarm i s l i k e l y to become a l e a r n e d alarm i f the context i s "prepared" i n some way. The example he g i v e s i s s i t u a t i o n s from which escape may be d i f f i c u l t , of more than 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 focus of t h i s study. 15 Most r e s e a r c h on f a l s e alarms has t.aken p l a c e with p a n i c - d i s o r d e r e d p a t i e n t s . I t i s c l e a r t h a t " i n t e r n a l " cues can become a s s o c i a t e d w i t h f a l s e alarms and t h a t they can come to s i g n a l the p o s s i b i l i t y of another f a l s e alarm. Whether such i n t e r n a l cues can serve a s i m i l a r f u n c t i o n i n simple phobias i s not yet known; i t had c e r t a i n l y been assumed t h a t only e x t e r n a l cues can p l a y t h i s r o l e . There i s a v a r i e t y of evidence to show t h a t p a t i e n t s w i t h panic d i s o r d e r do f e a r i n t e r o c e p t i v e cues (Reiss et a l , 1986; van den Hout et a l , 1987), but one needs to r e f l e c t on how f e a r 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 or i n t e r n a l cues. Barlow maintains t h a t d u r i n g a f a l s e alarm, u n l i k e a t r u e one, " a t t e n t i o n may be a l l o c a t e d i n many d i f f e r e n t ways, si n c e there i s no obvious cause f o r alarm". I f one experiences a f a l s e alarm at home, i t i s more l i k e l y t h a t a t t e n t i o n w i l l be f o c u s e d on i n t e r n a l cues a s s o c i a t e d with the f a l s e alarm. On the other hand, i f one experiences the f u l l e f f e c t s of a f a l s e alarm while unable to escape, then the l a r g e s t share of a t t e n t i o n i s l i k e l y to be d i r e c t e d at the "trapped" s i t u a t i o n . Barlow i s c l e a r t h a t most of those who experience f a l s e alarms are u n l i k e l y to f e a r one or the other e x c l u s i v e l y , but are l i k e l y to be apprehensive about a v a r y i n g mixture of i n t e r n a l and e x t e r n a l cues. Thus i t i s f a r from s a f e to presume, f o r example, t h a t c l a u s t r o p h o b i c s w i l l n e c e s s a r i l y f e a r o n l y e x t e r n a l cues and agoraphobics only i n t e r n a l cues, although such a t r e n d may appear. I t i s not, however, f u l l y c l e a r why a c l a u s t r o p h o b i c should f e e l 16 "safe" i n a range of s i t u a t i o n s i n which the agoraphobic would not. Norton et a l (1986) have p o i n t e d out that many more people seem to experience alarms ( f a l s e and learned) than those who a c t u a l l y p r e s e n t with c l i n i c a l d i s o r d e r s . One p o s s i b i l i t y t h a t Barlow proposes i s t h a t the alarms simply may not be of s u f f i c i e n t i n t e n s i t y to r e s u l t i n c l i n i c a l c o m p l i c a t i o n . But another and more l i k e l y p o s s i b i l i t y i s that people who develop f u l l - b l o w n panic or phobic d i s o r d e r s , are s p e c i f i c a l l y s u s c e p t i b l e to d e v e l o p i n g a n x i e t y over t h e i r alarms because of a combination of i n d i v i d u a l b i o l o g i c a l and p s y c h o l o g i c a l f a c t o r s . Among the f a c t o r s he suggests are b i o l o g i c a l l y based s t r e s s r e a c t i v i t y , 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 and u n c o n t r o l l a b i l i t y of the alarms or other n e g a t i v e events, and poor coping s k i l l s or s o c i a l support. I f these p o i n t s c a s t a r a t h e r new l i g h t on the method of f e a r a c q u i s i t i o n , then there i s s t i l l the q u e s t i o n of f e a r r e d u c t i o n to c o n s i d e r . Though the t h e o r e t i c a l wrangling seems set to c o n t i n u e , a t l e a s t there i s agreement t h a t the broad method of exposure works. Debate now focuses on questions such as whether a person should be s t r o n g l y encouraged not to escape from a f e a r e d s i t u a t i o n d u r i n g exposure (see de S i l v a & Rachman, 1984; Rachman e t a l , 1986), how i n t e n s i v e exposure should be (Jansson & Ost, 17 1982) and what i s the best r o l e f o r the t h e r a p i s t (Mathews et a l , 1981). These may seem r a t h e r p e r i p h e r a l questions f o r a technique that has shown i t s e l f so powerful, but i t i s s a l u t a r y to look more c l o s e l y a t r a t e s of c l i n i c a l improvement a f t e r treatment w i t h exposure. Though s t a t i s t i c s are l e s s r e a d i l y a v a i l a b l e f o r a simple phobia such as c l a u s t r o p h o b i a , the f i g u r e s from agoraphobia g i v e some cause f o r concern. For agoraphobia, and there i s no reason to suppose that i t i s u n t y p i c a l , c l o s e r a n a l y s i s has shown t h a t t h e r e are many examples of f a i l u r e , r e l a p s e and l i m i t e d c l i n i c a l improvement. Jannson & Ost (1982) estimate t h a t the median dropout r a t e from exposure-based treatments i s 12%. Furthermore, data r e p o r t i n g success r a t e s of 60-70% are a l s o r e f l e c t i n g the f a c t t h at 30-40% of a l l agoraphobics who complete treatment f a i l to b e n e f i t . Of the remaining 60-70%, a s u b s t a n t i a l percentage may not reach c l i n i c a l l y meaningful l e v e l s of f u n c t i o n i n g . For example McPherson et a l (1980) r e p o r t e d t h a t among c l i e n t s who showed some improvement f o l l o w i n g b e h a v i o u r a l treatment, only 18% of those c o n t a c t e d at follow-up r a t e d themselves as being completely f r e e of symptoms. F i n a l l y Munby & Johnson (1980) observed r e l a p s e s o c c u r r i n g i n as many as 50% of c l i e n t s who had b e n e f i t e d c l i n i c a l l y , although many subsequently r e t u r n e d t o t h e i r p r e v i o u s l e v e l of improvement. 18 What emerges, then, i s t h a t though they appear to have a complex e t i o l o g y , very l i t t l e i n t e r e s t has been shown i n the a c t u a l mechanism and process of change i n simple phobias. An u n f o r t u n a t e p o s i t i o n promises to be maintained: any progress i s l i k e l y to come about l i k e most p r e v i o u s developments - s e r e n d i p i t o u s l y . 19 C o g n i t i v e approaches I f exposure i s e f f e c t i v e f o r a range of a n x i e t i e s f o r u n c e r t a i n reasons, then c o g n i t i v e approaches can be seen as a p o l a r o p p o s i t e . There are extremely c l e a r reasons why they should work but, f o r the most p a r t , they have been remarkably i n e f f e c t u a l . One would have thought t h a t techniques which have worked w e l l w i t h mood d i s o r d e r s , n o t a b l y d e p r e s s i o n (Beckham & Leber, 1985), should t r a n s f e r to a n x i e t y d i s o r d e r s where c o g n i t i v e f e a t u r e s have a l s o been q u i t e conspicuous. However, such approaches have not, i n any sense, matched the promise t h a t might be i m p l i e d from the amount of t h e o r e t i c a l i n t e r e s t . Marks (1988) i s c h a r a c t e r i s t i c a l l y adamant i n h i s c o n c l u s i o n s . " C h a l l e n g i n g i r r a t i o n a l b e l i e f s , c o g n i t i v e or r a t i o n a l r e s t r u c t u r i n g , and c u r r e n t types of s e l f - s t a t e m e n t r e h e a r s a l are l a r g e l y redundant f o r the r e l i e f of phobic problems". Other major reviews have come up with s i m i l a r c o n c l u s i o n s (see Last 1987). E a r l y s t u d i e s were a l t o g e t h e r more promising, however, and some would argue t h a t s i g n s of a r e t u r n of such promise are emerging once ag a i n . C o g n i t i v e i n t e r v e n t i o n s f o r a n x i e t y have a long, i f not always venerable h i s t o r y . A s s o c i a t e d names i n t h i s century / might range from the French p s y c h i a t r i s t Emil Coue (1922) to Dale Carnegie (1948) and Norman V i n c e n t Peale (1960). Much of the e a r l i e s t c o n t r o l l e d r e s e a r c h d i d not take p l a c e u n t i l 20 the e a r l y 1970s and was i n f a c t not u n r e l a t e d to the l a t t e r two authors. I t was Meichenbaum's i n v e s t i g a t i o n i n t o why such g e n e r a l i z e d p r o h i b i t i o n s or e x h o r t a t i o n s tend to f a i l , t h a t was one of the paths to h i s subsequent i n f l u e n t i a l work on s e l f i n s t r u c t i o n s . His work with Cameron as f a r back as 15 years ago set the ground f o r much t h a t was to f o l l o w . T h e i r r e s e a r c h focused on r e d u c i n g f e a r s by modifying what c l i e n t s say t o themselves. They compared a treatment group who r e c e i v e d only s e l f - i n s t r u c t i o n a l r e h e a r s a l w i t h one t h a t i n a d d i t i o n r e c e i v e d " a p p l i c a t i o n t r a i n i n g " i n the form of exposure to e l e c t r i c shock. The former group i n i t i a l l y appeared to do w e l l but as demands were i n c r e a s e d , t h e i r a n x i e t y r o s e p r e c i p i t o u s l y . In c o n t r a s t , the s u b j e c t s who had an o p p o r t u n i t y to use the s e l f - c o n t r o l l i n g statements i n c o n f r o n t i n g the e l e c t r i c shock, s i g n i f i c a n t l y reduced t h e i r f e a r s f o l l o w i n g treatment. They concluded that "saying the ' r i g h t ' t h i n g s to y o u r s e l f may not be a s u f f i c i e n t c o n d i t i o n f o r change". One may have to t r y out these s e l f - s t a t e m e n t s g r a d u a l l y i n r e a l s i t u a t i o n s that are s i m i l a r to the c r i t e r i o n t a s k " f o r any e f f e c t to be noted". Optimism was f u r t h e r f o s t e r e d through the apparent e f f e c t of c o g n i t i v e procedures on animal phobias, t e s t a n x i e t y , and p u b l i c -speaking a n x i e t y (see Rachman & Wilson 1980). / When the focus s h i f t e d away from student s u b j e c t s p a r t i c i p a t i n g f o r course c r e d i t , the r e s u l t s were not n e a r l y so p r o m i s i n g . Emmelkamp et a l (1978) s e t up the f i r s t 2 1 c l i n i c a l t r i a l , u s i n g agoraphobics as s u b j e c t s . T h e i r study-had s e v e r a l n o t a b l e m ethodological f e a t u r e s i n c l u d i n g a c r o s s - o v e r d e s i g n and the f a c t t h at both i n t e r v e n t i o n s , one c o g n i t i v e and one exposure based, were ad m i n i s t e r e d i n groups. The r e s u l t s were q u i t e c l e a r - c u t . Prolonged exposure i n v i v o proved to be a c l e a r l y s u p e r i o r form of treatment to c o g n i t i v e r e s t r u c t u r i n g on a host of measures; the l a t t e r i n f a c t produced only very s l i g h t improvements a t a l l . B i r a n and W ilson (1981a) used a methodology which i n c e r t a i n r e s p e c t s resembled Emmelkamp's. Though t h e i r study i n c l u d e d a wider range of phobics, i t was a g a i n a comparison of c o g n i t i v e and exposure methods. T h e i r " c o g n i t i v e r e s t r u c t u r i n g " i n t e r v e n t i o n was very s i m i l a r , i n v o l v i n g the same three 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 i r r a t i o n a l b e l i e f s , and s e l f - i n s t r u c t i o n a l t r a i n i n g . As p r e v i o u s l y , t h i s proved no match f o r the performance based techniques which l e d to a s e r i e s of d u r a b l e ( s i x month follow-up) b e h a v i o u r a l gains. Exposure a l s o proved h i g h l y s u c c e s s f u l f o r s u b j e c t s who had f a i l e d to b e n e f i t much from the c o g n i t i v e treatment. In a l l cases these treatment e f f e c t s d i d g e n e r a l i z e to d a i l y l i f e . I t was i n t e r e s t i n g , too, t h a t s u b j e c t s i n the exposure c o n d i t i o n , but not i n the c o g n i t i v e one, d i s p l a y e d an o v e r a l l r e d u c t i o n i n p h y s i o l o g i c a l r e a c t i v i t y at p o s t t e s t . 22 The same authors' next study (1981b) appeared to g i v e r e s t r u c t u r i n g a more s p o r t i n g chance. To begin w i t h they chose s c r i p t o p h o b i a , the f e a r of w r i t i n g or s i g n i n g documents i n f r o n t of people. Apart from h i g h l y c i r c u m s c r i b e d avoidance behaviour, t h i s problem a l s o e n t a i l s a more g e n e r a l i z e d s o c i a l a n x iety about being exposed to the s c r u t i n y of other people. With such an ev i d e n t p r e o c c u p a t i o n with s o c i a l consequences, t h i s seems a more p r o m i s i n g arena f o r encouraging more p o s i t i v e and r a t i o n a l s e l f - s t a t e m e n t s . Exposure was here compared with both c o g n i t i v e r e s t r u c t u r i n g alone and c o g n i t i v e r e s t r u c t u r i n g with exposure. Though wi t h a very s m a l l number of sub j e c t s (N=3), they concluded that c o g n i t i v e r e s t r u c t u r i n g alone d i d not produce changes beyond b a s e l i n e l e v e l s , and " i t does not appear to be a necessary adjunct" t o i n v i v o exposure f o r producing b e h a v i o u r a l change. These examples were by no means i s o l a t e d . C o g n i t i v e r e s t r u c t u r i n g d i d not enhance the e f f e c t i v e n e s s of exposure i n v i v o i n the treatment of e i t h e r o b s e s s i v e p a t i e n t s (Emmelkamp e t a l , 1980) or agoraphobics with a f e a r of d r i v i n g ( W i l l i a m s & Rapport, 1980). The l a t t e r r e s e a r c h e r s a l s o c a r r i e d out a l a r g e r - s c a l e study (1983) i n which they s a m p l e d / p a r t i c i p a n t s ' c o g n i t i o n s d u r i n g the b e h a v i o u r a l avoidance task to v e r i f y that t h e i r c o g n i t i v e treatment was being implemented. They concluded that at both posttreatment and follow-up, c o g n i t i v e treatment was adding n o t h i n g to 23 exposure on i t s own. R e s u l t s from these and s i m i l a r s t u d i e s h e l p e d to set the tone f o r Marks' review (1987). He unearthed 32 s t u d i e s i n v o l v i n g c o g n i t i v e approaches to phobic problems. Of these he found t h a t 22 were n e g a t i v e , s i x e q u i v o c a l and j u s t f o u r p o s i t i v e . Two of the l a s t were r e l a t i v e l y s l i g h t (student s u b j e c t s , no follow-up e t c . ) , l e a v i n g j u s t B u t l e r et a l ' s (1984) study on s o c i a l phobics and Kendrick et a l ' s (1982) study on p i a n i s t s with performance a n x i e t y to g i v e any i n d i c a t i o n t h a t there might be some c o n t r i b u t i o n to be made by c o g n i t i v e i n t e r v e n t i o n s . T h i s l e d to h i s very l i m i t e d concession t h a t "perhaps c o g n i t i v e methods can p l a y a small r o l e i n h e l p i n g some s o c i a l phobics". Given the weighting i n h i s o v e r a l l t a l l y , 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 . "The abundance of c o g n i t i v e r e s e a r c h has y i e l d e d a le a n t h e r a p e u t i c h a r v e s t i n comparison w i t h t h a t of exposure alone, which i s a b e t t e r way to improve most phobias. In the gre a t m a j o r i t y of s t u d i e s , c o g n i t i v e methods alone had l i t t l e e f f e c t and combined with exposure f a i l e d to enhance the amount or speed of 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 of the review i s t h a t i t overlooked or om i t t e d some important s t u d i e s . In a l a t e r study Emmelkamp (1982) found t h a t w h i l e the e f f e c t s of exposure d i s s i p a t e d somewhat between posttreatment and follow-up, the s e l f - i n s t r u c t i o n a l group continued to improve. I n t e r e s t i n g l y , both M a r s h a l l (1985) and 24 M a v i s s a k a l i a n (1983) a l s o found the while s e l f - i n s t r u c t i o n c o n t r i b u t e d l i t t l e to exposure at posttreatment, i t s e f f i c a c y i n c r e a s e d d u r i n g follow-up. One p o s s i b i l i t y , then, was t h a t measurement was not going on long enough and perhaps n e i t h e r were the i n t e r v e n t i o n s . V a l l i s and Segal (1986) suggested t h a t the c o g n i t i v e i n t e r v e n t i o n s might be too b r i e f and that t h i s b r e v i t y might account f o r the f i n d i n g s of a " s l e e p e r e f f e c t " f o r the c o g n i t i v e coping s t r a t e g i e s j u s t mentioned. They put forward t h a t i t i s perhaps only a f t e r treatment has stopped t h a t s u b j e c t s get to employ the techniques more f u l l y , with the r e s u l t b e i n g an i n c r e a s e i n e f f e c t i v e n e s s from post-treatment to f o l l o w -up. The second group of s t u d i e s that Marks has i g n o r e d are those on panic d i s o r d e r . In h i s defence, many of these appeared a f t e r he went to p r e s s , though i t i s s t i l l s u r p r i s i n g that he gave no i n k l i n g of the dramatic f i n d i n g s t h a t were emerging. / 25 I n t e r o c e p t i v e exposure An important d i s t i n c t i o n made by Barlow (1988) i s between e x t e r o c e p t i v e and i n t e r o c e p t i v e exposure. The former r e f e r s t o the t r a d i t i o n a l approach, d u r i n g which s u b j e c t s are c o n f r o n t e d with t h e i r f e a r e d o b j e c t or s i t u a t i o n . The reasons f o r t h i s and some of i t s t h e o r e t i c a l i m p l i c a t i o n s have a l r e a d y been d i s c u s s e d . The numbers of s t u d i e s y i e l d i n g i n f o r m a t i o n i n the second area a r e , as yet, very s m a l l . The idea i s simple and n o v e l , although Barlow f e e l s t h a t others may have used the technique u n w i t t i n g l y . The p r i n c i p l e i s to expose the i n d i v i d u a l not to a f e a r e d o b j e c t or s i t u a t i o n but to f e a r e d s e n s a t i o n s . I t i s a treatment method shared by C l a r k (1987) and Beck (1988), i f i n a much l e s s prominent r o l e , and i n the area of p a n i c d i s o r d e r , at l e a s t , i t has been used as p a r t of a l a r g e r package with dramatic success. Barlow does not o v e r s t a t e the case when he says t h a t i f r e c e n t r e s u l t s are confirmed by a d d i t i o n a l r e s e a r c h and r e p l i c a t i o n , " i t w i l l be one of the most important and e x c i t i n g developments i n the h i s t o r y of psychotherapy". In a recent study by Beck (1988), panic was e l i m i n a t e d i n 16 s u b j e c t s who p r i o r to treatment had been having more than f o u r panics a week. C l a r k e t a l (1985, 1990) have shown s i m i l a r r e s u l t s i n a number of p a t i e n t s s u f f e r i n g from p a n i c e i t h e r with or without agoraphobia. T h e i r e a r l y r e s u l t s have h e l d up i m p r e s s i v e l y i n a f o l l o w - u p of more than two years. Klosko et a l (1988) have shown t h a t t h i s new treatment shows 2 6 a much broader p a t t e r n of p o s i t i v e t h e r a p e u t i c change than a group r e c e i v i n g alprazolam (Xanex). The most advanced study thus f a r has been by Barlow (1988). He i s c u r r e n t l y c o l l e c t i n g data on an unusual subsample of p a t i e n t s with panic d i s o r d e r i n t h a t they do not show s u b s t a n t i a l avoidance behaviour. They are randomly a l l o c a t e d to one of four groups. The f i r s t i s a w a i t i n g - l i s t c o n d i t i o n . The remaining three are a l l centred on s y s t e m a t i c s t r u c t u r e d exposure to f e a r e d i n t e r n a l s e n s a t i o n s . To t h i s common base, c o g n i t i v e procedures are added to one group, r e l a x a t i o n t r a i n i n g to a second and a combination of the two to the t h i r d . The numbers are as y e t too s m a l l to permit a comparative a n a l y s i s , but the very encouraging p r e l i m i n a r y data suggest that the combined treatment seems to be producing t h e r a p e u t i c e f f e c t s t h a t are s u p e r i o r on some measures to e i t h e r the somatic or c o g n i t i v e treatments alone. S e v e r a l p o i n t s a r i s e from these e x c i t i n g i f , as y e t , p r e l i m i n a r y data. The f i r s t i s to ask what are the a c t i v e i n g r e d i e n t s of t h i s treatment which i n c l u d e s a v a r i e t y of elements i n c l u d i n g r e s p i r a t o r y c o n t r o l , b a s i c e d u c a t i o n on the o r i g i n s of somatic symptoms, and exposure t o a n x i e t y -provoking s i t u a t i o n s . Barlow looks to have a l r e a d y gone some way to answering t h i s q u e s t i o n f o r h i m s e l f by p l a c i n g i n t e r o c e p t i v e exposure a t the h e a r t of a l l h i s three 27 treatment groups. While t h i s p l a y s a p a r t i n C l a r k ' s approach (1987), he tends to focus more on the c o g n i t i v e components; i n t e r o c e p t i v e e x e r c i s e s are used merely as t o o l s to change c o g n i t i o n s . T h i s i s an important d i s t i n c t i o n i n t h e i r t h e o r e t i c a l approaches, but, s i n c e t h e i r p r a c t i c a l s t y l e i s s i m i l a r , i t does not make i t easy to assess the i n f l u e n c e of e i t h e r c o g n i t i v e m o d i f i c a t i o n or i n t e r o c e p t i v e exposure i n the r e d u c t i o n of p a n i c . I t a l s o leaves the q u e s t i o n unanswered as to the e f f e c t of i n t e r o c e p t i v e exposure on phobias. T h i s has only been addressed i n one study, unpublished, and w i t h a sample of j u s t three s u b j e c t s . Rygh and Barlow (1986), i n a t a n t a l i z i n g l y small study, l i n k e d t r u e and f a l s e alarms to i n t e r o c e p t i v e and e x t e r o c e p t i v e exposure. They proposed t h a t an i n d i v i d u a l whose phobia arose a f t e r an unexpected p a n i c might respond to i n t e r o c e p t i v e exposure without any i m a g i n a l or i n v i v o exposure to t h e i r f e a r e d o b j e c t . On the o t h e r hand, those w i t h nonpanic e t i o l o g i e s would respond b e s t to e x t e r o c e p t i v e exposure. I t i s d i f f i c u l t to determine a n y t h i n g from the mixed r e s u l t s of such a t i n y sample. The importance of the study i s t h a t f o r the f i r s t time i t r a i s e d the q u e s t i o n of w h e t h e r / i n t e r o c e p t i v e exposure c o u l d be u s e f u l l y a p p l i e d to f e a r s other than panic d i s o r d e r s . Seen i n that l i g h t , an i n t r i g u i n g q u e s t i o n had been put forward and the i n i t i a l r e s u l t s d i d not seem d i s c o u r a g i n g . 28 METHODOLOGIES There are a great v a r i e t y of ways i n which one c o u l d c a r r y out r e s e a r c h i n an area such as c l a u s t r o p h o b i a , and i t i s worth l o o k i n g b r i e f l y at some of the s t r e n g t h s and l i m i t a t i o n s of s i x designs. The f i r s t of these are s t u d i e s which are , f o r the most p a r t , d e s c r i p t i v e . An example would be Beck et a l ' s (1974) study which was one of the f i r s t to look a t the c o g n i t i v e components of 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 able to i d e n t i f y common themes such as f e a r of death, s o c i a l r e j e c t i o n , or f a i l u r e . A decade l a t e r H i b b e r t (1984) took t h a t work a l i t t l e f u r t h e r , i n t e r v i e w i n g s u b j e c t s not only about the content of t h e i r anxious thoughts, but a l s o i n c l u d i n g q u e s t i o n s on frequency, i n t e n s i t y , c l a r i t y and c r e d i b i l i t y . From both s t u d i e s i t i s abundantly c l e a r t h a t anxious people overestimate p e r s o n a l r i s k , the l a t t e r study a l s o making important o b s e r v a t i o n s on the sequence of events, w i t h p h y s i c a l s e n s a t i o n s being seen to precede thoughts, which i n turn preceded episodes o f a n x i e t y . I t i s i n t e r e s t i n g t h a t though many j o u r n a l s tend to shun d e s c r i p t i v e s t u d i e s , i n many areas of psychology they are being c a l l e d f o r i n c r e a s i n g l y . In therapy process r e s e a r c h , i n d e e d , / i t i s c u r r e n t l y c o n s i d e r e d something of a p r i o r i t y (see G a r f i e l d & B e r g i n 1986). Far from b e i n g d e r i d e d , i t would seem a t l e a s t u s e f u l to i n c l u d e c a r e f u l d e s c r i p t i v e 29 data i n a h i g h e r percentage of s t u d i e s focused on experimental q u e s t i o n s . 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 and component de s i g n s . In c o n s t r u c t i v e designs, one element i s added to an e m p i r i c a l l y proven technique and then compared a g a i n s t t h i s technique alone. Component designs are used to i s o l a t e the potency of p a r t i c u l a r elements from a treatment package of known e f f i c a c y . There are many examples of the former, mixed between those t h a t add l i t t l e except to the u n n e c e s s a r i l y long l i s t of outcome s t u d i e s , and those t h a t r e a l l y c o n t r i b u t e important p o i n t s . An example of the l a t t e r i s the study by Marchione et a l (1987). They randomly assigned a group of agoraphobics to one of three c o g n i t i v e b e h a v i o u r a l treatments: c o g n i t i v e therapy p l u s graduated exposure, 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 graduated exposure, versus graduated exposure alone. I t was i n t e r e s t i n g t h a t those i n the combined treatment groups showed not only the most r a p i d , but the most s t a b l e improvements ac r o s s the three systems. Features such as assessment at mid-point, as w e l l as at the end of treatment h e l p to take e x c l u s i v e focus away from the s i n g l e q u e s t i o n of which treatment i s the most e f f e c t i v e . The emphasis on t h i s s i n g l e q u e s t i o n , to the e x c l u s i o n of how an i n t e r v e n t i o n i s c a u s i n g an e f f e c t , has been the shortcoming of these designs and c o n t r i b u t e d to a g r e a t d e a l of work having minimal v a l u e . I t causes l i t t l e wonder t h a t those at 30 the Conference i n Albany, c i t e d e a r l i e r , were so adamant i n d i s c o u r a g i n g s t u d i e s t h a t focused only on outcome. Component a n a l y s i s , on the other hand, aims to f i n d out as much as p o s s i b l e about a s i n g l e approach. An o u t s t a n d i n g example i s the work of V a l l i s (1984). His focus of i n t e r e s t was Meichenbaum's S t r e s s I n n o c u l a t i o n T r a i n i n g . T h i s g e n e r a l treatment approach can be d i v i d e d i n t o t h r e e d i s t i n c t p r o c e d u r a l phases (Education, S k i l l s A c q u i s i t i o n , and A p p l i c a t i o n ) . In an attempt "to examine the independent and i n t e r a c t i v e r o l e of each phase", V a l l i s i n c l u d e d a l l p r o c e d u r a l phases, and s y s t e m a t i c a l l y v a r i e d each of them i n a study with e i g h t treatment c o n d i t i o n s . The study's s t r e n g t h stems from i t s d e a l i n g with a s u b j e c t matter about which a g r e a t d e a l i s a l r e a d y known, and whose e f f i c a c y , i n comparison to other i n t e r v e n t i o n s , has a l r e a d y been e s t a b l i s h e d . T h i s i s c l e a r l y not a technique w i t h which to open an i n v e s t i g a t i o n i n t o a r e l a t i v e l y uncharted area. The f o u r t h design t o be d i s c u s s e d i s treatment consonance, w e l l i l l u s t r a t e d i n the work of Ost and h i s c o l l e a g u e s (1981, 1982, 1984). In response to c l i n i c i a n s ' d i f f i c u l t y i n a s s e s s i n g how i n d i v i d u a l c l i e n t s w i l l respond to s p e c i f i c treatments, they used the Three-System-Model ( i s o l a t i n g b e h a v i o u r a l , p h y s i o l o g i c a l , and c o g n i t i v e components) as a b a s i s f o r matching i n d i v i d u a l c l i e n t to most a p p r o p r i a t e treatment. With s o c i a l , c l a u s t r o p h o b i c , and 31 f i n a l l y agoraphobic c l i e n t s , they i n v e s t i g a t e d whether " p h y s i o l o g i c a l " and " b e h a v i o u r a l " r e a c t o r s would achieve more b e n e f i t from a method s u i t e d to t h e i r response p a t t e r n than one which was not. T h i s i s not the only way th a t c l i e n t s c o u l d be s u b d i v i d e d , but i t was a reasonable d e c i s i o n , and i n two of t h e i r three s t u d i e s y i e l d e d p r o m i s i n g r e s u l t s . There was much d i s c u s s i o n about t h i s approach which has been f a v o u r a b l y reviewed, but r e l a t i v e l y few s t u d i e s f o l l o w e d i n which i n d i v i d u a l s were s e l e c t e d f o r treatment on the b a s i s of t h e i r "unique a n x i e t y p r o f i l e s " . The reasons f o r t h i s are not based on any doubts of the m e r i t s of the approach but i t s p r a c t i c a l d i f f i c u l t i e s . These i n c l u d e the f a c t t h a t i t i s onl y the p h y s i o l o g i c a l component t h a t i s e a s i l y measured and i d e n t i f i e d (see Hugdahl 1981), and t h a t i t i s d i f f i c u l t to compare change across response systems. Further, the n o t i o n of a "consonant" treatment has not been easy to s a t i s f y : Is p a r a d o x i c a l i n t e n t i o n l i k e l y to s u i t many c o g n i t i v e responders?; i s exposure a method f o r best changing behaviour o r c o g n i t i o n s ? While there are many reasons to suggest t h a t i t i s premature to be o f f e r i n g i n d i v i d u a l l y t a i l o r e d treatments, i t i s c e r t a i n l y an important g o a l , and the i n c l u s i o n of attempts to p r e d i c t outcome could be made more o f t e n . I t may be more v i a b l e , too, i f / a l e s s r i g i d i n t e r p r e t a t i o n i s made of consonance, i s o l a t i n g f o r example not j u s t q u a n t i t a t i v e but q u a l i t a t i v e d i f f e r e n c e s . Rather than comparing degrees of c o g n i t i v e r e a c t o r s , i t might seem more p r o f i t a b l e to look at the 32 p a r t i c u l a r s t y l e of c o g n i t i v e m i s i n t e r p r e t a t i o n or d y s f u n c t i o n and choose a treatment a c c o r d i n g l y ( f o r example s t r e s s i n n o c u l a t i o n as opposed t o breaking of l i n k s ) . More c o u l d a l s o be made of the o b s e r v a t i o n s o f t e n noted i n these s t u d i e s . Why should i t be the case t h a t " c o g n i t i v e " s u b j e c t s tend to have a g r e a t e r p o t e n t i a l f o r improvement r e g a r d l e s s of treatment (Mackay & L i d d e l l , 1986)? They a l s o suggested t h a t treatments might be "mixed", as i n t e a c h i n g s u b j e c t s t o b r i n g t h e i r p h y s i o l o g i c a l response down to a l e v e l at which c o g n i t i v e c o n t r o l might be e x e r t e d . I t i s i n t r i g u i n g , too, t h a t Michelson (1986) should note a "temporal l a g " w i t h "consonant s t a t u s appearing t o m a n i f e s t i t s moderating f u n c t i o n i n a delayed f a s h i o n , i n c r e a s i n g i t s i n f l u e n c e as treatment progresses". A f i f t h approach i s c h a r a c t e r i z e d by the work of D.A. C l a r k (1988). H i g h l i g h t i n g the almost e x c l u s i v e focus on c o g n i t i v e treatment, he has shown a concern t h a t f u r t h e r p r o g r e s s w i l l be impeded without "concomitant advances i n the methodology u t i l i z e d to assess the c o g n i t i v e c o n s t r u c t s p u r p o r t e d to mediate maladaptive responding". He i s thus one of a number of workers (see a l s o Ingram & K e n d a l l , 1986; K e n d a l l & H o l l o n , 1981) working t o improve the assessment of r e l e v a n t c o n s t r u c t s . His re c e n t review (1988) i s a s o l i d attempt to develop an e m p i r i c a l l y based model of c o g n i t i v e assessment. Such an approach y i e l d s immediate and u s e f u l i n f o r m a t i o n on the streng t h s and l i m i t a t i o n s of d i f f e r e n t 33 forms of assessment. I t a l s o r a i s e s p o i n t e r s such as the need to look not only at the presence or absence of c o g n i t i o n s , but t h e i r emotional i n t e n s i t y , the degree of b e l i e f i n which they are h e l d , and the d i f f i c u l t y w i t h which they are c o n t r o l l e d . I t i s i n the l i g h t of these f i v e approaches t h a t work on the "process" of change can best be seen. In p a r t i t i n v o l v e s the i n c l u s i o n of what has a l r e a d y o f t e n appeared i n s t u d i e s , such as n o t i n g discordance and f o c u s i n g on maintenance and g e n e r a l i z a t i o n r a t h e r than merely immediate outcome. I t i s an approach fraught w i t h some r i s k . I t c o u l d d e t e r i o r a t e i n t o t r y i n g to make something of a murky mass of data without c l e a r hypotheses. The approach, however, need not s l i d e i n t o such an abyss. The p r i n c i p l e i s to go f u r t h e r than a s k i n g a s i n g l e q u e s t i o n by a s k i n g m u l t i p l e q u e s t i o n s , each c a r e f u l l y s p e c i f i e d and c l e a r l y hypothesized. The r e s u l t aims to g i v e a r a t h e r f u l l e r and more d e s c r i p t i v e p i c t u r e of how change takes p l a c e . An example, though on a s m a l l s c a l e , i s Last et a l ' s s e r i e s of s t u d i e s ( L a s t , 1984, 1985) l o o k i n g at the e f f e c t s of a v a r i e t y of treatments on the c o g n i t i o n s of phobic s u b j e c t s , and how these i n t u r n r e l a t e d t o treatment e f f i c a c y . A f t e r s t u d y i n g the r e s u l t s of t h e i r m u l t i p l e measures, the reader i s l e f t i n no doubt t h a t i f assessment i s only taken p r i o r t o and a f t e r treatment, the c o n c l u s i o n s drawn are l i k e l y to be very s i m p l i s t i c . These are s t u d i e s which l a c k the neat ends t h a t i t might be 34 comforting to f i n d , but t h e i r d e t a i l , i f not always easy to i n t e r p r e t , comes across as v a l u a b l e and a u t h e n t i c . A f t e r an overview of work already c a r r i e d out i n the area of c l a u s t r o p h o b i a , t h i s theme w i l l be taken up again. 35 CLAUSTROPHOBIA C l a u s t r o p h o b i a may not seem the most p r e s s i n g area f o r c l i n i c a l r e s e a r c h . Very few c l a u s t r o p h o b i c s a t t e n d f o r treatment and the s u b j e c t has a t t r a c t e d o n l y a very small l i t e r a t u r e . In Marks' (1987) voluminous "Fears, Phobias and R i t u a l s " , as much i s w r i t t e n on the s u b j e c t as on a v e r s i o n to the s k i n s of peaches; there i s r a t h e r more on the f e a r of b u t t e r f l i e s . Yet i n the 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 study, simple phobias were found to be the most p r e v a l e n t of a l l mental d i s o r d e r s i n women (Robins et a l , 1974). Of these, c l a u s t r o p h o b i a i s among the most common ( C o s t e l l o , 1982) w i t h e s t i m a t e s ranging from 5% to 13% of women i n the ge n e r a l p o p u l a t i o n r e p o r t i n g i t as an i n t e n s e f e a r (Agras et a l , 1969; K i r k p a t r i c k , 1984). The h i g h e s t frequency of f e a r i s r e p o r t e d i n the age group 18 to 25. The reason c l a u s t r o p h o b i a i s not seen more f r e q u e n t l y a t the c l i n i c appears to be i n f l u e n c e d by two f a c t o r s which have nothing to do w i t h the s i g n i f i c a n c e of the problem. C l a u s t r o p h o b i c s are o f t e n not motivated to seek treatment because they can cope w i t h the problem i n a way t h a t not a l l phobias permit: they simply a v o i d . Secondly, i t has become apparent that most e i t h e r do not t h i n k that t h i s i s a problem that c o u l d be t r e a t e d , or t h a t t h e i r d i s a b i l i t y would not be / s u f f i c i e n t l y s e r i o u s to merit p r o f e s s i o n a l a t t e n t i o n (Ost, 1982). Matching t h i s l a c k of enthusiasm to seek p r o f e s s i o n a l a t t e n t i o n has been a gen e r a l l a c k of r e s e a r c h i n t e r e s t . 36 Indeed, i t has r e c e i v e d so l i t t l e a t t e n t i o n t h a t one c o u l d attempt t h a t very r a r e task, the exhaustive l i t e r a t u r e review. I t i s p o s s i b l e that c l a u s t r o p h o b i a w i l l become an important focus of i n t e r e s t s i n c e the r e s u l t s of s t u d i e s on panic d i s o r d e r r a i s e v i t a l q uestions about o t h e r f e a r s . C l a u s t r o p h o b i a i s h a r d l y the l e a s t of these w i t h i t s i n t e r e s t i n g l i n k s t o both panic d i s o r d e r and simple phobias, a theme taken up i n the next s e c t i o n . In t h i s s e c t i o n i t w i l l be shown t h a t i t has not always been a t e s t i n g ground f o r such important q u e s t i o n s , although i n r e c e n t years there have been some f i n d i n g s of i n t e r e s t . The l i t e r a t u r e on c l a u s t r o p h o b i a b r i n g s up a sometimes c u r i o u s assortment of s t u d i e s . These range from questions of demand c h a r a c t e r i s t i c s ( M i l l e r & B e r n s t e i n , 1972) and the e f f i c a c y of i m a g i n a l procedures (Knapp et a l , 1978), to papers 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 (e.g., Gehl, 1973). The bulk of the work, however, i s made up of c l i n i c a l 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 to the treatment of c l a u s t r o p h o b i a . As Ost has lamented i n an e x c e l l e n t review (1982), these are f o r the most an e c d o t a l or experimental s i n g l e - c a s e s t u d i e s . He c o u l d have been h a r s h e r i n h i s c r i t i c i s m s f o r i t i s r a r e l y the f i n d i n g s or i m a g i n a t i v e approach t h a t l i n g e r i n the mind a f t e r r e a d i n g these s t u d i e s , but other q u e s t i o n s e n t i r e l y . How d i d L e i t e n b e r g and h i s c o l l e a g u e s (1968, 1970) persuade an i n d i v i d u a l to endure over 1300 t r i a l s ? How d i d G a t c h e l (1977) overlook 37 t h a t by g i v i n g 14 hours of biofeedback t r a i n i n g i n an e n c l o s e d c u b i c l e w i t h i n the l a b o r a t o r y , t h a t he was a l s o g i v i n g h i s s u b j e c t e x t e n s i v e exposure to the phobic s i t u a t i o n ? What r e a l - l i f e s i t u a t i o n were Spelz and B e r n s t e i n (1979) p r e p a r i n g t h e i r s u b j e c t f o r , by having as the g o a l of treatment that the s u b j e c t should be able to remain r e l a t i v e l y r e l a x e d wearing a s u r g i c a l mask, h i s head at the wrong end of a f u l l y - z i p p e d s l e e p i n g bag, with both h i s hands and f e e t t i e d ? Ost's (1982) p o i n t i s w e l l taken t h a t i t would be q u i t e i m p o s s i b l e to draw any g e n e r a l c o n c l u s i o n s from these and s i m i l a r s t u d i e s . The number of s u b j e c t s d e s c r i b e d had been very s m a l l , and at t h a t time no c o n t r o l l e d treatment outcome study had yet been p u b l i s h e d . He a l s o noted t h a t the encouraging r e s u l t s "must be considered a g a i n s t the f a c t t h a t treatment f a i l u r e s are r a r e l y p u b l i s h e d " . Ost's own c o n t r o l l e d group study on c l a u s t r o p h o b i a (1982) i s o u t s t a n d i n g not j u s t i n t h i s area but i n the behaviour therapy l i t e r a t u r e as a whole. I t i s p a r t of a s e r i e s which g i v e s due prominence to i n d i v i d u a l d i f f e r e n c e s , as was d i s c u s s e d i n the p r e v i o u s s e c t i o n . He c l a s s i f i e d c l a u s t r o p h o b i c s u b j e c t s i n t o " b e h a v i o u r a l " or " p h y s i o l o g i c a l " r e a c t o r s and then s t u d i e d the e f f e c t of a b e h a v i o u r a l l y focused method (exposure) or a p h y s i o l o g i c a l l y - f o c u s e d method ( a p p l i e d r e l a x a t i o n ) . With 38 t h i s sample, though not l a t e r with agoraphobics (1984), "the r e s u l t s supported the h y p o t h e s i s that g r e a t e r e f f e c t s are achieved when the method used f i t s the p a t i e n t ' s response p a t t e r n than when i t does not". Ost and Hugdahl (1981) were a l s o c u r i o u s about the ways i n which phobic p a t i e n t s (animal, s o c i a l , or c l a u s t r o p h o b i c ) a c q u i r e d t h e i r f e a r s . They were p a r t i c u l a r l y i n t e r e s t e d i n 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 responses were more l i k e l y to be prominent i n those who a t t r i b u t e d t h e i r 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 . They s i m i l a r l y q u estioned whether those w i t h higher s u b j e c t i v e r e p o r t s would be more l i k e l y to have a c q u i r e d t h e i r f e a r s v i c a r i o u s l y or through the t r a n s m i s s i o n of i n f o r m a t i o n . They d i d not f i n d a c l e a r c u t r e l a t i o n s h i p between the ways of a c q u i s i t i o n and a n x i e t y components (thus f a i l i n g to support Rachman's 1978 h y p o t h e s i s ) , nor d i d the c o n d i t i o n e d and i n d i r e c t l y a c q u i r e d phobias d i f f e r i n s e v e r i t y . There were, however, other i n t e r e s t i n g f i n d i n g s . Of the 23 c l a u s t r o p h o b i c s ' i n t h e i r sample, over 2/3 r e p o r t e d t h a t t h e i r problem had been a c q u i r e d as a r e s u l t of a c o n d i t i o n i n g e x p e r i e n c e (a h i g h e r f i g u r e than f o r the o t h e r two f e a r s i n the r e p o r t ) . In l a b o r a t o r y t e s t i n g these s u b j e c t s had a s i g n i f i c a n t l y l a r g e r 'increase i n h e a r t r a t e than those who had a c q u i r e d t h e i r f e a r s i n d i r e c t l y . In comparison to those w i t h the other two f e a r s , the 39 c l a u s t r o p h o b i c s showed more p h y s i o l o g i c a l r e a c t i o n s , had more n e g a t i v e thoughts, and engaged i n more worrying. In a r e c e n t q u e s t i o n n a i r e (Rachman, Booth, & W h i t t a l , 1988), the c o n d i t i o n i n g e x p l a n a t i o n was a l s o the most common (though s u b j e c t s ' r e c a l l and i n t e r p r e t a t i o n of t h e i r e xperiences i s , as i n the p r e v i o u s study, not an e n t i r e l y s a t i s f a c t o r y way of c o l l e c t i n g d a t a ) . U s u a l l y from e i t h e r p a r e n t a l punishment or a s i b l i n g prank, a r a t h e r l a r g e r p r o p o r t i o n than Ost (1978) r e p o r t e d - i n h i s study some 37% by the age of 14- were ab l e to d e t a i l e a r l y a v e r s i v e e x p e r i e n c e s i n an e n c l o s e d space which they saw as c a u s a l l y r e l a t e d t o t h e i r c u r r e n t f e a r . ( P l o e g e r ' s study of trapped miners i s an i n t e r e s t i n g account of how t h i s f e a r can become c o n d i t i o n e d , see Rachman, 1989). T h i s survey may not have been as w e l l s t r u c t u r e d as the Ost (1981) q u e s t i o n n a i r e , and i s at an e a r l y stage of f o r m u l a t i o n , but i t has y i e l d e d some i n t e r e s t i n g questions and thrown up some problems. The focus was on the presence and i n f l u e n c e of c o g n i t i o n s and the responses were v a r i a b l e . Some gave c l a s s i c examples of c a t a s t r o p h i c thoughts such as " t h e r e ' l l be an earthquake while I'm stuck i n here". Some re c o r d e d thoughts of a more s o c i a l n ature ( " i t w i l l be so h u m i l i a t i n g to be seen t h i s upset"), 7 and embarrassment was almost as common a theme as entrapment. One s u b j e c t s a i d t h a t her f i r s t p a n i c i n a s i t u a t i o n was n o n - c o g n i t i v e and the p o t e n t i a l of thoughts was to cause a r e - p a n i c . T h i s r a i s e s the q u e s t i o n of whether 40 c o g n i t i o n s p l a y a l e s s e r r o l e i n f e a r that peaks very q u i c k l y . Another s u b j e c t r e p o r t e d t h a t being shut i n brought back a l o t of f r i g h t e n i n g c h i l d h o o d images, but t h a t she had no worry of c u r r e n t harm. However, some r e p o r t e d having n e i t h e r thoughts nor images. One r e p o r t e d having broken a c a s t on her l e g e i g h t times because she f i n d s l a c k of movement " an i m p o s s i b i l i t y " , though she was q u i t e unable to i d e n t i f y any r e l e v a n t thoughts, c a t a s t r o p h i c or not, on t h i s or p r e v i o u s o c c a s i o n s . S e v e r a l r e p o r t e d that at the peak of a n x i e t y they do not t h i n k a t a l l (or so they t h i n k ! ) which r a i s e s the i n t e r e s t i n g p o s s i b i l i t y t h a t c o g n i t i o n s ( s e v e r i t y and frequency) may be l e s s l i k e l y t o be noted once a c e r t a i n l e v e l of a n x i e t y has been reached. There were a v a r i e t y of p o i n t s t h a t were h a r d l y s u r p r i s i n g . C a t a s t r o p h i c b e l i e f s were always a g r e a t d e a l s t r o n g e r i n the f e a r e d s i t u a t i o n ; o u t s i d e i t , they o f t e n h e l d no c r e d i b i l i t y at a l l . Some found that d i s t r a c t i o n or b r e a t h i n g techniques were h e l p f u l , but s e l f - i n d u c e d c o g n i t i v e therapy (such as "you are being r i d i c u l o u s " ) had almost no e f f e c t . I t was t h e r e f o r e somewhat p u z z l i n g t h a t so many f e l t t h a t c o g n i t i v e therapy sounded to be a very promising approach and needed l i t t l e or no encouragement to s t a t e t h a t t h e i r thoughts were i n f a c t at the r o o t of t h e i r a n x i e t y . 41 In many cases i t was d i f f i c u l t to get r e c e n t examples simply because so much avoidance behaviour was.engaged i n . I t was indeed s t r i k i n g j u s t how e f f e c t i v e c u r r e n t avoidant s t r a t e g i e s are, as w e l l as the len g t h s undergone to accomplish them. Though very few had ever c o n s i d e r e d treatment, some 50% s a i d t h a t they would take up the op p o r t u n i t y i f they knew i t was a v a i l a b l e . The s u b j e c t s i n c l u d e d one o u t s t a n d i n g example of 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 of a p a r t i c i p a n t had had a tr a u m a t i c experience trapped i n a hot sauna wi t h f o u r o t h e r s . The atmosphere "went r e a l l y c r a z y " as the temperature i n c r e a s e d u n t i l f i n a l l y the door was axed i n from the o u t s i d e . She has a very s t r o n g image of what i t was l i k e , and i n an encl o s e d space or i n a crowd what i n c r e a s e s her a g i t a t i o n more than anything e l s e i s an i n c r e a s e i n temperature. One of the main d i f f i c u l t i e s f a c e d i n s e t t i n g up t h i s study was to e s t a b l i s h i n c l u s i o n and e x c l u s i o n c r i t e r i a . I t i s not easy to 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 w i t h agoraphobia f u r t h e r complicates the i s s u e . Fear of enclosed spaces i n agoraphobics has been d e s c r i b e d as "usual" by Johnston et a l (1984), and i n Doctor's survey (1982) only 17% of agoraphobics found c l o s e d - i n spaces t o be "no problem". At one extreme, being c o n f i n e d i n an enclosed space ( c l a u s t r o = cl o s e d ) such as a loc k e d room, does not 42 pose a problem. But w a i t i n g i n l i n e a t a supermarket i s s u r e l y not always i n d i c a t i v e of c l a u s t r o p h o b i a as Rachman has i n d i c a t e d (1989). I t could s i g n i f y a range of f e a r s depending on the p r e c i s e c o g n i t i o n s . The h a b i t of c l a s s i f y i n g f e a r s by s i t u a t i o n i s s u r e l y no l o n g e r a p p r o p r i a t e , p a r t i c u l a r l y those which are open to m u l t i p l e i n t e r p r e t a t i o n . I f one were to i n c l u d e a broader assessment of phobias one would be able to improve on the DSM III-R (1987). I t c u r r e n t l y only allows simple phobias as a r e s i d u a l category, to be employed only when agoraphobia and s o c i a l phobia have been r u l e d out. I n c l u s i o n of c o g n i t i o n s i n assessment might encourage a more f l e x i b l e d i a g n o s i s . One of the few groups to d e f i n e the d i s t i n c t i o n between c l a u s t r o p h o b i a and agoraphobia was Neiger and h i s a s s o c i a t e s (1981) i n t h e i r f a c t o r a n a l y s i s of p e r s o n a l i t y and f e a r v a r i a b l e s i n phobic d i s o r d e r s . They do so on the b a s i s of three p o i n t s . F i r s t l y , c l a u s t r o p h o b i c s never have t r o u b l e walking out i n the f r e s h a i r while agoraphobics do, i f such a walk takes them away from home; secondly, the c l a u s t r o p h o b i c ' s d i f f i c u l t i e s remain u n a f f e c t e d by d i s t a n c e from home, wh i l e agoraphobic problems are aggravated by i n c r e a s i n g d i s t a n c e from home or "safe p l a c e " ; t h i r d l y , the presence of a "safe person" does not h e l p to reduce the l i k e l i h o o d of c l a u s t r o p h o b i c m a n i f e s t a t i o n s , i n c o n t r a s t to agoraphobic d i f f i c u l t i e s . While t h i s i s a t l e a s t an 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 at a l l c l e a r how the two groups were a c t u a l l y d i s t i n g u i s h e d i n t h e i r study. What one can conclude s a f e l y i s that many agoraphobics have f e a r s of c l o s e d spaces, but the r e v e r s e i s not always found s i n c e some c l a u s t r o p h o b i c s have i s o l a t e d f o c a l f e a r s . One must be c a u t i o u s i n going f u r t h e r than t h i s as i s i l l u s t r a t e d by Ost et a l (1984) i n an u n u s u a l l y u n s u b s t a n t i a t e d s e r i e s of remarks. They w r i t e t h a t "a w e l l -known c h a r a c t e r i s t i c of agoraphobia i s t h a t the agoraphobics are more concerned w i t h the f e a r i t s e l f ( i . e . p a n i c a t t a c k s ) , more than the a c t u a l s i t u a t i o n s where t h i s r e a c t i o n c o u l d be t r i g g e r e d . The c l a u s t r o p h o b i c i s more a f r a i d of the c l o s e d space per se than of h i s / h e r own r e a c t i o n s i n the s i t u a t i o n s . The tendency to completely a v o i d the phobic s i t u a t i o n s may be much st r o n g e r i n agoraphobics compared t o c l a u s t r o p h o b i c s , who o f t e n f i n d ways to render the s i t u a t i o n more s a f e , e.g. by l e a v i n g doors unblocked or u s i n g the s t a i r s i n s t e a d of the e l e v a t o r " . Not only are s a f e t y s i g n a l s a noted f a c t o r of agoraphobics, but most would argue (e.g., Rachman, 1989) that f a r from being f r i g h t e n e d of an e n c l o s e d space, r a t h e r the c l a u s t r o p h o b i c i s f r i g h t e n e d of what might b e f a l l him there. T h i s i n f a c t i s s u r e l y one of the l i n k i n g r a t h e r than d i s t i n g u i s h i n g f a c t o r s of the two d i s o r d e r s . 44 Many of these i s s u e s have been r a i s e d i n Rachman's (1989) chapter on c l a u s t r o p h o b i a which, though s h o r t , i s one of the l e n g t h i e s t p i e c e s i n the whole area. I t c e r t a i n l y has many s t r e n g t h s . P u t t i n g p a n i c i n an experimental s e t t i n g , without l a c t a t e or i t s e q u i v a l e n t s , opens up many e x c i t i n g p o s s i b i l i t i e s (Rachman & L e v i t t , 1985; Rachman, L e v i t t , & Lopatka, 1988). The " l i n k s " between b o d i l y s e n s a t i o n s and c o g n i t i o n s are very i n t e r e s t i n g and the d i s c u s s i o n of s e n s i t i z a t i o n , symbolic f e a r and exposure i s extremely important. Of the l a s t he asks the v i t a l q u e s t i o n as to whether i t achieves i t s e f f e c t s d i r e c t l y and independently, or through the i n f l u e n c e of f e a r f u l c o g n i t i o n s . He sums up much of our c u r r e n t knowledge when he s t a t e s t h a t "at present our grasp of the r e d u c t i o n of c l a u s t r o p h o b i a i s an uneasy mixture of an e f f e c t i v e b e h a v i o u r a l procedure f o r reduc i n g f e a r and a g r o p i n g towards a c o g n i t i v e e x p l a n a t i o n f o r the process by which the changes occur". There are two p o i n t s Rachman br i n g s up t h a t a re p a r t i c u l a r l y worth n o t i n g . He s t a t e s f i r s t l y t h a t " i t i s p o s s i b l e t h a t the human f e a r of enclosed spaces i s a v e s t i g i a l f e a r of being trapped i n a way t h a t p r e v e n t s escape when threatened" but f a i l s to e l a b o r a t e on t h i s q u e s t i o n . Might t h i s make i t more l i k e l y t h a t t h e r e c o u l d be a n o n - c o g n i t i v e q u a l i t y to f e a r s i n c l a u s t r o p h o b i a ? Secondly, w h i l e i t seems p l a u s i b l e that the person's f e a r i s not of the e x t e r n a l circumstance, i t i s not c o n v i n c i n g that 45 the c r i t i c a l 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 s t i m u l a t i o n " . The m i s i n t e r p r e t a t i o n of b o d i l y s e n s a t i o n s does not seem to play the same c r i t i c a l r o l e 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 so c l o s e to C l a r k i s l i k e l y to prove hard t o h o l d on to o u t s i d e an area such as agoraphobia. Maladaptive thoughts can s u r e l y c e n t r e on avoidance or escape from the phobic s i t u a t i o n , without f o c u s i n g on the p h y s i o l o g i c a l changes accompanying a n x i e t y . Looking back at p r e v i o u s s t u d i e s on c l a u s t r o p h o b i a one can s t i l l c h a r t many developments i n behaviour therapy. For almost a decade there was a l u l l i n t h i s area but i n the l a s t two or three years, i t has become an area of i n t e r e s t once again. T h i s i n t e r e s t f o c u s e s on three areas: the l a b o r a t o r y i n d u c t i o n of p a n i c , the r o l e of c o g n i t i o n s i n a n x i e t y , and the use of i n t e r o c e p t i v e exposure f o r a n x i e t i e s other than panic d i s o r d e r . These are a l l addressed i n the next s e c t i o n i n which s p e c i f i c q u e s t i o n s are formulated. 46 THE PRESENT STUDY In t h i s s e c t i o n the aim w i l l be to b r i n g t o g e t h e r and o u t l i n e the i s s u e s which w i l l be addressed i n t h i s study, and l a y out the i n t e r v e n t i o n s and measures t h a t w i l l be used. In the l i t e r a t u r e review, much mention has been made of the apparent success of c u r r e n t treatments f o r p a n i c d i s o r d e r . The r e v e r b e r a t i o n s of such a dramatic f i n d i n g have r e c e i v e d very l i t t l e 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 s i n c e the f i n d i n g s themselves are s t i l l q u i t e t e n t a t i v e . The f i r s t q u e s t i o n that i s c o n s i d e r e d here centres on i n t e r o c e p t i v e exposure which some i n v e s t i g a t o r s , such as Barlow (1988), would see as the l y n c h p i n of the new approach. I t w i l l be of gre a t i n t e r e s t to see how t h i s i n t e r v e n t i o n w i l l b e n e f i t c l a u s t r o p h o b i c s . They, too, i t w i l l be noted from p r e v i o u s work, are prone to experience p a n i c s i n an experimental s e t t i n g . However, with much l e s s experience of panic i n everyday s e t t i n g s i t remains to be seen i f they w i l l f i n d the technique u s e f u l . W i l l any ga i n s be d i m i n i s h e d i n the face of f a r more potent e x t e r n a l cues than those t y p i c a l l y r e f e r r e d w i t h panic d i s o r d e r ? W i l l i t be p o s s i b l e to f i n d e x e r c i s e s t h a t w i l l b r i n g on s e n s a t i o n s resembling those t h a t are experie n c e d d u r i n g c l a u s t r o p h o b i c panic? Can i t work without the backing of experience or t r a i n i n g i n the f e a r e d s i t u a t i o n ? There are many qu e s t i o n s 47 surrounding the a p p l i c a t i o n of i n t e r o c e p t i v e exposure to an a n x i e t y other than panic d i s o r d e r . A second notable p a r t of the treatment f o r panic d i s o r d e r i s t h a t i n a l l the major c e n t r e s i n which i t i s p r a c t i c e d , t h e r e i s a s t r o n g c o g n i t i v e component. Some re s e a r c h e r s such as C l a r k (1987) have, over time, moved to s trengthen and enlarge t h i s component. T h i s i s s u r p r i s i n g i n t h a t the c o g n i t i v e c o n t r i b u t i o n had l a r g e l y been w r i t t e n o f f as having l i t t l e to c o n t r i b u t e i n the a n x i e t y d i s o r d e r s . I t was c o n s i d e r e d a p a r t i c u l a r l y f r u i t l e s s e x e r c i s e i f the f e a r had been c o n d i t i o n e d . T h i s was a f i n d i n g backed not only by most t h e o r i s t s but by the bulk of the evidence i n the l i t e r a t u r e . C o g n i t i v e approaches were p a r t i c u l a r l y i n e f f e c t u a l w i t h the s t r o n g l y c o n d i t i o n e d simple phobias, w h i l e of some, i f l i m i t e d , value to f e a r s with l e s s of a c o n d i t i o n i n g component such as s o c i a l phobias. I t now appears that the c o g n i t i v e c o n t r i b u t i o n i s a c r u c i a l i n g r e d i e n t i n the s u c c e s s f u l treatment of panic d i s o r d e r , a t l e a s t as p r a c t i c e d by the Oxford group (Hawton et a l , 1989). I f t h i s f i n d i n g holds f i r m , then there would have to be a r e a p p r a i s a l both of what groups might b e n e f i t from a c o g n i t i v e i n t e r v e n t i o n , and of how t h i s can be p r e d i c t e d . Panic d i s o r d e r , a f t e r a l l , i s l i k e l y to have a p a r t i c u l a r l y s t r o n g c o n d i t i o n i n g h i s t o r y , whether t h i s be l i n k e d to e i t h e r s i t u a t i o n s or p h y s i c a l s e n s a t i o n s . A h i g h l y c o n d i t i o n e d f e a r may not then be a good b a s i s f o r e x c l u d i n g 48 a c o g n i t i v e i n t e r v e n t i o n . I t may be t h a t another b a s i s f o r p r e d i c t i n g the potency of c o g n i t i v e i n t e r v e n t i o n s w i l l emerge such as, f o r example, the s t r e n g t h w i t h which a s s o c i a t e d d y s f u n c t i o n a l c o g n i t i o n s are h e l d . C l a u s t r o p h o b i a would again appear to be a good t e s t i n g ground. T h i s l a s t p o i n t helps to make i t c l e a r that a b e t t e r understanding of a f e a r such as c l a u s t r o p h o b i a , w i l l be of importance i n the r e a p p r a i s a l t h a t seems l i k e l y to be necessary a f t e r the dust has s e t t l e d on the treatment of panic d i s o r d e r . Much can l e a r n e d and suggested from the senses i n which c l a u s t r o p h o b i a and panic d i s o r d e r are r e a l l y s i m i l a r , and the s i g n i f i c a n c e of the ways i n which they d i f f e r . But even without the r e s u l t s from p a n i c d i s o r d e r , there would be no shortage of questions to ask of comparative i n t e r v e n t i o n s f o r c l a u s t r o p h o b i a . T h i s i s an i d e a l format i n which to study the mechanisms of change. Rachman and W h i t t a l (1989) have r e f e r r e d to t r y i n g t o c a t c h such mechanisms " i n a g l a s s j a r " . The ambitions here would be somewhat more modest, and p a r t i c u l a r l y r e l a t e to m o n i t o r i n g changes acr o s s s e l f - r e p o r t e d a n x i e t y , 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 . How do Changes i n these systems compare between the three i n t e r v e n t i o n s ? What i s the d i f f e r e n c e i n t i m i n g of t h e i r e f f e c t ? 49 Turning now to methodology, i t can be noted that some re s e a r c h e r s have favoured v a r y i n g the b e h a v i o u r a l options by having a v a r i e t y of t a s k s to perform (such as M a v i s s a k a l i a n et a l ' s [1983] "course" f o r agoraphobics that becomes i n c r e a s i n g l y d i f f i c u l t ) . Rachman and h i s a s s o c i a t e s (1987, 1988), however, have found i t more u s e f u l to have a sh o r t s t a n d a r d i z e d t e s t w i t h , a t most, a choice between s e v e r a l " l e v e l s " of the same t a s k . The l a t t e r o p t i o n was favoured here. The c h i e f measure of a n x i e t y i s thus a s e r i e s of s e l f -r e p o r t s . While the c l a u s t r o p h o b i c may f i n d i t e a s i e r than the agoraphobic to a v o i d the s m a l l e r range of s i t u a t i o n s a s s o c i a t e d w i t h alarms, the advantage f o r the r e s e a r c h e r i s that w i t h i n the narrower range of s i t u a t i o n s , the c l a u s t r o p h o b i c w i l l r e c e i v e many more cues f o r p a n i c . I t i s thus an e x c e l l e n t t e s t i n g ground f o r s u b j e c t i v e r e p o r t s of anxiety and p a n i c . There i s g e n e r a l consensus, too, t h a t r e s e a r c h i n t h i s area w i l l be unable to s t r e t c h e i t h e r i t s t h e o r e t i c a l or a p p l i e d wings without p h y s i o l o g i c a l assessment. The method by which t h i s should be done i s h o t l y debated although heart r a t e i s u s u a l l y r e c o g n i z e d as the most r e l i a b l e marker (Liebowitz e t a l , 1985). Since the advent of ambulatory monitoring (see Freedman et a l , 1985; T a y l o r et a l , 1983), p h y s i o l o g i c a l assessment i n a l a b o r a t o r y s e t t i n g might seem l i m i t e d , but there are important q u e s t i o n s t h a t can be answered i n such a s e t t i n g . I f the c o g n i t i v e i n t e r v e n t i o n i s 50 e f f e c t i v e , f o r example, i s i t that i t leads to a marked r e d u c t i o n i n he a r t r a t e , or a lower p r o b a b i l i t y of m i s i n t e r p r e t i n g the same l e v e l of p h y s i o l o g i c a l response? In the area of s e l f - r e p o r t e d c o g n i t i o n s and sensat i o n s the pioneers have been Chambless and her a s s o c i a t e s (1984). They have developed q u e s t i o n n a i r e s t h a t have proved a s o l i d f o undation f o r r e s e a r c h i n t h i s area. The Agoraphobic C o g n i t i o n s Q u e s t i o n n a i r e (ACQ) has items p e r t a i n i n g to c a t a s t r o p h i c thoughts about the r e s u l t s of a n x i e t y , while the Body Sensations Q u e s t i o n n a i r e (BSQ) i s a l i s t of p h y s i c a l s e n s a t i o n s a s s o c i a t e d with a n x i e t y t h a t c l i e n t s f r e q u e n t l y r e p o r t to be d i s t u r b i n g . There have been some v a r i a t i o n s on s c o r i n g the ACQ, though the most common means has been to r a t e each thought from "never o c c u r s " to "always occur s " . For the BSQ the sub j e c t i s allowed more l a t i t u d e as to how the s e n s a t i o n s are p e r c e i v e d , w i t h c h o i c e s from "not f r i g h t e n e d or w o r r i e d by t h i s s e n s a t i o n " (score of 1), to "extremely f r i g h t e n e d by t h i s s e n s a t i o n " (score o f 5). The scores on i n d i v i d u a l items, whether i n d i c a t i n g merely presence or i n c l u d i n g p e r c e p t i o n , are summed and expressed as e i t h e r a t o t a l or an averaged score. The importance of outcome has thus f a r been downplayed, but that i s not to say t h a t i t i s to be t o t a l l y i g n o r e d . However, i n p l a c e of a comparison of the d i f f e r e n t groups on a s i n g l e measure, th e r e w i l l be g r e a t e r focus on which 51 treatment g e n e r a l i z e s b e t t e r and how each f a r e s over time. One of the c l e a r e s t statements on the r i s k s and l i m i t a t i o n s of a s i n g l e p o i n t of measuring change was made by Bandura (1978). He i s both c r i t i c a l t h a t the e f f e c t s of p s y c h o l o g i c a l procedures "are o f t e n judged i n terms of u n d i f f e r e n t i a t e d outcomes a k i n to cure r a t e s " and p o i n t s out t h a t any behaviour i s l i k e l y t o "vary markedly i n d i f f e r e n t environmental s e t t i n g s toward d i f f e r e n t people and at d i f f e r e n t times". In p l a c e of such u n d i f f e r e n t i a t e d outcomes, he appeals f o r the more a n a l y t i c questions of whether a method induces p s y c h o l o g i c a l change, whether the changes g e n e r a l i z e a c r o s s s i t u a t i o n s and response systems, and whether the changes are maintained over time. As he s t a t e s , "the r e t i r e m e n t of amorphous, inadequately measured outcomes i s long overdue". Such a design promises to be of p a r t i c u l a r r e l e v a n c e i n t h i s study since c o g n i t i v e i n t e r v e n t i o n s o f t e n seem to improve t h e i r e f f i c a c y even a f t e r treatment has ceased (e.g. M a r s h a l l , 1985), and y e t have f a r e d l e s s w e l l i n r e d u c i n g anxiety i n u n f a m i l i a r s e t t i n g s ( B i r a n & Wilson, 1981). At t h i s p o i n t the i n t e r v e n t i o n s w i l l be c l a r i f i e d . The f i r s t i n t e r v e n t i o n comes e a s i l y to mind: i t i s one aimed s o l e l y and e x c l u s i v e l y a t c o g n i t i o n s . The c l i e n t ' s a n x i e t y -p rovoking thoughts w i l l be e l i c i t e d , and t r a i n i n g w i l l f o l l o w showing how such c o g n i t i o n s might be countered. The major p o i n t i s t h a t t h e r e w i l l be no exposure to the f e a r e d 52 s i t u a t i o n . I t seems almost c e r t a i n that such an i n t e r v e n t i o n w i l l be l e s s s u c c e s s f u l than d i r e c t contact w i t h the f e a r e d s i t u a t i o n but i t i s not c l e a r why. Is i t th a t one needs e v i d e n t i a l experience f o r a c o g n i t i o n to change? Is i t t h a t i n an anxious s i t u a t i o n the p h y s i o l o g i c a l a r o u s a l i s too h i g h t o all o w c o g n i t i v e techniques to be put i n t o a c t i o n ? I t would c e r t a i n l y be of gr e a t i n t e r e s t to e s t a b l i s h whether c o g n i t i o n s can be changed without exposure, and what e f f e c t t h i s i s l i k e l y to have on the other two systems both over time and across other s i t u a t i o n s . Teasdale (1988) has c a l l e d f o r such an i n t e r v e n t i o n i n p a n i c d i s o r d e r , but i t i s o n l y s i n c e t h i s study was i n i t i a t e d t h a t there has been any s i g n of a response (P.M. S a l k o v s k i s , p e r s o n a l communication, A p r i l 1990). One p o i n t should be made c l e a r about t h i s i n t e r v e n t i o n . I t i s not proposed f o r a moment that t h i s i s how c o g n i t i v e therapy should i d e a l l y be c a r r i e d out. There i s not a s i n g l e s t y l e of c o g n i t i v e therapy t h a t would aim to change c o g n i t i o n s i n t h i s manner, i . e . without i n c l u d i n g exposure to the fea r e d s i t u a t i o n . Beck and Emery (1985) s t a t e u n e q u i v o c a l l y t h a t simple phobias are not a s u i t a b l e t a r g e t f o r c o g n i t i v e i n t e r v e n t i o n s s i n c e "the c o g n i t i v e s e t i s a c t i v a t e d with a minimum of primary and secondary a p p r a i s a l s " , and the c o g n i t i v e responses are " r e f l e x i v e " , "automatic" and " f a r removed from v o l u n t a r y c o n t r o l and a p p r a i s a l " . I t i s to exposure t h a t Beck looks to move 53 c l i e n t s from what he terms r e f l e x i v e to r e f l e c t i v e t h i n k i n g . Bandura (1977), too, i s adamant t h a t c o g n i t i v e processes are induced and a l t e r e d most r e a d i l y "by experience of mastery a r i s i n g from e f f e c t i v e performance". One of the freedoms of t h i s s t y l e of study i s to be able to i n c l u d e an i n t e r v e n t i o n to see what happens, without b e l i e v i n g t h a t i t can n e c e s s a r i l y match other i n t e r v e n t i o n s . I t i s important to decide on the s t y l e of t h i s c o g n i t i v e i n t e r v e n t i o n . As t h e o r i e s and p r a c t i c e have developed and p r o l i f e r a t e d , i t no longer makes sense to group " c o g n i t i v e approaches" as i f they were a s i n g l e phenomenon. There i s c e r t a i n l y a s t a r k c o n t r a s t between the approach of Meichenbaum and Beck, f o r example. The former w i l l l e a d t o a v a r i e t y of coping s e l f - i n s t r u c t i o n s , the l a t t e r to i d e n t i f i c a t i o n and c o u n t e r i n g of d y s f u n c t i o n a l thoughts. I t i s t h i s second approach which w i l l be used here. I t i s one that has been c l e a r l y s p e c i f i e d (see Beck & Emery, 1985) and has t r a n s f e r r e d r e l a t i v e l y w e l l from the same authors' work on d e p r e s s i o n . The second group i s a l s o r e l a t i v e l y easy to s e l e c t . Barlow's 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 to the " s e n s a t i o n s " of exposure, r a t h e r than to p a r t i c u l a r s i t u a t i o n s was so i n g e n i o u s l y simple that once seen i t was a s t o n i s h i n g that i t had not been used years p r e v i o u s l y . Barlow (1988) does g i v e an i n t e r e s t i n g account of some very 54 e a r l y examples of t h i s approach which he b e l i e v e s were e i t h e r m i s i n t e r p r e t e d or ignored. Wolpe (1958) used C0 2 i n h a l a t i o n s but saw them only as a means of f a c i l i t a t i n g r e l a x a t i o n . Orwin's (1973) "running treatment" a l s o i n a d v e r t e n t l y exposed s u b j e c t s to the somatic cues of p a n i c . L i t t l e , too, was made of some e a r l y case r e p o r t s by Lum (1976) and Latimer (1977). Thus i t was not u n t i l the mid-1980s t h a t workers such as C l a r k (1985), S a l k o v s k i s e t a l (1984), Ley (1985), Rapee (1987) and Barlow (1988) came to use i n t e r o c e p t i v e exposure, though i t was as o f t e n used to t e s t s p e c i f i c hypotheses than as a d e l i b e r a t e focus of d e s e n s i t i z a t i o n . For many of the reasons mentioned i n the pr e v i o u s paragraph, i t i s more l i k e l y to be e f f e c t i v e p r a c t i c e d i n v i v o , but much can be l e a r n e d 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 without the b e n e f i t of exposure. Indeed r e s e a r c h e r s such as C l a r k (1990) have expressed grave doubt t h a t i t co u l d e x e r t any s i g n i f i c a n t e f f e c t on i t s own, other than when o p p o r t u n i t y might be p r o v i d e d t o c h a l l e n g e a c o g n i t i o n . To some extent i t i s tempting t o have j u s t these two groups so as to f a c i l i t a t e w i t h i n - g r o u p a n a l y s i s , but on balance t h e r e are d i s t i n c t advantages to having groups w i t h which r a t e s of change might be compared. An obvious c h o i c e i s to have an exposure group, even i f t h i s b r i n g s about some d i f f i c u l t i e s . The main l i m i t a t i o n i s the r i s k t h a t the i n c l u s i o n o f exposure would d e t r a c t from the process 55 emphasis of the study; i t would be a l l too easy f o r the reader to note t h a t t h i s was the most e f f e c t i v e i n t e r v e n t i o n (the almost c e r t a i n outcome) and so miss the important d e t a i l of the changes i n the three i n t e r v e n t i o n s . A second important p o i n t i s that i t i s not easy to a d m i n i s t e r a "pure" form of exposure i n p r a c t i c e , as Wilson (1986) has r e p o r t e d . When he r e q u i r e d t h e r a p i s t s to f o s t e r exposure without e x p l a i n i n g c l i e n t s ' r e a c t i o n s , c h a l l e n g i n g d y s f u n c t i o n a l thoughts, or a d d r e s s i n g i s s u e s r e l a t e d to response p r e v e n t i o n , they r e p o r t e d how d i f f i c u l t i t was to adhere to the treatment p r o t o c o l . While h i s experience suggests t h a t any form of mute exposure would be i m p r a c t i c a l , e a r l y p i l o t work f o r t h i s study suggests that i t i s p o s s i b l e t o g i v e very much l e s s emphasis to c o g n i t i o n s . Since there i s exposure to a f e a r e d stimulus both before and a f t e r the i n t e r v e n t i o n s , a c o n t r o l group i s a l s o i n c l u d e d c o n t r o l l i n g f o r the e f f e c t of these assessments over the time p e r i o d of the i n t e r v e n t i o n s . Another important i s s u e i s s u b j e c t s e l e c t i o n . T h i s i s a t o p i c which needs to be considered d i s p a s s i o n a t e l y s i n c e i t s d i s c u s s i o n o f t e n tends to generate more heat than l i g h t . More study i s r e q u i r e d of the type c a r r i e d out by Emmelkamp et a l (1986) which looked s p e c i f i c a l l y at the e x t e r n a l v a l i d i t y of analogue outcome r e s e a r c h . The use of c o l l e g e students i s the commonest source of c r i t i c i s m s i n c e they do appear to be more s t r o n g l y i n f l u e n c e d by f a c t o r s such as 56 demand c h a r a c t e r i s t i c s and expectancy of t h e r a p e u t i c g a i n (Emmelkamp e t a l 1975) than c l i n i c a l p a t i e n t s . I t i s p o s s i b l e (and a g a i n t h i s i s open to t e s t i n g ) t h a t c o g n i t i v e i n t e r v e n t i o n s are more e f f e c t i v e with i n t e l l i g e n t students who can adapt more e a s i l y to c o g n i t i v e demands. A t h i r d area of d i f f e r e n c e i s t h a t student s u b j e c t s are l i k e l y to r e a c t with a much s l i g h t e r degree of a r o u s a l than c l i n i c a l s u b j e c t s (Lader, 1967). Since s e v e r a l authors ( B i r a n & Wilson, 1981; Rachman & Wilson, 1980) have suggested t h a t c o g n i t i v e r e s t r u c t u r i n g i s only l i k e l y to be e f f e c t i v e f o r low p h y s i o l o g i c a l r e a c t o r s , t h i s a g a i n would be a l i m i t a t i o n i n s t udying s o l e l y student v o l u n t e e r s . There ar e , as yet, l i m i t e d data on the q u e s t i o n but Borkovec's view (1976) i s s t i l l widely quoted, i f not yet supported w i t h c l e a r d ata: "As long as the p h y s i o l o g i c a l component i s s t r o n g l y present i n the i n d i v i d u a l ' s immediate a n x i e t y r e a c t i o n , simple manipulations of the other two components ( i . e . c o g n i t i v e and o v e r t - b e h a v i o u r a l ) w i l l be i n e f f e c t i v e , or a t very l e a s t , i n e f f i c i e n t " . The s t e r n e r t e s t s are thus l i k e l y to be found with c l i n i c a l p a t i e n t s . There remain a few concepts about which a few words should be s a i d . With regard to the measurement of the three systems; the p o s i t i o n put forward by Lang i n 1964 s t i l l makes good sense. He warned that n e i t h e r v e r b a l , motor nor somatic concepts c o u l d be used to d e f i n e f e a r on t h e i r own s i n c e each c o u l d g i v e out a f a l s e l e a d . Though widely used, 57 i t i s a system that has i n v i t e d c r i t i c i s m . Schwartz (1978) cons i d e r s that i t i s a r b i t r a r y to focus on three dimensions and, moreover, m i s l e a d i n g s i n c e i t i m p l i e s that they are somehow separate and ignores "the n o v e l , i n t e r a c t i v e or emergent property that p a t t e r n s a c q u i r e " . Peterson's (1984) concern i s t h a t the r e s u l t i n g i n c r e a s e i n the number of measurements i n c r e a s e s the p r o b a b i l i t y of chance f i n d i n g s and can l e a d to an emphasis on a few v a r i a b l e s t h a t best f i t one's preconceptions. With the number of hypotheses i n t h i s study, t h i s i s an important p o i n t to bear i n mind. However v a l i d these c a u t i o n s , the t r i p l e response system i s not yet b e t t e r e d and i s now f i r m l y e s t a b l i s h e d i n the f i e l d . As Hollandsworth (1986) wrote: "As long as the t r i p l e modes way of viewing t h i n g s i s presented as a t e n t a t i v e and even flawed c o n s t r u c t with s p e c i f i c uses and d e f i n i t e l i m i t a t i o n s , then one need not a p o l o g i z e f o r i t s s i m p l i c i t y or p r a c t i c a l a p p l i c a b i l i t y " . I t had been hoped t o i n v e s t i g a t e f u r t h e r Barlow's n o t i o n of true and f a l s e alarms. I t i s a d i s t i n c t i o n which he makes on the b a s i s of a r e t r o s p e c t i v e i n t e r v i e w . Though i n a g e n e r a l sense i t i s p o s s i b l e to e s t a b l i s h t h a t there are such events as f a l s e alarms, i t becomes much more d i f f i c u l t on an i n d i v i d u a l b a s i s to determine the causes of a person's l e a r n e d response. In t h i s study i t i s a n t i c i p a t e d t h a t s u b j e c t s w i l l show a range of avoidance and p a n i c experience. Rather than g e t t i n g embroiled i n d i f f e r e n t i a t i n g 58 c l a u s t r o p h o b i a from agoraphobia, su b j e c t s e l e c t i o n w i l l be based s o l e l y on the degree of anxiety e x p e r i e n c e d i n the c l o s e t i n the l a b o r a t o r y . Though assessed and used, s u b j e c t s ' avoidance or l e v e l s of experienced a n x i e t y i n other s i t u a t i o n s w i l l not be a b a s i s f o r i n c l u s i o n i n , or e x c l u s i o n from, the study. A f i n a l c o n s t r u c t to be b r i e f l y d i s c u s s e d i s s e n s i t i v i t y to symptoms of a n x i e t y . Whether or not they are l i k e l y to be m i s i n t e r p r e t e d , the q u e s t i o n must be answered as to how p h y s i c a l s e n s a t i o n s are t r i g g e r e d i n the f i r s t p l a c e . A h y p othesis proposed by Shear (1988) i s t h a t panic v u l n e r a b i l i t y might r e s u l t from " t r a n s i e n t , n o n s p e c i f i c p e r i p h e r a l p h y s i o l o g i c a l changes which occur more f r e q u e n t l y i n panic p a t i e n t s " . However, she f i n d s l i t t l e e v idence f o r a primary d i s t u r b a n c e i n such p h y s i o l o g i c a l a c t i v i t y . T h i s then suggests t h a t those s u s c e p t i b l e to a p a n i c a t t a c k are perhaps p a r t i c u l a r l y s e n s i t i v e to n o t i c i n g t h e i r b o d i l y s e n s a t i o n s . A way of measuring such s e n s i t i v i t y i s w i t h R e i s s ' (1986) Anxi e t y S e n s i t i v i t y Index and the r e l a t i o n between t h i s and i n t e r o c e p t i v e exposure w i l l be p a r t i c u l a r l y noted. I t ; i s s t r e s s e d t h a t process r e s e a r c h i s not proposed as being a t h e o r e t i c a l . P r a c t i c e and theory i n the f i e l d of a n x i e t y d i s o r d e r s have tended to remain q u i t e f a r removed from each other: advances i n p r a c t i c e have r a r e l y been 59 d e r i v e d from theory. What i s needed i s some c l e a r evidence which can have b e a r i n g on more than one t h e o r i s t . I t i s i n t r y i n g to meet such a need that the f o l l o w i n g study has been planned, and emphasis p l a c e d on the importance of d e s c r i p t i v e as w e l l as experimental data. 6 0 METHOD 1. SAMPLE SELECTION F o r t y - e i g h t p a r t i c i p a n t s were s e l e c t e d from the community a f t e r e x t e n s i v e a d v e r t i s i n g i n l o c a l r a d i o and newspapers. T h i s p u b l i c i t y s t r e s s e d (a) t h a t the focus of the study would be on the f e a r of smal l e n c l o s e d spaces, although f e a r s of l a r g e r spaces, such as a i r c r a f t or shopping m a l l s , might a l s o be e v i d e n t ; (b) that p a r t i c i p a n t s would be t r a i n e d over t h r e e v i s i t s i n a p a r t i c u l a r coping s t r a t e g y ; (c) that t h i s was a r e s e a r c h study i n which p a r t i c i p a n t s n e i t h e r p a i d nor were p a i d ; and (d) t h a t c o n f i d e n t i a l i t y was assured. I t was e x p l a i n e d t h a t having f i l l e d out some q u e s t i o n n a i r e s , answered a v a r i e t y of q u e s t i o n s , and taken p a r t i n the three s e s s i o n i n t e r v e n t i o n , a minimum of a f u r t h e r hour would be devoted s o l e l y to answering q u e r i e s and g i v i n g a d v i c e s p e c i f i c a l l y t a i l o r e d to the needs of each p a r t i c i p a n t . C r i t e r i a f o r e x c l u s i o n . E x c l u s i o n a r y c r i t e r i a were (a) those c u r r e n t l y i n treatment f o r a mental d i s t u r b a n c e or with a h i s t o r y of p s y c h o s i s ; (b) those s u f f e r i n g from a major i l l n e s s i n c l u d i n g any c a r d i o v a s c u l a r d i s o r d e r (such as h y p e r t e n s i o n ) or r e s p i r a t o r y d i s e a s e (such as asthma or b r o n c h i t i s ) ; (c) those t a k i n g m e dication (other than minor t r a n q u i l i z e r s ) 61 t h a t could not be d i s c o n t i n u e d ; and (d) those who were e i t h e r pregnant or (e) e p i l e p t i c . C r i t e r i o n f o r i n c l u s i o n . The c r i t e r i o n f o r i n c l u s i o n was t i e d to the s p e c i f i c demands of the study r a t h e r than on the b a s i s of any g e n e r a l c l a u s t r o p h o b i c or more g e n e r a l f e a r survey. Subjects who r e p o r t e d a f e a r score of more than 50 (on a V i s u a l Analogue Scale [VAS] of 0-100) a f t e r two minutes exposure to the l a b o r a t o r y t e s t - c l o s e t were, f o r the purposes of t h i s study, d e f i n e d as c l a u s t r o p h o b i c . Such a score i s above the 99th p e r c e n t i l e of the UBC student p o p u l a t i o n sampled over the l a s t two years (Rachman, Booth, & W h i t t a l , 1989). 2. MEASURES The assessment was made up of t h r e e s e t s of dependent measures (seven i n a l l ) that were g i v e n a t d i f f e r e n t i n t e r v a l s throughout the study. A summary of these measures and the i n t e r v a l s a t which they were a d m i n i s t e r e d i s presented i n Table 1. 62 ASSESSMENT I The f i r s t 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 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 a t fo l l o w - u p : The A n x i e t y S e n s i t i v i t y Index ( R e i s s , 1986) T h i s i s a measure of an x i e t y s e n s i t i v i t y , which Reiss et a l (1986) have 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 v a r i a b l e c o n s i s t i n g of the b e l i e f t h a t the experience of an x i e t y causes i l l n e s s , embarrassment or a d d i t i o n a l a n x i e t y " . A n x i e t y s e n s i t i v i t y i s l i k e l y t o have important consequences, i n c l u d i n g m o t i v a t i o n to a v o i d a n x i e t y -provoking s t i m u l i , but i t s importance i n t h i s study i s t h a t i t i s c o n s i d e r e d l i k e l y "to i n c r e a s e a l e r t n e s s to s t i m u l i s i g n a l l i n g the p o s s i b i l i t y of becoming nervous". The s c a l e has 16 items s p e c i f y i n g negative consequences to the experience of a n x i e t y . These consequences i n c l u d e a d d i t i o n a l a n x i e t y or f e a r , i l l n e s s , embarrassment and l o s s of c o n t r o l . Subjects r a t e each item from "very l i t t l e " (scored as 0) to "very much" (4 p o i n t s ) . An i n d i v i d u a l ' s A n x i e t y S e n s i t i v i t y Score i s the sum of scores on the 16 items. R e i s s et a l (1986) have p r o v i d e d evidence of the psychometric p r o p e r t i e s of the s c a l e , demonstrating i t s r e l i a b i l i t y and v a l i d i t y . While i t i s s i m i l a r to other " f e a r 63 of f e a r " s c a l e s , i t i s the f i r s t to have been shown to measure something d i f f e r e n t from that measured by c o n v e n t i o n a l a n x i e t y s c a l e s , thus v a l i d a t i n g the d i s t i n c t i o n between an x i e t y and a n x i e t y s e n s i t i v i t y . I t i s important to note that though hi g h scores on the s c a l e are more s t r o n g l y a s s o c i a t e d w i t h agoraphobia than with other a n x i e t y d i s o r d e r s , r e s u l t s from s t u d i e s r e p o r t e d i n the same a r t i c l e c l e a r l y c o n t r a d i c t the view of a unique a s s o c i a t i o n . ASSESSMENT I I The second p a r t of the assessment was made up of f i v e measures and focused on the B e h a v i o u r a l Approach Test (BAT) 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 , f o l l o w - u p , and at a t e s t of g e n e r a l i z a t i o n i n a second e n c l o s e d space. Before e n t e r i n g the l a b o r a t o r y c l o s e t , s u b j e c t s p r e d i c t e d the peak l e v e l of f e a r t h a t they were l i k e l y to e x p e r i e n c e , u s i n g a 0-100 V i s u a l Analogue Scale (VAS). While they were i n the c l o s e t ( f o r a p e r i o d of two minutes), t h e i r h e a r t r a t e was measured by a pulsemeter attached to t h e i r earlobe with readings taken every 15 seconds: A h e a r t r a t e measure was a l s o taken f o r a s i m i l a r l e n g t h of time b e f o r e the BAT, when s u b j e c t s were asked to s i t q u i e t l y w i t h t h e i r eyes c l o s e d ( r e s t i n g h e a r t r a t e ) . 64 A f t e r the BAT, s u b j e c t s r e p o r t e d t h e i r l e v e l of f e a r (VAS 0-100), as w e l l as whether or not they panicked. Subjects a l s o f i l l e d i n : (a) a Negative C o g n i t i o n s C h e c k l i s t , n o t i n g not only which commonly r e p o r t e d negative thoughts were brought to mind, but the degree to which they were b e l i e v e d (0-100%) while i n the c l o s e t ; and (b) a P h y s i c a l Symptoms C h e c k l i s t , i n c l u d i n g the unpleasantness (0-100%) of any symptoms experienced. The s c a l e s f o r c o g n i t i o n s and s e n s a t i o n s are reduced to a s i n g l e score f o r each, by m u l t i p l y i n g each item endorsed by i t s accompanying percentage and summing the t o t a l . Both s c a l e s are 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 by Chambless et a l (1984): the Agoraphobic C o g n i t i o n s Q u e s t i o n n a i r e and the Body Sensations Q u e s t i o n n a i r e . The authors have demonstrated the r e l i a b i l i t y of these measures on c l i n i c a l samples, as w e l l as t h e i r d i s c r i m i n a n t and c o n s t r u c t v a l i d i t y . They draw a t t e n t i o n to the s t a b i l i t y of scores p r i o r to treatment, and to t h e i r s e n s i t i v i t y to change wi t h treatment. Changes made f o r t h i s study are a d d i t i o n s r e l e v a n t to c l a u s t r o p h o b i a , n o t a b l y c o g n i t i o n s r e l a t i n g to entrapment, and the omission of items not endorsed by c l a u s t r o p h o b i c s ("I am going b l i n d " ; "I w i l l h u r t someone"). While p r e v i o u s l y used w i t h t h i s group (see Rachman & L e v i t t , 1986), no psychometric data i s yet a v a i l a b l e on these adapted q u e s t i o n n a i r e s . 65 When the p o s t - i n t e r v e n t i o n assessments had been completed, p a r t i c i p a n t s were asked to go a second room where there was an even s m a l l e r t e s t - c l o s e t , used to assess how the e f f e c t s of each i n t e r v e n t i o n had g e n e r a l i z e d . U n l i k e the f i r s t c l o s e t , i t was soundproof and had no button with which to s i g n a l the r e t u r n of the experimenter. The time p e r i o d was a l s o changed from two minutes to "a time, randomly drawn, between two and f o u r minutes", although t h i s was always two and a h a l f minutes i n p r a c t i c e . P a r t i c i p a n t s were asked to make a s e t of p r e d i c t i o n s about how anxious they would f e e l i n t h i s second c l o s e t under s i x c o n d i t i o n s (from doors open and l i g h t on, to door of room c l o s e d , c l o s e t l o c k e d and l i g h t o f f ) , u s i n g a V i s u a l Analogue S c a l e 0 - 1 0 0 ("no f e a r to t e r r i f y i n g f e a r " ) . They were then asked to s e l e c t and c a r r y out one of these c o n d i t i o n s . ASSESSMENT I I I An aim of t h i s study was to monitor change more f r e q u e n t l y than by simply r e c o r d i n g b e f o r e / a f t e r measures. Since there c o u l d be no exposure to the c l o s e t d u r i n g t r a i n i n g f o r two of the groups, i t was not p o s s i b l e to take r e g u l a r measures of h e a r t r a t e , p h y s i c a l s e n s a t i o n s , and c o g n i t i o n s i n the f e a r e d s e t t i n g . Assessment b e f o r e and a f t e r each s e s s i o n of t r a i n i n g was thus c o n f i n e d t o s e l f -r e p o r t measures, of which a n x i e t y p r e d i c t i o n was c o n s i d e r e d the most c e n t r a l . Thus, once again u s i n g a V i s u a l Analogue S c a l e , at the beginning and end of each t r a i n i n g s e s s i o n s u b j e c t s were asked to p r e d i c t how anxious they would f e i f they were to go i n the c l o s e t f o r a two minute p e r i o d 6 7 T a b l e 1 Summary and t i m i n g of assessment-. MEASURES Assessment I (Anxiety S e n s i t i v i t y Index) Assessment II ( P r e d i c t / R e p o r t A n x i e t y ) (Report panic) (Heart Rate) (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 ) Assessment I I I ( P r e d i c t a n x i e t y ) TIMING OF ASSESSMENT Assessment I Assessment II PRE-TEST I n t e r v e n t i o n : End of S e s s i o n 1 B e g i n n i n g and end of S e s s i o n 2 Beginning and end of S e s s i o n 3 Assessment I Assessment I I POST-TEST Assessment I I GENERALIZATION Assessment I I I Assessment I I I Assessment I I I Assessment I I I E i g h t weeks Assessment I Assessment I I FOLLOW-UP 68 3. APPARATUS The l a b o r a t o r y " c l o s e t " used i n t h i s study was a sturdy but w e l l - v e n t i l a t e d f i l i n g c a b i n e t , 7'x 4'x 2', pl a c e d i n a small dark room. A f t e r the c l o s e t door had been locked, the experimenter shut the door of the ou t s i d e room l e a v i n g i t i n darkness. The only l i g h t came from a small s w i t c h i n s i d e the c l o s e t which, i f p r e s s e d , s i g n a l l e d f o r the experimenter to r e t u r n . The room used f o r g e n e r a l i z a t i o n was borrowed from a c l i n i c where i t was used as a mobile h e a r i n g l a b o r a t o r y . I t s dimensions were 6'x 2'x 2' and the seat and a l l i t s u s u a l equipment had been removed. The p u l s e meter used to assess heart r a t e was a Sanyo HRM-97E. T h i s works through a p h o t o - e l e c t r i c p u l s e sensor c l i p p e d to the e a r l o b e , y i e l d i n g a d i g i t a l d i s p l a y showing both time and pul s e r a t e . I t s range i s from 38 to 200 beats a minute and i t i s a c c u r a t e to w i t h i n 3% on each beat. 4. PROCEDURE / Subjects r e s p o n d i n g to r a d i o and newspaper a d v e r t i s i n g were screened f o r c e r t a i n e x c l u s i o n a r y c r i t e r i a (see above) over the telephone. Those i n v i t e d to come to the c l i n i c were 6 9 g i v e n the p r e - i n t e r v e n t i o n i n t e r v i e w and q u e s t i o n n a i r e s , and the assessment package which i n c l u d e d the BAT. At t h i s f i r s t and a l l subsequent t e s t i n g p o i n t s , the p r e d i c t i o n s , r e p o r t s , as w e l l as l e a d i n g s u b j e c t s to and from the c l o s e t , were a l l c a r r i e d out by an experimenter b l i n d to s u b j e c t c o n d i t i o n s , and who took no p a r t i n any of the i n t e r v e n t i o n s . The i n s t r u c t i o n s f o r the BAT were "high demand". That i s t o say t h a t a f t e r s u b j e c t s had b r i e f l y seen the c l o s e t and i t had been e x p l a i n e d that they would be asked to stay i n i t f o r a p e r i o d of some two minutes, they were t o l d t h a t "only i f they r e a l l y needed to" should they p r e s s a button i l l u m i n a t e d i n the c l o s e t , which would s i g n a l the experimenter to l e t them out immediately. P r a c t i c e use of the button was d i s c o u r a g e d . Subjects who r e f u s e d to p a r t i c i p a t e i f the door was loc k e d , were encouraged to take p a r t with both doors shut, but n e i t h e r l o c k e d . They were assured on the e t h i c a l consent form that they were not i n any way o b l i g e d to take p a r t , and c o u l d withdraw from the study at any time. Those s u b j e c t s who d i d not s t a y i n the c l o s e t f o r the two minutes were not n e c e s s a r i l y excluded from the study. The minimum requirements were t h a t they stay i n f o r at l e a s t 30 seconds at the f i r s t assessment, and were w i l l i n g to stay i n f o r the same l e n g t h of time a t a l l subsequent BATs. S i m i l a r l y , those on whom the door was not lo c k e d , went i n t o the c l o s e t under i d e n t i c a l c o n d i t i o n s at a l l subsequent assessments. 70 Subjects whose r e p o r t e d f e a r was more than 50 (on a VAS of 0-100) were asked to p a r t i c i p a t e i n the study. Those wi t h lower f e a r l e v e l s were t o l d t h a t t h e i r a n x i e t y i n t h i s s i t u a t i o n was lower than t h a t c u r r e n t l y being s t u d i e d . They were then g i v e n at l e a s t an hour's c o u n s e l l i n g about t h e i r own f e a r s and how these might best be handled, as w e l l as the o p p o r t u n i t y to ask any q u e s t i o n s . Subjects i n c l u d e d i n the study were randomly a s s i g n e d to one of the f o u r groups: (a) e x t e r o c e p t i v e exposure (b) 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) a c o n t r o l group In the e x t e r o c e p t i v e exposure group, t h e r e was an e x p l a n a t i o n of how a f e a r i s l e a r n e d , and how humans seem to be p a r t i c u l a r l y s u s c e p t i b l e to p i c k i n g up c e r t a i n f e a r s of which c l a u s t r o p h o b i a i s a good example. The bulk of the time was spent d i s c u s s i n g what we know about exposure and implementing an a p p r o p r i a t e programme. A h i e r a r c h y was c r e a t e d f o r each i n d i v i d u a l so t h a t exposure c o u l d proceed from the l e s s to the more f e a r e d items (e.g. door wide open w i t h the l i g h t on, to door l o c k e d l i g h t o f f ) over the t h r e e s e s s i o n s of the i n t e r v e n t i o n . A l l exposure took p l a c e i n the same c l o s e t that was used f o r assessment. 71 In the i n t e r o c e p t i v e group, the e x p l a n a t i o n of f e a r a c q u i s i t i o n emphasized how e a s i l y one can pic k up f e a r not merely of s i t u a t i o n s , but of sensat i o n s r e l a t e d t o a n x i e t y . A h i e r a r c h y was formed i n a s i m i l a r f a s h i o n to the e x t e r o c e p t i v e group, but of se n s a t i o n s r a t h e r than s i t u a t i o n s . Subjects were g i v e n b r i e f exposure to a range of e x e r c i s e s (some pionee r e d by Zarate, Personal Communication, March 1989) which b r i n g on the p h y s i c a l s e n s a t i o n s l i k e l y to be experienced when anxious. These i n c l u d e d u n d e r b r e a t h i n g (through a straw with nose h e l d ) , o v e r b r e a t h i n g , s p i n n i n g and running on the spot. The e x e r c i s e s i d e n t i f i e d by the i n d i v i d u a l as c l o s e l y resembling those experienced w h i l e i n the c l o s e t , formed the s e n s a t i o n s h i e r a r c h y . They were ordered from l e a s t to most a n x i e t y - p r o v o k i n g and were p r a c t i c e d f o r i n c r e a s i n g l y extended p e r i o d s of time, i n i s o l a t i o n , and i n combination w i t h one c l o s e l y f o l l o w i n g another. To ma i n t a i n a maximum emphasis on exposure to the s e n s a t i o n s , r e l a t e d coping s t r a t e g i e s such as h y p e r v e n t i l a t i o n t r a i n i n g ( 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 not i n c l u d e d . Other than i n answer t o d i r e c t enquiry, n e i t h e r was t h e r e e x p l i c i t mention made of c o g n i t i o n s , nor the c o g n i t i v e l i n k s between such s e n s a t i o n s and c a t a s t r o p h i c m i s i n t e r p r e t a t i o n s . In the c o g n i t i v e group, i t was emphasized i n the i n i t i a l e x p l a n a t i o n how important thoughts c o u l d be i n the p r o v o c a t i o n of a n x i e t y . S u b j e c t s l e a r n e d how to i d e n t i f y 72 automatic thoughts, and d i s c u s s e d those experienced d u r i n g the assessment and how these might have c o n t r i b u t e d to t h e i r a n x i e t y . With the use of methods such as f l a s h c a r d s and the t h i r d c h a i r ( t r y i n g to persuade an "imagined other" out of t h e i r own i r r a t i o n a l t h i n k i n g ) , the aim was f o r c l i e n t s to l e a r n , without exposure, to i d e n t i f y and d e a l with l o g i c a l e r r o r s i n t h i n k i n g as a way of r e d u c i n g a n x i e t y . Information sheets were p r o v i d e d to h e l p the process of l e a r n i n g how to r a t i o n a l l y d i s p u t e thoughts r e l a t e d to p h y s i c a l s e n s a t i o n s ( " l i n k s " such as "I f e e l d i z z y t h e r e f o r e I am l i k e l y to f a i n t " ; "I f e e l b r e a t h l e s s and so I am i n danger of s u f f o c a t i n g " ) as w e l l as those without such an a s s o c i a t i o n ("What happens i f I am f o r g o t t e n / t r a p p e d i n h e r e " ? ) . In a l l three i n t e r v e n t i o n s , the f i r s t t r a i n i n g s e s s i o n took p l a c e immediately f o l l o w i n g the p r e - t e s t assessment, and the p o s t - t e s t assessment took p l a c e immediately f o l l o w i n g the t h i r d t r a i n i n g s e s s i o n . Assessments and i n t e r v e n t i o n s were thus c a r r i e d out w i t h i n three v i s i t s , the f i r s t some two hours long, the second s h o r t e r a t j u s t over an hour, and the t h i r d a g a i n about two hours s i n c e i t a l s o i n c l u d e d the t e s t of g e n e r a l i z a t i o n . I n s t r u c t i o n s a t the ou t s e t i n c l u d e d the d i r e c t i v e t h a t as f a r as p o s s i b l e p a r t i c i p a n t s should not seek out c l a u s t r o p h o b i c experiences while the study was i n progress 73 A l l t h r e e i n t e r v e n t i o n s were g i v e n by the same t h e r a p i s t who had worked f o r t h r e e years as a c l i n i c a l p s y c h o l o g i s t , as w e l l as having r e c e i v e d extensive s u p e r v i s e d experience i n c o g n i t i v e - b e h a v i o u r a l therapy. P i l o t s e s s i o n s were a l l taped and d i s c u s s e d to improve the e f f i c i e n c y of a l l three i n t e r v e n t i o n s . Once the study s t a r t e d , every t h i r d s e s s i o n was taped so that checks c o u l d be made on treatment i n t e g r i t y (see Appendix K). A date was set some s i x to e i g h t weeks a f t e r the t h i r d v i s i t f o r a r e t u r n appointment. I t was e x p l a i n e d to s u b j e c t s t h a t they would be asked to f i l l out the assessments and r e -e n t e r the c l o s e t f o r one f i n a l time. T h i s would be f o l l o w e d by up to an hour of d i s c u s s i o n of the study, p r e l i m i n a r y f i n d i n g s , i m p l i c a t i o n s f o r t h e i r own f e a r s , as w e l l as any q u e s t i o n s t h a t they should l i k e to ask. P a r t i c i p a n t s were g i v e n a w r i t t e n and v e r b a l e x p l a n a t i o n of the aims and procedures of the study a t t h a t time. 74 HYPOTHESES EXPERIMENTAL STUDY: HYPOTHESES The hypotheses stem from f o u r q u e s t i o n s which are posed below. Set 1. Do the three i n t e r v e n t i o n s d i f f e r from the c o n t r o l group a t p o s t - t e s t ? I t was thought t h a t there would be some improvement i n the scores of the c o n t r o l group, i n a d d i t i o n to the e f f e c t of r e g r e s s i o n t o the mean. T h e r a p i s t c o n t a c t , b r i e f exposure to a stim u l u s t h a t may w e l l not be the top of t h e i r a n x i e t y h i e r a r c h y , l i k e l y o v e r p r e d i c t i o n i n view of t h e i r widespread avoidance, as w e l l as a l l a y i n g of a d d i t i o n a l f e a r s ( d i s t r u s t of the experimenter, e t c , ) , were a l l c o n s i d e r e d l i k e l y to l e a d to some r e d u c t i o n i n scores even i n the absence of an i n t e r v e n t i o n . N e v e r t h e l e s s , f o r these i n t e r v e n t i o n s to be shown to be e f f e c t i v e , they should show s i g n i f i c a n t change over and above such improvement. I t was hy p o t h e s i z e d t h a t on s i x of the seven v a r i a b l e s ( p r e d i c t e d f e a r , r e p o r t e d f e a r , r e p o r t e d p a n i c , negative c o g n i t i o n s , unpleasant s e n s a t i o n s and h e a r t r a t e ) that the three i n t e r v e n t i o n s would be s u p e r i o r t o the c o n t r o l group. Since the Anxie t y S e n s i t i v i t y Index r e f l e c t s a g e n e r a l r a t h e r than a s p e c i f i c r e a c t i o n to a n x i e t y , i t was thought that only the i n t e r o c e p t i v e i n t e r v e n t i o n was l i k e l y to reduce scores on t h i s measure s i g n i f i c a n t l y . S p e c i f i c a l l y , the p r e d i c t i o n s were t h a t : 75 The t h r e e i n t e r v e n t i o n s would b r i n g about a more marked r e d u c t i o n on s i x v a r i a b l e s than the c o n t r o l group. On the seventh (the A n x i e t y S e n s i t i v i t y Index), the i n t e r o c e p t i v e group alone would show a r e d u c t i o n i n s c o r e s compared with the c o n t r o l group. Set 2 Do the three i n t e r v e n t i o n s d i f f e r from each other a t p o s t - t e s t and follow-up? I t was a n t i c i p a t e d t h a t the exposure group would be equal or s u p e r i o r to the other two groups on a l l but the Index of A n x i e t y S e n s i t i v i t y . More i n t e r e s t would focus on how the o t h e r two i n t e r v e n t i o n s r e l a t e t o exposure and each other. The c o g n i t i v e i n t e r v e n t i o n would be expected to i n f l u e n c e r e p o r t e d c o g n i t i o n s and to reduce r e p o r t e d panic even at p o s t - t e s t . In a d d i t i o n i t has been proposed t h a t the c o g n i t i v e group i s l i k e l y to have a " s l e e p e r " e f f e c t , c o n t i n u i n g to reduce, or h o l d constant, p r e d i c t i o n s and r e p o r t s of a n x i e t y d u r i n g the f o l l o w - u p p e r i o d , i n p l a c e of the u s u a l degree of r e t u r n of f e a r . The i n t e r o c e p t i v e group on the other hand, with i t s e x c l u s i v e f ocus on p h y s i c a l s e n s a t i o n s , would be expected to reduce the r e p o r t e d unpleasantness of p h y s i c a l s e n s a t i o n s and scores on the A n x i e t y S e n s i t i v i t y Index. S p e c i f i c a l l y the p r e d i c t i o n s were t h a t : 7 6 The exposure and c o g n i t i v e groups would show r e d u c t i o n on scores of r e p o r t e d panic and negative c o g n i t i o n s . The exposure group would show g r e a t e r r e d u c t i o n i n scores of p r e d i c t e d and r e p o r t e d f e a r and h e a r t r a t e at p o s t - t e s t than the o t h e r two groups, but by follow-up the c o g n i t i v e group would a l s o be s u p e r i o r to the i n t e r o c e p t i v e group on these measures. The exposure and i n t e r o c e p t i v e groups would show more r e d u c t i o n i n scores on p h y s i c a l s e n s a t i o n s than the c o g n i t i v e group. The i n t e r o c e p t i v e group would show a g r e a t e r r e d u c t i o n i n scores on the A n x i e t y S e n s i t i v i t y Index than e i t h e r of the other two groups. Set 3 Is there a d i f f e r e n c e i n the r a t e a t which f e a r i s reduced i n the t h r e e groups (measured a t s i x p o i n t s ) ? T h i s t h i r d s et of hypotheses i s focused on changes i n s e l f - r e p o r t a n x i e t y t h a t occur before and a f t e r i n d i v i d u a l s e s s i o n s of the i n t e r v e n t i o n . The most important q u e s t i o n concerns the t i m i n g a t which the e f f e c t s of an i n t e r v e n t i o n become apparent. I t has been argued t h a t the 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 are l i k e l y to show a r e d u c t i o n i n an x i e t y , only a f t e r s u b j e c t s have had the chance t o check out what they have l e a r n e d i n the p o s t - t e s t BAT. Thus i t was p r e d i c t e d t h a t g r a d u a l changes i n s e l f - r e p o r t p r e d i c t e d a n x i e t y should be e v i d e n t i n the exposure group over the three t r a i n i n g s e s s i o n s , the l a r g e s t decrement coming d u r i n g the second s e s s i o n (the longest p e r i o d of expo s u r e ) . On the other hand, l i t t l e such change should be seen i n the other two groups u n t i l the measure i s taken a f t e r the p o s t - t e s t BAT. S p e c i f i c a l l y the p r e d i c t i o n s were t h a t : At the t h i r d of s i x measuring p o i n t s , t h e r e would be a r e d u c t i o n i n p r e d i c t e d f e a r i n the exposure group. At the s i x t h measuring p o i n t , there would be a r e d u c t i o n i n the c o g n i t i v e and i n t e r o c e p t i v e groups on the same measure. Set 4 Do the f o u r groups d i f f e r on measures r e l a t e d to g e n e r a l i z a t i o n ? A f e a t u r e of t h i s study i s i t s c o n s i d e r a t i o n of g e n e r a l i z a t i o n . A f t e r the p o s t - i n t e r v e n t i o n assessment p a r t i c i p a n t s r a t e a second enclosed space under s i x d i f f e r e n t c o n d i t i o n s , and choose one of s i x " l e v e l s " under which they would en t e r i t f o r a short p e r i o d of time. I t i s p r e d i c t e d t h a t the t h r e e i n t e r v e n t i o n s would be s u p e r i o r to the c o n t r o l group on these two measures of g e n e r a l i z a t i o n . 78 A PHENOMENOLOGICAL STUDY OF CLAUSTROPHOBIA: OUTLINE In a d d i t i o n to the experimental study, and as p a r t of the emphasis on p r o c e s s , o p p o r t u n i t y was a l s o taken to c o l l e c t d e s c r i p t i v e d ata. I t was hoped that much c o u l d be l e a r n e d of the nature of c l a u s t r o p h o b i a from t h i s i n f o r m a t i o n s i n c e so l i t t l e i s known about t h i s f e a r . As a p r e l i m i n a r y step, i t was intended to e s t a b l i s h some f a c t s about the sample. The next s t e p was to look a t the r e s u l t s of the q u e s t i o n n a i r e s on both c o g n i t i o n s and s e n s a t i o n s to see which were the most commonly endorsed items, b e f o r e moving to the r e s u l t s of the s t r u c t u r e d i n t e r v i e w s which i n c l u d e d i n f o r m a t i o n on the onset of the f e a r , l i k e l y p r e c i p i t a t i n g events, as w e l l as areas of c u r r e n t avoidance. The s o r t of i s s u e s on which i l l u m i n a t i o n was sought, were such as whether t h i s i s a f e a r that can be s p l i t c l e a n l y between f e a r of s u f f o c a t i o n and f e a r of entrapment, whether, as i n agoraphobia, s e c u r i t y seems to be gained from the presence of o t h e r s , and what are the major c o g n i t i v e themes of t h i s f e a r . 79 RESULTS In t h i s main s e c t i o n of the r e s u l t s , the data are p r e s e n t e d f o r the four s e t s of hypotheses a f t e r two i s s u e s have been b r i e f l y d i s c u s s e d . Alpha l e v e l The s e t t i n g of an alpha l e v e l i s an important d e c i s i o n . C l i n i c i a n s have perhaps too o f t e n favoured a l i b e r a l b i a s without a p p r o p r i a t e j u s t i f i c a t i o n . S i n c e t h i s i s e x p l o r a t o r y r e s e a r c h , however, where c o n c l u s i o n s w i l l be t e n t a t i v e and as p a r t of a s e r i e s of s t u d i e s w i l l be f u l l y t e s t e d a g a i n , the r i s k of Type I e r r o r s need not have the o v e r r i d i n g importance i t must assume i n some circumstances. Indeed i f power i s o v e r l y reduced, there i s a r i s k t h a t important threads might not be noted and duly f o l l o w e d up. An alpha of .05 i s c o n s i d e r e d a p p r o p r i a t e . M i s s i n g data Two s u b j e c t s attended only the f i r s t s e s s i o n (one i n the exposure and one i n the i n t e r o c e p t i v e g r o u p ) . In one case, domestic problems n e c e s s i t a t e d the postponing of her second v i s i t f o r such a long p e r i o d t h a t i t f e l l o u t s i d e the time boundaries s e t . In the o t h e r , the i n d i v i d u a l was o f f e r e d a job o u t s i d e Vancouver and d i d not want 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 about c l a u s t r o p h o b i a before her d e p a r t u r e . These p a r t i c i p a n t s were r e p l a c e d . The only other c o m p l i c a t i o n was t h a t one s u b j e c t (from the i n t e r o c e p t i v e group) r e f u s e d to go i n t o the c l o s e t 80 a t f o l l o w - u p and so was unable to complete three of the measures at that p o i n t . The reasons f o r her r e f u s a l were c l e a r and expressed f u l l y . She had panicked on the previous t r i a l , her heart was a l r e a d y r a c i n g a t the prospect of going i n again, and she had no d e s i r e to have another p a n i c . In an e x c e l l e n t a r t i c l e on a t t r i t i o n (Howard et a l , 1986) i t i s p o i n t e d out that g i v i n g her e i t h e r a mean score or o m i t t i n g her from the study would be q u i t e m i s l e a d i n g . The recommendation f o r t h i s i n s t a n c e , which was duly f o l l o w e d , was to g i v e her the same h i g h s c o r e s which she had endorsed on the p r e v i o u s o c c a s i o n on these f o u r measures. Question 1. The p r e d i c t i o n s f o r the f i r s t q u e s t i o n were t h a t the t h r e e i n t e r v e n t i o n s would b r i n g about a more marked r e d u c t i o n on s i x v a r i a b l e s than the c o n t r o l group. On the seventh, (the ASI), the i n t e r o c e p t i v e group alone would show a r e d u c t i o n i n scores compared w i t h the c o n t r o l group. A one-way MANCOVA ( c o v a r y i n g out the p r e - i n t e r v e n t i o n scores) was performed to t e s t f o r an o v e r a l l e f f e c t and was s i g n i f i c a n t ( P i l l a i s ) E (49, 259) = 2.35, £ <.001. Means and standard 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 presented i n Table 2 and c o v a r i a n c e - a d j u s t e d means are presented i n Appendix L. A s e r i e s of u n i v a r i a t e ANCOVAs were then performed on the 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 f o r each of the seven 81 dependent v a r i a b l e s , the p r e - t e s t s c o r e s again being c o v a r i e d out. The r e s u l t s are p r e s e n t e d i n Table 3. For s i x of the seven v a r i a b l e s these ANCOVAs were s i g n i f i c a n t : p r e d i c t e d f e a r , negative c o g n i t i o n s , unpleasant p h y s i c a l s e n s a t i o n s a t p. <.001, r e p o r t e d f e a r a t £2 <.01 and r e p o r t e d p a n i c and hea r t r a t e at £ <.05. More f i n e l y g r a i n e d analyses were thus warranted. For each of these main e f f e c t s found to be s i g n i f i c a n t , follow-up m u l t i p l e comparisons were conducted u s i n g Dunnett's procedure ( s i n c e the c o n t r o l group was being compared with a l l other g r o u p s ) , with the necessary adjustment f o r the c o v a r i a t e (see K i r k , 1982, p.735). These comparisons are p r e s e n t e d i n Table 4 . The r e s u l t s show t h a t the exposure group was lower than the c o n t r o l group on scores of p r e d i c t e d and r e p o r t e d f e a r , h e a r t r a t e , negative c o g n i t i o n s , unpleasant p h y s i c a l s e n s a t i o n s ( a l l at c <.01) and r e p o r t e d panic (B <.05). The c o g n i t i v e group had lower scores on ne g a t i v e 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 at £ <.01), and r e p o r t e d f e a r and pan i c (e <.05). The i n t e r o c e p t i v e group had lower scores on neg a t i v e 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 exposure group showed a broad and expected r e d u c t i o n i n scores i n r e l a t i o n to the c o n t r o l group. In the c o g n i t i v e group, i t i s of note t h a t the r e p o r t s of f e a r , r a t h e r than i t s p r e d i c t i o n , were s i g n i f i c a n t l y reduced and 82 t h a t heart r a t e remained unchanged. Changes i n the i n t e r o c e p t i v e group were more modest, and only those i n r e p o r t e d c o g n i t i o n s and sensations d u r i n g the assessment reached s t a t i s t i c a l s i g n i f i c a n c e . There was no support f o r the p r e d i c t i o n t h a t ASI scores i n the i n t e r o c e p t i v e group would be reduced. 83 TABLE 2 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 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 Pre Post CONTROL EXPOSURE INTERO COGNITIVE REPORTED FEAR 87 .33 84 . 83 82 . 58 83 . 16 Pre (17. (14 (21 (22, 2) 5) 1) 7) 67 . 33 25 . 00 51 . 33 49 . 83 Post ( 22 (24. ( 26 , (10 2) 9) 6) 7) CONTROL EXPOSURE INTERO COGNITIVE REPORTED PANIC 76 78 78 75 50 83 25 33 (17 (15 (13 (19 2) 8) 8) 4) 52 . 59 15.92 34 . 41 21 . 00 (33 ( 20 (32 (12 2) 4) 5) 0) Pre Post CONTROL 1.92 (0.79) EXPOSURE 2.0 0 (0.74) INTERO 1.58 (0.52) COGNITIVE 2.3 3 (0.62) NEGATIVE COGNITIONS Pre 75 08 50 25 (0 (0 (0 (0 87) 29) 67) 45) Post CONTROL EXPOSURE INTERO COGNITIVE 273 300 187 244 42 75 58 25 (247, ( 215 , (187 , (180 , 2) 5) 0) 6) 251 18 81 29 00 83 33 50 (244 , ( 32 , (128 ( 40 , 3) 9) 5) 7) PHYSICAL SENSATIONS Pre Post CONTROL 396.00 (375.1) EXPOSURE 286.92 (230.7) INTERO 360.67 (233.4) COGNITIVE 386.17 (263.8) MEAN HEART RATE Pre 259 , 38 , 126 , 69 , 50 00 83 92 (254 ( 39 (135 ( 64 2) 2) 4) 6) Post CONTROL EXPOSURE INTERO COGNITIVE ASI / CONTROL EXPOSURE INTERO COGNITIVE 99.67 (23 93.25 (23, 93.58 (20 98.58 (24, 4) 9) 3) 9) Pre 29.58 (5.4) 23.08 (7.2) 24.16 . (13.0 ) 27.16 (8.6) 97 79 87 90 08 50 7 5 83 Post 25 18 20 , 23 33 67 41 92 (18 (12 (11 (23 2) 4) 3) 1) (10.6) (5.8) (10.5) (9.3) 84 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 d i f f e r e n c e s between the four groups fpre-assessment scores c o v a r i e d out) Dependent v a r i a b l e £ value (3, 43) p. P r e d i c t e d f e a r 7.64 <.001 Reported f e a r 4.82 <.01 Reported p a n i c 3.99 <.05 Negative c o g n i t i o n s 8.81 <.001 Unpleasant p h y s i c a l s e n s a t i o n s 6.73 <.001 Heart Rate 3.39 <.05 Anxiety S e n s i t i v i t y Index 0.26 >.05 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 between the three i n t e r v e n t i o n s and the c o n t r o l group fDunnett's t values with adjustment f o r the c o v a r i a t e ) Exposure C o g n i t i v e I n t e r o c e p t i v e t a £ P r e d i c t e d f e a r 4.70** 1.85 1.66 Reported f e a r 3.51** 2.94* 1.76 Reported panic 2.93* 2.55* 0.65 Cog n i t i o n s 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 0.32 The c r i t i c a l t values were 3.09 f o r p. <.01 and 2.44 f o r p. <.05. **p. < . 01 *p_ < . 05 86 Question 2 The second q u e s t i o n focused on the d i f f e r e n c e s between the three groups at p o s t - i n t e r v e n t i o n and follow-up. The c o n t r o l group was not i n c l u d e d i n these a n a l y s e s s i n c e i t d i d not continue to follow-up. A two-way between-within MANCOVA was f i r s t c a r r i e d out (the 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) on the t h r e e groups at p o s t - i n t e r v e n t i o n and follow-up. That i s the between-groups f a c t o r was treatment group (three l e v e l s ) , and the within-groups f a c t o r was measurement time (two l e v e l s ) . The r e s u l t s were Group: P i l l a i s £ (14, 42) = 1.77, p. >.05; Group by Time: P i l l a i s £ (14, 56) = 1.97, p. <.05; Time: P i l l a i s £ (7, 27) = 3.2, p. <.05. Means and standard d e v i a t i o n s are presented i n Table 5. A s e r i e s of u n i v a r i a t e ANCOVAs, with the same between-wi t h i n d e s i g n as noted above, were then performed on each dependent measure f o r group by time, and f o r time. The r e s u l t s are presented i n Table 6. Since the m u l t i v a r i a t e main e f f e c t f o r group was n o n - s i g n i f i c a n t (as noted above), none of the group main e f f e c t s were examined i n these u n i v a r i a t e ANCOVAs. In^no case was t h e r e a s t a t i s t i c a l l y s i g n i f i c a n t group x time i n t e r a c t i o n . For four of the v a r i a b l e s t h e r e was an e f f e c t f o r time. Averaged a c r o s s groups from post i n t e r v e n t i o n to follow-up, scores were lower a t the l a t t e r p o i n t f o r p r e d i c t e d f e a r and on the ASI, but s c o r e s were h i g h e r on r e p o r t e d f e a r and h e a r t r a t e . O v e r a l l there was no support found f o r the s p e c i f i c p r e d i c t i o n s f o r t h i s q u e s t i o n a l l of which i n v o l v e d group time i n t e r a c t i o n s . 88 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 PREDICTED FEAR Pre Post Follow-up EXPOSURE INTERO COGNITIVE 84.83 (14.5) 82.58 (21.1) 83.16 (22.7) 25.00 (24.9) 51.33 (26.6) 49.83 (10.7) 22.41 (21.5) 47.50 (28.7) 28.50 (22.9) REPORTED FEAR Pre Post Follow-up EXPOSURE INTERO COGNITIVE 78.83 (15.8) 15 78.25 (13.8) 34 75.33 (19.4) 21 92 (20.4) 41 (32.5) 00 (12.0) 27.00 (27.0) 39.08 (33.8) 34.58 (30.5) REPORTED PANIC Pre Post Follow-up EXPOSURE INTERO COGNITIVE 2 1 2 00 (0.74) 58 (0.52) 33 (0.62) 1.08 (0.29) 1.5 (0.67) 1.25 (0.45) 1.25 (0 1.5 (0 1.25 (0 45) 67) 45 ) NEGATIVE COGNITIONS Pre Post Follow-up EXPOSURE 300.75 (215.5) 18.83 (32.9) 57.75 (83.8) INTERO 187.58 (187.0) 81.33 (128.5) 99.42 (118) COGNITIVE 244.25 (180.6) 29.50 (40.7) 22.16 (27.1) PHYSICAL SENSATIONS Pre Post Follow-up EXPOSURE 286.92 (230.7) 38.00 (39.2) 54.20 (79.9) INTERO 360.67 (233.4) 12 6.83(135.4) 155.25 (180.8) COGNITIVE 386.17 (263.8) 69.92 (64.4) 55.42 (80.7) MEAN HEART RATE Pre Post Follow-up EXPOSURE INTERO COGNITIVE 93.25 (23.9) 79.50 (12.4) 93 . 58 (20.4) 87.75 (11.3) 98.58 (24.9) 90.83 (23.1) 80.25 (13.6) 98.08 (17.5) 96.33 (23.2) AS I Pre Post Follow-up EXPOSURE INTERO COGNITIVE 23 . 08 (7.2) 24.16 (13.0) 27.16 (8.6) 18.67 (5.9) 20.41 (10.5 23.92 (9.3) 17.08 (5.6) 19.25 (11.9) 19.33 (10.9) Table 6 U n i v a r i a t e ANCOVAs frepeated measures) on d i f f e r e n c e s between the th r e e 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 follow-up. TIME F (1,33) GRP X TIME F (2,33) P r e d i c t e d f e a r 4.96* 2 .12 Reported f e a r 6.16* 0 .45 Reported pa n i c 0.48 0 . 48 Negative c o g n i t i o n s 2 .65 1 .73 Unpleasant s e n s a t i o n s 1. 42 1 . 08 Heart r a t e 7 . 77* 1 . 95 ASI 5.71* 1 .11 *p_ < . 05 90 Question 3 In the t h i r d q u e s t i o n , the h y p o t h e s i s was that the t i m i n g of the r e d u c t i o n i n f e a r p r e d i c t i o n s would be d i f f e r e n t between the three i n t e r v e n t i o n s . There would be a r e d u c t i o n i n the scores of the exposure group at time thr e e , and i n the c o g n i t i v e and i n t e r o c e p t i v e groups at the s i x t h time p o i n t . The time p e r i o d s were as f o l l o w s : Time 1: A f t e r the f i r s t assessment, b e f o r e i n t r o d u c t i o n to the i n t e r v e n t i o n , day 1. Time 2: Before the main s e s s i o n of the i n t e r v e n t i o n , day 2 . Time 3: A f t e r the main s e s s i o n of the i n t e r v e n t i o n , day 2 . Time 4: Before the f i n a l s e s s i o n of the i n t e r v e n t i o n , day 3 . Time 5 : A f t e r the f i n a l s e s s i o n of the i n t e r v e n t i o n , day 3 Time 6: A f t e r the p o s t - i n t e r v e n t i o n assessment, day ,3. Means and standard d e v i a t i o n s of the t h r e e groups at the s i x time p o i n t s are presented i n Table 7 and the means are graphed i n F i g u r e 1. The experimental design was a 3 x 6 between-within a n a l y s i s of v a r i a n c e , with three l e v e l s of the between f a c t o r (treatment group) and s i x l e v e l s of the w i t h i n f a c t o r 91 (time p o i n t ) . To t e s t i f the assumption of s p h e r i c i t y had been v i o l a t e d , a Mauchly s p h e r i c i t y t e s t was c a r r i e d out (Chi square = 56.84, df = 14 ) and was s i g n i f i c a n t at p_ <.001. The Greenhouse-Geisser c o r r e c t i o n was thus used (hence the change i n the degrees of freedom) on the repeated measures ANOVA, E (6.65, 109.77) = 3.48, p. <.01. A n a l y s i s was then c a r r i e d out f o r simple main e f f e c t s f o r each group. The r e s u l t s were: f o r the exposure group £ (3.33, 109.77) = 28.60, p.<.01; f o r the c o g n i t i v e group E ( 3.33, 109.77) = 11.48, f2<.05; f o r the i n t e r o c e p t i v e group E ( 3.33, 109.77) = 10 . 47, p< . 05 . Since these were s i g n i f i c a n t f o r a l l t h r e e groups, i t was j u s t i f i e d to t e s t the s i g n i f i c a n c e of the t h r e e p a i r w i s e comparisons on which the p r e d i c t i o n s focused. Since these had been s p e c i f i e d a p r i o r i (the d i f f e r e n c e between time 2 and time 3 i n the exposure group, and between time 5 and time 6 i n the o t h e r two groups) and s i n c e they were orthogonal, planned comparisons were used. Because the assumption of s p h e r i c i t y had been v i o l a t e d , s e p a r a t e e r r o r terms were c a l c u l a t e d f o r each c o n t r a s t . The d a t a are presented i n t a b l e 8. Within each group the l a r g e s t mean r e d u c t i o n came at these p r e d i c t e d p o i n t s , and i n each case r e a c h e d / s t a t i s t i c a l s i g n i f i c a n c e : i n the exposure group E (1, 11) = 20.97, p. <.001; i n the c o g n i t i v e group E (1, H ) = 27.56, p. <.001; i n the i n t e r o c e p t i v e group E (1, 11) = 8.94 P. < . 025 . 92 The p r e d i c t i o n s were thus confirmed. Not only were f e a r p r e d i c t i o n s reduced, but the ti m i n g of these r e d u c t i o n s were as hypothesized. In the exposure group, the r e d u c t i o n a f t e r the longest p e r i o d of t h a t i n t e r v e n t i o n was s t a t i s t i c a l l y s i g n i f i c a n t ; i n the c o g n i t i v e and i n t e r o c e p t i v e groups the r e d u c t i o n a f t e r the second assessment, which i n c l u d e d a f u r t h e r two minutes i n the t e s t - c l o s e t , was a l s o s i g n i f i c a n t . The lower l e v e l of s i g n i f i c a n c e a t t a i n e d i n the i n t e r o c e p t i v e group r e f l e c t s once again the l a r g e r standard d e v i a t i o n i n that group. 93 Table 7 P r e d i c t e d a n x i e t y at s i x time p o i n t s d u r i n g f e a r r e d u c t i o n f r e - t e s t between time 5 and time 6) Time 1 Time 2 Time 3 Time 4 Time 5 Time 6 Exposure 70.25 57.25 29.00 23.50 16.25 9.00 (22.27) (26.52) (24.29) (14.07) (14.06) ( 7.86) C o g n i t i v e 60.25 65.75 48.33 49.58 44.17 21.67 (23.89) (21.48) (19.92) (22.81) (15.64) (20.15) I n t e r o c e p t i v e 72.42 61.67 50.42 54.17 54.17 28.25 (15.87) (14.82) (17.89) (20.87) (22.42) (30.11) PREDICTIONS OF FEAR AT 6 TIME POINTS 95 Table 8 P l a n n e d c o m p a r i s o n s O_Q $_h_S timing 2 j c h a n g e i n t h e t h r e e i n t e r v e n t i o n s f O u e s t i o n U . C o n t r a s t Mean MSres f_ p_ D i f f e r e n c e (1, 11) Exposure Time 2-Time 3 28.25 228.38 20.97 p_<.001 C o g n i t i v e Time 5-Time 6 22.50 110.23 27.56 pX.OOl I n t e r o c e p t i v e Time 5-Time 6 25.92 450.95 8.94 p_<.025 96 Question 4. The p r e d i c t i o n s f o r the f o u r t h q u e s t i o n were t h a t the three i n t e r v e n t i o n s would be s u p e r i o r to the c o n t r o l group on the two measures of g e n e r a l i z a t i o n , c a r r i e d out u s i n g a second enclosed space. The f i r s t measure was a sum of f e a r p r e d i c t i o n s , the second the h i g h e s t l e v e l (from a c h o i c e of s i x ) a t which p a r t i c i p a n t s would be prepared to e n t e r t h i s enclosed space. The means and standard d e v i a t i o n s were as f o l l o w s : FEAR PREDICTIONS Mean Std. dev C o g n i t i v e 124.50 74.99 Exposure 182.67 86.56 I n t e r o c e p t i v e 212.92 141.96 C o n t r o l 281.17 126.52 SITUATION CHOSEN Mean Std. dev, C o g n i t i v e 4.42 1.16 Exposure 4.8 3 0.94 I n t e r o c e p t i v e 4.42 1.38 C o n t r o l 3.3 3 1.37 A one-way MANOVA was c a r r i e d out with the two dependent v a r i a b l e s noted above (Fear P r e d i c t i o n s and S i t u a t i o n Chosen). The r e s u l t of t h i s was s i g n i f i c a n t , P i l l a i s £ (6, 88) = 3.85, p. <.01. U n i v a r i a t e ANOVAS were then conducted: f o r Fear P r e d i c t i o n s £ (3, 44) = 4.14, p. = <.05 and f o r the S i t u a t i o n Chosen £ ( 3, 44) = 3.29, p_ < .05. 97 In the subsequent m u l t i p l e comparisons ( u s i n g Tukey's method), s t a t i s t i c a l s i g n i f i c a n c e was reached o n l y f o r the l a r g e s t p a i r w i s e d i f f e r e n c e among the means i n both cases. With a c r i t i c a l a of 3.79 (p <.05) and 4.7 (p <.01), f o r Fear P r e d i c t i o n s the l a r g e s t d i f f e r e n c e was between the c o g n i t i v e and the c o n t r o l group, a = 4.89, p <.01. The next l a r g e s t d i f f e r e n c e was between the exposure and c o n t r o l groups where a a t 3.08, p >.05. For the S i t u a t i o n s Chosen, the l a r g e s t d i f f e r e n c e between means was between exposure and c o n t r o l where a = 4.29, p <.05. The next l a r g e s t d i f f e r e n c e was between the c o n t r o l and both the i n t e r o c e p t i v e and c o g n i t i v e groups where a = 3.11, p >.05. O v e r a l l , the s i n g l e d i f f e r e n c e between groups f o r Fear P r e d i c t i o n s was t h a t the c o g n i t i v e group made lower p r e d i c t i o n s than the c o n t r o l group; f o r the S i t u a t i o n Chosen the exposure group chose a h i g h e r l e v e l of d i f f i c u l t y than the c o n t r o l group. 98 PHENOMENOLOGICAL STUDY: DESCRIPTIVE DATA THE SAMPLE Since so l i t t l e work has been c a r r i e d out u s i n g c l a u s t r o p h o b i c s u b j e c t s , there are few y a r d s t i c k s a g a i n s t which to compare t h i s sample. The only other study w i t h more than two dozen s u b j e c t s at l e a s t provides some comparison p o i n t f o r the group who took p a r t i n t h i s r e s e a r c h . Of the 34 p a t i e n t s who completed Ost's study (1982), the g r e a t m a j o r i t y were female (30), the average age was 36 years o l d , and the average d u r a t i o n of t h e i r phobias was 16.8 years (range 4-54 y e a r s ) . A l l were o u t p a t i e n t s at the U l l e r a k e r Mental H o s p i t a l i n Sweden, and had as t h e i r major p r e s e n t i n g complaint a n x i e t y i n and avoidance of " c l o s e d spaces such as e l e v a t o r s and t o i l e t s " . I t i s not c l e a r whether any a d v e r t i s i n g had been c a r r i e d out to encourage t h e i r p a r t i c i p a t i o n , s i n c e i t i s s t a t e d that "the overwhelming m a j o r i t y (of those who had p r e v i o u s l y sought treatment) would have a p p l i e d f o r treatment e a r l i e r had they o n l y known t h a t there were treatments, other than p h a r m a c o l o g i c a l , a v a i l a b l e . " The s u b j e c t s i n the UBC c l a u s t r o p h o b i a study were not o u t p a t i e n t s of a p s y c h i a t r i c h o s p i t a l but community v o l u n t e e r s , s o l i c i t e d through a d v e r t i s i n g i n the media. As i n the Swedish study the m a j o r i t y were women (42 of 48), w i t h an average age of 42 y e a r s . T h i s i s a g a i n an o l d e r 99 sample than might have been expected from the d i s t r i b u t i o n of the f e a r d e s c r i b e d i n the l i t e r a t u r e review. The reasons f o r t h i s are u n c l e a r . I t may be t h a t women i n t h i s age group are the most l i k e l y to hear about such s t u d i e s and have the time to take p a r t i n them. I t would be easy i n any case to presume t h a t t h i s sample might be l e s s s e r i o u s l y c l a u s t r o p h o b i c than the o u t p a t i e n t group, but there i s no evidence to support t h i s . A s i m i l a r p r o p o r t i o n of t h i s sample (17 of 48) had p r e v i o u s l y sought p r o f e s s i o n a l treatment ( p s y c h i a t r y , psychology, h y p n o s i s ) . Almost h a l f the sample had had some form of p a n i c attack o u t s i d e a c l a u s t r o p h o b i c s i t u a t i o n , a lthough few were c u r r e n t l y having such a t t a c k s . One can f u r t h e r r e l a t e the two groups i n t h a t i n both s t u d i e s s u b j e c t s were asked to go i n to a c l a u s t r o p h o b i c s e t t i n g f o r a l i m i t e d time. Ost's s e t t i n g was c e r t a i n l y more benign i n t h a t i t was l i t , not o v e r l y cramped, sub j e c t s were s i t t i n g , and they both locked and c o u l d unlock the door d u r i n g the t e n minute t r i a l . T h i s c o n t r a s t s with the UBC study i n which s u b j e c t s were l o c k e d , s t a n d i n g , i n a small c l o s e t w i t h i n a small dark room f o r a p e r i o d of two minutes. N e v e r t h e l e s s , even a l l o w i n g f o r the d i f f e r e n c e i n demand, the h e a r t r a t e changes h a r d l y suggest t h a t t h i s i s the l e s s f e a r f u l sample. The average h e a r t r a t e i n c r e a s e i n the Swedish study (from r e s t i n g r a t e to experimental s e t t i n g ) was 7 bpm, w i t h the h i g h e s t j u s t 15 bpm. In the UBC study the mean i n c r e a s e was 2 5 bpm and the h i g h e s t an increase of 82 bpm. From t h i s index alone, i t can 100 be seen t h a t t h i s i s a group with a h i g h l e v e l of c l a u s t r o p h o b i c f e a r , even i f imbalanced towards o l d e r women wi t h the f e a r . I t i s proposed to look at the r e s u l t s of the q u e s t i o n n a i r e s they f i l l e d i n and t h e i r i n t e r v i e w s i n more depth. PRE-INTERVENTION QUESTIONNAIRES A l l s u b j e c t s f i l l e d i n three q u e s t i o n n a i r e s - the Anx i e t y S e n s i t i v i t y Index, the Chambless Agoraphobic M o b i l i t y Inventory, and a p i l o t C l a u s t r o p h o b i a Q u e s t i o n n a i r e - the means and standard d e v i a t i o n s of which are presented from the i n i t i a l p r e - i n t e r v e n t i o n i n t e r v i e w . The A n x i e t y Symptoms Index fASIl Set out i n the order of the s t r e n g t h of response ( u s i n g a s c a l e where 0 = "very l i t t l e " , up to 4 = "very much") the r e s u l t s were as f o l l o w s : ASI MEAN STD.DEV. I t i s important to stay i n c o n t r o l of my emotions 3.4 0.9 I t i s important to me not to appear nervous 2.8 1.2 I t s cares me when I f e e l f a i n t 2.5 1.0 / I t s c ares me when I become s h o r t of b r e a t h 2.5 1.2 I t s cares me when my he a r t beats r a p i d l y 2.4 l . i I t s c a r e s me when I f e e l shaky (t r e m b l i n g ) 1.8 1.1 101 I t s c a r e s me when I am nauseous 1.6 1.3 Unusual body s e n s a t i o n s scare me 1.6 1.2 I t embarrasses me when my stomach growls 1.4 1.0 Other people n o t i c e when I f e e l shaky 1.1 1.1 I t s c a r e s me when I am nervous 1.1 1.0 When I n o t i c e t h a t my he a r t i s b e a t i n g r a p i d l y , I worry that I might have a heart a t t a c k . 1.0 1.3 I t s c a r e s me when I am unable to keep my mind on a t a s k . 0.9 1.0 When my stomach i s upset, I worry that I might be s e r i o u s l y i l l . 0.8 1.1 When I cannot keep my mind on a task, I worry t h a t I might be going c r a z y . 0.6 0.9 When I am nervous, I worry that I might be m e n t a l l y i l l . 0.6 0.9 Of symptoms that are found f r i g h t e n i n g , i t i s heart r a t e , f a i n t n e s s , and becoming shor t of b r e a t h that are the most prominent. However, the two h i g h e s t s c o r i n g items r e f l e c t a d i f f e r e n t c o n s t r u c t , and one w i t h a more s o c i a l element, namely the importance of s t a y i n g i n c o n t r o l of emotion and the importance of not appearing nervous. The Agoraphobic Inventory Items from the Agoraphobic Inventory are presented only where tfye mean i s above 2 (with 1 = "never a v o i d " , 2 = " r a r e l y a v o i d " , 3 = "avoid about h a l f the time", 4 = "avoid most of the time" and 5 = "always a v o i d " ) . 102 WHEN WHEN ALONE ACCOMPANIED PLACES (Mean, Std dev) (Mean, Std Dev) Enclosed spaces 3. 4 (1. • 4) 3. 0 (1.4) E l e v a t o r s 3. 1 (1. • 4) 2 . 6 (1.4) Parking garages 2 . 4 (1. • 4) 1. 8 (1.2) Heights 2 . 3 (1. .4) 2 . 0 (1.1) RIDING IN Subways 2 . 6 (1. 5) 2 . 4 (1.5) A i r p l a n e s 2 . 3 (1. 5) 2 . 1 (1.4) Though s e v e r a l of the sample had high agoraphobic s c o r e s , t h i s was uncommon. On only the s i x items above was there a mean score of above 2.0 and, with the e x c e p t i o n of h e i g h t s , these are the f i v e that have c l e a r a s s o c i a t i o n s with, or are more a c c u r a t e l y conceived of as c l a u s t r o p h o b i a . The C l a u s t r o p h o b i c Inventory The study was taken as an op p o r t u n i t y t o p i l o t a s c a l e measuring the extent and degree of c l a u s t r o p h o b i c a n x i e t y . The means are from a s c a l e where 1 = "not anxious", 2 = " s l i g h t l y anxious", 3 = "moderately anxious", 4 = "very anxious", 5 = "extremely anxious" and the s t a n d a r d d e v i a t i o n s are i n b r a c k e t s . 103 Alone Accompanied In an e l e v a t o r at a time when there i s a s t r o n g l i k e l i h o o d 4.6 (0.9) 4.3 (0.9) of a power cut. At the f u r t h e s t p o i n t from an e x i t on a tour of an underground mineshaft. 4.6 (1.0) 4.4 (1.0) Locked i n a s m a l l dark room without 4.2 (1.0) 3.5(1.4) windows f o r 15 mins. Standing f o r 15 minutes i n a s t r a i t j a c k e t . 4.0 (1.3) 3.8 (1.5) Standing i n the middle of the t h i r d row at a packed c o n c e r t , r e a l i z i n g that you w i l l be unable to lea v e u n t i l the end of the show. 3.7 (1 .2) 3 . , 5 ( 1 • 5) In a p u b l i c t o i l e t and the lock jams 3 .7 (1 • 2) 3 . , 1 (1. .3) Locked i n a s m a l l w e l l l i t room without 3.5 windows f o r 15 mins. (1 .3) 2 , 9 (1. • 4) In the back of a s m a l l two-door car with a person e i t h e r s i d e of 3. you, and a l l the windows fogged up. 5 (1.4) 3 ,  3 (1. • 5) In a crowded s k y t r a i n which stops between s t a t i o n s . 3.4 (1 • 4) 3 . , 0 (1. .4) Back of a crowded bus. 2.8 (1 •4) 2 . , 4 (1. •3) In the centre of a f u l l row at a cinema. 2.5 (1 .4) 2 , 3 (1. •4.) In the middle of a long l i n e at a supermarket. 1.4 (0.9) 1.3 (0.7) In a barber's / h a i r d r e s s e r ' s c h a i r 1.3 (0.8) 1.2 (0.6) I t can be noted how l i t t l e reassurance i s gained by b e i n g accompanied, i n s t r i k i n g c o n t r a s t to agoraphobia where the presence of a t r u s t e d f r i e n d can d r a m a t i c a l l y reduce a n x i e t y . The higher scores are a l l s i t u a t i o n s from which escape would be d i f f i c u l t . COGNITIONS AND PHYSICAL SENSATIONS The mean c o g n i t i o n s and sen s a t i o n s are presented f o r a l l f o u r groups at p r e - and p o s t - i n t e r v e n t i o n and f o r the t h r e e i n t e r v e n t i o n s without the c o n t r o l a t follow-up. COGNITIONS Mean (max=12) PRETEST POSTTEST FOLLOW UP (N=48) (N=48) (N=36) DID YOU THINK THAT.... You were trapped 9.0 4.75 5.0 You were going to l o s e c o n t r o l 7.5 3.75 3.67 You had been f o r g o t t e n i n the room 6.25 1.5 3.0 You were going to a c t f o o l i s h l y 5.5 2.25 2.0 You might s u f f o c a t e 5 . 5 2 .25 1 . 0 105 You were going to run out of a i r to breathe 5.25 2.25 2.0 You were going to pass out 5.25 1.25 1.0 The w a l l s were c l o s i n g i n 4.75 2.5 .67 You were i n danger 4.0 1.25 1.33 You were going to f a l l 2.25 1.25 1.33 You were going to have a h e a r t a t t a c k 1.25 0.25 0.0 Other ( t y p i c a l l y f i r e , earthquake or concern about demands being s e c r e t l y i n c r e a s e d ) 1.0 1.0 2.0 You were going t o choke to death 0.25 0.0 0.0 One can note t h a t the c o g n i t i o n of entrapment was the most common with s u f f o c a t i o n b e i n g present very much l e s s f r e q u e n t l y . The f e a r s of l o s i n g c o n t r o l or a c t i n g f o o l i s h l y , h i g h l i g h t e d i n the ASI, are a g a i n prominent. PHYSICAL SENSATIONS Mean(max=12) PRETEST POSTTEST FOLLOW UP (N=48) (N=48) (N=36) P a l p i t a t i o n s or a c c e l e r a t e d h e a r t r a t e 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, or unsteady f e e l i n g s 6.5 3 .25 2 .33 T i g h t e n i n g muscles 5 . 0 4 . 0 3 . 0 Sweating 4.75 3 .25 1. 67 Too warm 4 . 25 3 . 25 3 . 0 F l u s h e s , hot f l a s h e s or c h i l l s F a i n t n e s s 4.25 3.75 0.75 1 . 0 0 . 33 0 . 5 Dry mouth 3 . 5 2 . 0 1 . 33 D e p e r s o n a l i z a t i o n or d e r e a l i s a t i o n T e a r f u l 2 . 5 2 . 25 1 . 25 1 . 0 1 . 0 0.33 F e e l i n g s i c k , abdominal d i s t r e s s , or any form of nausea 2.0 1. 0 0. 0 Numbness or t i n g l i n g s e n s a t i o n s Choking or smothering s e n s a t i o n s Headache 2. 0 1 . 5 1 . 5 0 . 5 1.75 1 . 25 0 . 0 1 . 33 0.33 Chest p a i n o r dis c o m f o r t 1.25 0 . 5 0.33 The most common sensat i o n s of i n c r e a s e d heart r a t e , s h o r t n e s s of bre a t h , t r e m b l i n g and d i z z i n e s s are signs c h a r a c t e r i s t i c not only of a n x i e t y but p a n i c d i s o r d e r , where they are symptoms that are commonly m i s i n t e r p r e t e d . 107 STRUCTURED INTERVIEWS S t r u c t u r e d i n t e r v i e w s (see Appendix A f o r the complete p r o t o c o l ) p r o v i d e d important m a t e r i a l f o r therapy i n a l l three groups. They a l s o p r o v i d e d i n f o r m a t i o n on many aspects of the f e a r . Some of the responses are presented i n a t a b l e (see t a b l e 9 ) . However most are not of the s o r t or l e n g t h that allows f o r such p r e s e n t a t i o n , and so are set out w i t h a r a t h e r f u l l e r commentary than would be u s u a l , to h e l p convey the most s a l i e n t p o i n t s . 108 Table 9 S e l e c t e d f i n d i n g s from the s t r u c t u r e d i n t e r v i e w The q u e s t i o n s asked d u r i n g the s t r u c t u r e d i n t e r v i e w are presented i n Appendix A. Many of the 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 to g i v e d e t a i l e d answers. Ten of those that do not r e q u i r e such e l a b o r a t i o n s are presented here. 1. Do you remember any c l a u s t r o p h o b i c experiences from your c h i l d h o o d ? Yes 30 No 18 2. Do you remember being c l a u s t r o p h o b i c a l l y f e a r f u l as an ad o l e s c e n t ? Yes 16 No 32 3. Do you f e e l t h a t there was a s i n g l e event i n your 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 you had pan i c a t t a c k s other than i n a c l a u s t r o p h o b i c s e t t i n g Yes 21 No 27 5. Is the f e a r g e t t i n g b e t t e r or worse ? B e t t e r 11 Stable 22 Worse 15 6. Have you had c l a u s t r o p h o b i c dreams ? Yes 16 No 32 7. Have you used a l c o h o l or medication on a r e g u l a r b a s i s as a means of coping w i t h your f e a r ? A l c o h o l 4 M e d i c a t i o n 13 Both 4 Nei t h e r 27 8. Do you know ot h e r s who have t h i s f e a r ? Yes 30 No 18 9. Have you p r e v i o u s l y sought treatment f o r c l a u s t r o p h o b i a ? Yes 17 No 31 10. to 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 your f e a r of enclosed spaces ? Major 23 Minor 17 No 8 a i r c o n t r i b u t e s 109 AVOIDANCE The two most f r e q u e n t l y r e p o r t e d areas of c l a u s t r o p h o b i c avoidance i n the past have been e l e v a t o r s and f l y i n g , r e f l e c t i n g presumably not only p r e v a l e n c e but the type of avoidance most l i k e l y to l e a d to p r o f e s s i o n a l a t t e n t i o n . Both were h e a v i l y endorsed by t h i s sample. A s u b s t a n t i a l m i n o r i t y would not use e l e v a t o r s under any circumstances. A g r e a t e r number were prepared to use them under c e r t a i n c o n d i t i o n s : p a r t i c u l a r e l e v a t o r s i n the company of p a r t i c u l a r people at p a r t i c u l a r times. F l y i n g has been seen by some as a d i s t i n c t f e a r , but i n t h i s sample i t would seem c o n s i s t e n t with other c l a u s t r o p h o b i c f e a r s . Peak f e a r was o f t e n r e p o r t e d e i t h e r as the door was shut or a f t e r the plane had landed and the doors had s t i l l not been opened. Being i n the a i r , or concerns about the s a f e t y of f l y i n g , were f a r l e s s prominent responses. I t would be i n t e r e s t i n g to i n v e s t i g a t e whether these c l a u s t r o p h o b i c s are r e p r e s e n t a t i v e of f l y i n g phobics as a whole, or are a subgroup with c l e a r d i s t i n g u i s h i n g c h a r a c t e r i s t i c s . Other commonly avoided s e t t i n g s were carwashes, p u t t i n g one's head under water, a c t i v i t i e s underground (such as underground p a r k i n g or a tour of a w i n e r y ) , crowds, s l e e p i n g i n the dark or without access to f r e s h a i r , l o c k i n g doors, t i g h t c l o t h i n g or j e w e l r y , g e t t i n g stuck i n a t r a f f i c jam, s i t t i n g i n the middle of a row i n a t h e a t r e or cinema, or i n the back of a two door c a r . Some of the reasons t h a t these 110 p a r t i c u l a r s i t u a t i o n s may be found so unpleasant are reviewed i n the d i s c u s s i o n . Far l e s s commonly r e p o r t e d to date are a whole range of f e a r s which have h e a l t h or s a f e t y r e p e r c u s s i o n s . Some 40% of t h i s sample r e p o r t e d t h a t they could not conceive of undergoing a CAT scan, a t l e a s t without being s t r o n g l y sedated which i s d i s c o u r a g e d f o r t h i s procedure. T h i s i s c o n s i s t e n t with r e p o r t s from UBC Health Sciences H o s p i t a l (Paty, Personal Communication, 1989,) which suggest that about 5% of those recommended f o r a scan r e f u s e the o p t i o n , even i f the r e s u l t s might have important i m p l i c a t i o n s f o r t h e i r h e a l t h . Two had t u r n e d down surgery because of the f e a r of waking up and b e i n g c o n s t r a i n e d i n the bed, two o t h e r s had removed d r i p s from t h e i r arm so that they could l e a v e " i f they had t o " . The d e n t i s t i s another area of concern f o r some, p a r t i c u l a r l y now t h a t there i s more r o u t i n e use of the rubber dam. The presence of d e n t a l equipment i n the mouth t h a t cannot be q u i c k l y removed not o n l y prevents a hasty e x i t , but can make b r e a t h i n g d i f f i c u l t , a s u b j e c t addressed below. A r e p o r t of the premature removal of the c a s t o f f a limb, and the a l a r m i n g l y common r e f u s a l to 'wear a seat b e l t , are j u s t two f u r t h e r i n s t a n c e s i n which t h i s f e a r was shown to have h e a l t h i m p l i c a t i o n s . I l l ONSET In many cases i t i s not p o s s i b l e to determine the age a t which any phobia s t a r t s , and c l a u s t r o p h o b i a i s no e x c e p t i o n . In t h i s sample, there were those who r e p o r t e d a c l e a r p r e c i p i t a t i n g event l a t e i n t h e i r a d u l t l i f e which they saw as i n c o n t r o v e r t i b l y marking the s t a r t of t h e i r f e a r . However, there were a g r e a t e r number who have memories of child h o o d i n c i d e n t s whose importance and impact, even i f v i v i d , were not easy f o r them to assess. I t might h e l p i f one had access to i n f o r m a t i o n on such e a r l y memories from a n o n - c l a u s t r o p h o b i c sample to provide at l e a s t some p o i n t f o r comparison. The most t y p i c a l experience i n the 30 from t h i s sample who d i d r e p o r t some c h i l d h o o d memories was some form of p a r e n t a l punishment, or a c h i l d h o o d game or prank. Others r e p o r t e d not i n c i d e n t s but j u s t a f e e l i n g of g r e a t d i s c o m f o r t to have had, f o r example, the b l a n k e t s p u l l e d over t h e i r head, or to have had to wear a gas mask d u r i n g the war. I n f r e q u e n t l y there were sign s of thoughts more common i n l a t e r l i f e . "I can s t i l l r e c a l l the h i d e o u s l y embarrassing s i g h t of s e e i n g a c h i l d vomit. Though I was o n l y f i t f e , I determined t h a t I would always t r y to be near a door to ensure t h a t I would never a t t r a c t t h a t s o r t of a t t e n t i o n 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 t h e i r own v a r i a t i o n s such as the woman who r e c a l l e d wondering i f her 112 lungs had holes i n them so i n e f f e c t u a l was her b r e a t h i n g when she was anxious. I t w i l l be f o r l a t e r study t o analyze the d i f f e r e n c e s and s i m i l a r i t i e s between ch i l d h o o d and a d u l t c l a u s t r o p h o b i a , and to answer s p e c i f i c questions such as the age a t which one develops the c a p a c i t y to m i s i n t e r p r e t s e n s a t i o n s c a t a s t r o p h i c a l l y . I t i s s t r i k i n g t h a t more than h a l f of t h i s group r e p o r t i n g c h i l d h o o d c l a u s t r o p h o b i a d i d not see t h i s as b e i n g the s t a r t of the f e a r , i n s o f a r as they were r e l a t i v e l y f r e e of i t d u r i n g t h e i r c h i l d h o o d and i n t o t h e i r adolescence. I t was more common that the f e a r was seen to develop s e r i o u s l y e a r l y i n a d u l t l i f e , and the c h i l d h o o d experience was seen as a t most a v u l n e r a b i l i t y f a c t o r . Adult p r e c i p i t a n t s appeared to be i n d i s t i n g u i s h a b l e between those who had and who had not had c l a u s t r o p h o b i c memories or concerns. ADULT PRECIPITATING EVENT The d e s c r i p t i o n s of what was seen by many as the p r e c i p i t a t i n g event f o r t h e i r c l a u s t r o p h o b i a evoked the most a r o u s a l d u r i n g the i n t e r v i e w and were n a r r a t e d i n the most de t a i l . / E x a m p l e s g i v e some f l a v o u r of the d i f f e r e n t c a t e g o r i e s . 113 There were, f i r s t l y , some i n c i d e n t s which very many people, whether or not p r e d i s p o s e d to c l a u s t r o p h o b i a , are l i k e l y to have found very f r i g h t e n i n g . One woman r e c o v e r i n g from an a n a e s t h e t i c came to consciousness strapped to the bed and i n a l l s o r t s of r e s t r i c t i v e bandages and p l a s t e r . The f i r s t t h i n g she heard, and t h i s i n the dead of n i g h t , was a c r y of " f i r e " from what l a t e r t r a n s p i r e d to be a d e l i r i o u s p a t i e n t beside her. Many might a l s o empathize w i t h the d i s c o m f o r t of the s u b j e c t on a T u r k i s h a i r l i n e s f l i g h t from I s t a n b u l which aborted t a k e - o f f on three s u c c e s s i v e o c c a s i o n s . Passengers had then to s t a y on the plane as mechanics, whose demeanour d i d l i t t l e to i n s p i r e c o n f i d e n c e , t i n k e r e d with the engine b e f o r e i t t a x i e d out yet again. The i n i t i a l response of o t h e r s made an unpleasant s i t u a t i o n a f r i g h t e n i n g one. A s u b j e c t r e p o r t e d b e i n g i n an e l e v a t o r on her own. I t jammed and the l i g h t went out. She remained reasonably c o n t r o l l e d u n t i l she went to p r e s s the buttons and was unable to l o c a t e them ( i t turned out t h a t a t t h i s p o i n t she was on her knees) and then s t a r t e d to p a n i c . Included here a l s o are those who found themselves i n t h r e a t e n i n g but probably not o b j e c t i v e l y dangerous s i t u a t i o n s . "I was e i g h t months pregnant and i n New York. I got on a subway along w i t h about h a l f the r e s t of the c i t y on t h e i r way to watch a b a l l game. A f t e r f i v e minutes I j u s t had to get out of that crowd". 114 The t h i r d group can be d i s t i n g u i s h e d i n that they were doing something t h a t they had done on many previous o c c a s i o n s , f i t t i n g i n t o Barlow's category of f a l s e alarm. "I had never minded being i n e l e v a t o r s i n the s l i g h t e s t . But one day I got on one i n Eatons and j u s t suddenly had to get o f f . I was amazed as there was nothi n g l e a d i n g up to i t ; i t came r i g h t out of a c l e a r blue sky". Another example i s someone who had flown f r e q u e n t l y i n the f o r c e s . Years l a t e r and w i t h no a n t i c i p a t o r y a n x i e t y , she boarded a plane f o r a h o l i d a y i n Europe. She r e p o r t e d t h a t i t h i t her l i k e a hammer when she caught a glimpse of the i n s i d e of the plane (what she d e s c r i b e d as that "no way out" l o o k ) . And there i s , f i n a l l y , the group on whom the f e a r c r e p t up q u i e t l y . Some can i d e n t i f y no p r e c i p i t a t i n g i n c i d e n t at a l l . Others can i d e n t i f y a p r e c i p i t a n t but one that had a sl o w - a c t i n g e f f e c t . "At the time my husband withdrew support, I s t a r t e d to f i n d my own car f e e l very t i g h t , I became a b i t uncomfortable i n the bathroom, m i l d l y bothered by b r i d g e s , and aware f o r the f i r s t time of j u s t how s m a l l e l e v a t o r s were". Through a l l these groupings run some common threads. The f i r ^ t i s one noted i n the genesis of many f e a r s , namely s t r e s s , which i s c e r t a i n l y e v i d e n t here. Loss, f o r example, was mentioned commonly although i n some q u i t e unusual forms. "The day I heard t h a t my mother's i l l n e s s was t e r m i n a l , my 115 bedroom seemed so small and s t u f f y and c l o s e " . Not a l l the s t r e s s o r s have such c l e a r l y n e g a t i v e overtones. For many t h e i r f i r s t p a n i c was while on h o l i d a y , f o r others i t was while pregnant. "I had been i n t o t h a t m a l l o f t e n before but never had i t been t h i s crowded, and being seven months pregnant I j u s t f e l t so v u l n e r a b l e . Suddenly I knew that I had to get out". Two h o l i d a y l o c a l e s are p a r t i c u l a r l y common. The f i r s t i s camping, e i t h e r i n a t e n t or i n a r e c r e a t i o n a l v e h i c l e . The second i s w h i l e c l i m b i n g to the top of a t a l l b u i l d i n g such as the V a t i c a n or St Paul's C a t h e d r a l i n London. While the combination of b r e a t h l e s s n e s s and d i f f i c u l t y of escape seem l i k e l y t o be i m p l i c a t e d i n the second case, the reason f o r the former i s not c l e a r although one c o u l d s p e c u l a t e a v a r i e t y of p o s s i b l e e x p l a n a t i o n s . Some o b s e r v a t i o n s about these " c r i t i c a l i n c i d e n t s " are, f i r s t l y , t h a t most are not o b j e c t i v e l y dangerous s i t u a t i o n s : a sudden r e a l i z a t i o n of one's v u l n e r a b i l i t y i n a packed t h e a t r e or a t r a i n stopping between s t a t i o n s . F u r t h e r , the p e r i o d of entrapment i s o f t e n very s h o r t . T h i r d l y , the p a t t e r n of onset has much i n common w i t h t h a t f o r agoraphobia or f o r the onset of p a n i c d i s o r d e r . A l l three p o i n t s w i l l be taken up i n the d i s c u s s i o n . / • 116 TYPICAL SUBSEQUENT CLAUSTROPHOBIC EVENTS Though avoidance i s the s t r a t e g y of ch o i c e f o r almost a l l f e a r s , i t i s s t r i k i n g how s u c c e s s f u l l y t h i s can be c a r r i e d out f o r c l a u s t r o p h o b i a . One can i n s i s t or arrange to be on the a i s l e seat, walk up s t a i r s i n s t e a d of u s i n g an e l e v a t o r , miss out on underground t o u r s . However, i t i s not always p o s s i b l e to 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 accurate p r e d i c t i o n can become much more d i f f i c u l t ) , and there are occasions when one f e e l s pressured by others or i n some way cannot a v o i d an enclosed s i t u a t i o n . Most people can thus r e a d i l y come up w i t h examples of subsequent times on which they f e l t i n some way trapped. In many cases these events f o l l o w c l o s e l y those d e s c r i b e d as f i r s t i n c i d e n t s , but i n v i t e f u r t h e r comment. With regard to the l e n g t h of time the a n x i e t y can l a s t , i t has alre a d y been p o i n t e d out that a n x i e t y i s u s u a l l y reduced q u i c k l y by escape from the s i t u a t i o n . Where people have been unable to l e a v e a s i t u a t i o n , they have g e n e r a l l y been s u r p r i s e d by the speed at which t h e i r a n x i e t y has gone down. There are however some st a r k e x c e p t i o n s . One woman f e l t that her panic h a r d l y abated throughout the course of a 12 h o u r / f l i g h t , d u r i n g which she d i d not eat or even dare go to the t o i l e t . The s u b j e c t mentioned a l r e a d y who had been trapped i n an e l e v a t o r i n which the l i g h t had gone out, crouched i n the corner m o t i o n l e s s f o r an hour. In both cases 117 they were i n a s t a t e of shock f o r more than a day l a t e r . T h i s r a i s e s two p o i n t s . The f i r s t i s t hat even when the worst does happen, i t takes a very d i f f e r e n t form from that which most c l a u s t r o p h o b i c s a n t i c i p a t e d : most commonly they f r e e z e , p h y s i c a l l y and m e n t a l l y , r a t h e r than b l i n d l y go out of c o n t r o l as they would f e a r . I f a c t i o n i s taken a t t h i s p o i n t , i t tends to be h i g h l y g o a l d i r e c t e d . "When I got l o c k e d i n the t o i l e t someone sensed my d e s p e r a t i o n and t o s s e d i n a s c r e w d r i v e r t o g i v e me something to do w h i l e they sought h e l p . I was l i k e a person possessed, and w i t h i n f i v e minutes I had the r u s t y screws and r i v e t s out, and had removed the door be f o r e they r e t u r n e d w i t h a s s i s t a n c e " . The second p o i n t was t h a t many i n the study r e p o r t e d a d e l a y e d 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 . I t would be a mistake to underestimate the g r a v i t y of the r e a c t i o n s ; i n many cases people are c o r r e c t l y p r e d i c t i n g severe r e a c t i o n s r a t h e r than c a t a s t r o p h i z i n g i n some f a u l t y or exaggerated way. "I knew i f I went i n t h a t c l o s e t t h a t I would be s h a t t e r e d f o r the r e s t of t h a t day; and t h a t i s e x a c t l y how i t was". S i f t i n g through the d e s c r i p t i o n s , one comes a c r o s s two themes not common i n o t h e r f e a r s . The f i r s t i s t h a t of d i s o r i e n t a t i o n . A reason why n i g h t - t i m e c l a u s t r o p h o b i c p a n i c s occur i s t h a t a person may wake up i n a s t r a n g e place and be unable to see e i t h e r where he or she i s or to work out where the e x i t s are. As with entrapment, t h i s i s the 118 s o r t of i n s t a n c e i n which i t i s d i f f i c u l t to work out whether r e l a t e d c a t a s t r o p h i c c o g n i t i o n s are c a u s a l or epiphenomenal. A second i s an i n c r e a s e i n temperature. T h i s can l e a d to p a r t i c u l a r c o g n i t i o n s , n o t a b l y f a i n t i n g , but seems a l s o to be a s s o c i a t e d with n o n - c o g n i t i v e d i s c o m f o r t : some s u b j e c t s take short showers because of the unease they f e e l as the temperature i n c r e a s e s , without r e p o r t i n g accompanying anxious thoughts. A t h i r d theme t h a t has been touched on, and i s one of the most i n t r i g u i n g of t h i s f e a r , i s that of s u f f o c a t i o n . Rachman (1989) s u b t i t l e d h i s chapter on c l a u s t r o p h o b i a "The Fear of S u f f o c a t i o n " , so prominent was t h i s c o g n i t i o n . One s p e c u l a t i o n was t h a t those w i t h c l a u s t r o p h o b i a c o u l d be s p l i t i n t o those who f e a r entrapment and those who f e a r s u f f o c a t i o n . In t h i s study the dichotomy has been c l e a r but not q u i t e along these l i n e s . Instead i t i s more a c c u r a t e to r e f e r to entrapment w i t h or without s u f f o c a t i o n , the l a t t e r b e i n g the most common but by no means the e x c l u s i v e c o g n i t i o n f o r those f o r whom b r e a t h i n g can become so uncomfortable. I t i s important to co n s i d e r why t h i s p a r t i c u l a r c o g n i t i o n should be so prominent. One reason f o r the v u l n e r a b i l i t y to t h i s f e e l i n g not p r e v i o u s l y mentioned i n the l i t e r a t u r e was a s e n s i t i v i t y t o 119 a i r and breathing, even o u t s i d e a c l a u s t r o p h o b i c s i t u a t i o n . Some h a l f dozen had had a c c i d e n t s to t h e i r nose which e i t h e r s t a r t e d or exacerbated t h e i r s e n s i t i v i t y to a i r , an o b s e r v a t i o n not p r e v i o u s l y noted. A f u r t h e r seven r e p o r t e d t h a t the presence of t h e i r a l l e r g i e s c o u l d g r e a t l y i n c r e a s e the p r o b a b i l i t y of t h e i r h a ving a panic. While many i n the group d i s l i k e d the f e e l i n g of a r a p i d change i n t h e i r b r e a t h i n g , f o r those with b r e a t h i n g d i f f i c u l t i e s t h i s i s a p a r t i c u l a r l y f r i g h t e n i n g f e e l i n g and one they are very keen to a v o i d . At i t s most extreme, and t h i s i n s e v e r a l cases, i n d i v i d u a l s w i l l not stay i n h o t e l rooms i n which the windows cannot be opened, and w i l l stay f o r a minimum l e n g t h of time i n places where they f e e l the a i r c o u l d e i t h e r be " s t a l e " or l i m i t e d . "When I am i n the s k y t r a i n I l i t e r a l l y crane my neck to t r y and get the a i r above everyone e l s e " . "In crowded e l e v a t o r s I can get a g i t a t e d i f people are t a l k i n g too much as I f e e l t h a t they are j u s t u s i n g up the a i r q u i c k e r . " The importance of " f r e s h " a i r i s shown by the s u b j e c t who always c a r r i e s around a Vi c k s i n h a l a n t w i t h her so t h a t she can s m e l l " f r e s h n e s s " around her nose whenever she needs i t . I t may be shown t h a t such s e n s i t i v i t y to the q u a l i t y , amount, and r a t e of i n t a k e of a i r i s b i o l o g i c a l l y based, showing up i n C0 2 t e s t s as w e l l as e x e r c i s e s such as straw b r e a t h i n g . But c o g n i t i o n s , too, may play at the very l e a s t a c o n t r i b u t o r y r o l e f o r those who may be b i o l o g i c a l l y 120 v u l n e r a b l e . I t i s suggested t h a t s p e c i f i c c o g n i t i o n s may be generated the f i r s t o c c a s i o n an i n d i v i d u a l panics and are e a s i l y accessed, and found d i f f i c u l t to d i s p u t e at subsequent h i g h l e v e l s of a n x i e t y . There do seem to be examples where people i n i t i a l l y , i f q u i t e e r roneously, f e l t t h a t there was a r i s k of running out of a i r . An example i s the s u b j e c t who found h e r s e l f on a f l i g h t , which a f t e r a saf e l a n d i n g took some time to t a x i to the t e r m i n a l . The c a p t a i n announced that both passengers and stewardesses should r e t u r n t o t h e i r s e a t s . As a r e g u l a r f l i e r she knew th a t t h i s was not normal procedure. She suddenly sensed t h a t there was no a i r coming out of the vents. Her mind turned immediately t o the p o s s i b i l i t y of s u f f o c a t i o n as she s t a r t e d to h y p e r v e n t i l a t e , d e s p e r a t e l y concerned t h a t she might not be g e t t i n g enough a i r . When the door was opened a minute l a t e r she f e l t f i n e and thought no more about i t . However, s i n c e t h i s event, i t i s thoughts r e l a t i n g to a i r and s u f f o c a t i o n which are the most l i k e l y t o be summoned i n any c l a u s t r o p h o b i c s e t t i n g . The p r o g r e s s i o n i n the development of t h i s f e a r thus takes i n many of the stages that appear to be prominent i n many cases i n t h i s study: There were c e r t a i n v u l n e r a b i l i t i e s i n t h a t i t was a time of h i g h s t r e s s (her husband had a t e r m i n a l d i s e a s e ) ; a s i t u a t i o n was m i s i n t e r p r e t e d (the sound of the s h u t t i n g o f f of the p r e s s u r i z a t i o n system) and exacerbated by her own h y p e r v e n t i l a t i o n ; she then developed a f e a r i n which t h i s c o g n i t i o n was the most l i k e l y to be accessed when a c e r t a i n 121 l e v e l of a n x i e t y had been reached; she developed a p a t t e r n of avoidance of entrapment c o n s i s t e n t w i t h p l a c e s where she f e l t a i r might be a problem. Yet, and t h i s i s perhaps why c l a u s t r o p h o b i a s t i l l f i t s i n t o the s t r i c t d e f i n i t i o n of a phobia, she knows t h a t the f e a r i s q u i t e without foun d a t i o n and t h a t she w i l l not a c t u a l l y run out of a i r . N e i t h e r reassurance nor the p r o v i s i o n of i n f o r m a t i o n are thus any guarantee f o r improvement. There are f u r t h e r p o i n t s to be c o n s i d e r e d from the s t r u c t u r e d i n t e r v i e w s , but these are t i e d i n with o b s e r v a t i o n s from a l l f o u r groups and the d i s c u s s i o n of the experimental d a t a i n the f o l l o w i n g s e c t i o n . DISCUSSION A main, aim of t h i s study was to see i f two i n t e r v e n t i o n s , pared to a pure form and without the usual a d d i t i o n of exposure, c o u l d produce a r e d u c t i o n i n a simple phobia i n ways t h a t would have been thought d e c i d e d l y unpromising even s e v e r a l years ago. The answer was broadly i n the a f f i r m a t i v e , and g i v e s encouragement to t r y i n g out the techniques t h a t have worked so w e l l w i t h p a n i c d i s o r d e r i n other a n x i e t y d i s o r d e r s , i n c l u d i n g simple phobias. Within t h i s main o b j e c t i v e was the wish to study the mechanism with which change was brought about by these methods, u s i n g a c o n t r o l and an exposure group to p r o v i d e bench marks a g a i n s t which to assess the t i m i n g and areas of change. I n e v i t a b l y with such s m a l l numbers, such a search y i e l d e d a more meagre harv e s t , though one by no means without i n t e r e s t . A second aim was to f i n d out more about c l a u s t r o p h o b i a and, without q u a l i f i c a t i o n , t h i s was a f r u i t f u l quest. Since t h i s study was i n i t i a t e d , Barlow has p u b l i s h e d the r e s u l t s of h i s treatment study on p a n i c d i s o r d e r (Barlow, Craske, Cerny, & Klosko, 1989) which found 80% success r a t e f o r h i s c e n t r a l treatment approach. T h i s c o n s i s t e d of exposure to somatic s e n s a t i o n s a s s o c i a t e d with panic a t t a c k s , as w e l l as some c o g n i t i v e therapy d i r e c t e d at s a l i e n t c a t a s t r o p h i c thoughts. C l a r k has a l s o f i n i s h e d h i s major t r i a l (1990) r e p o r t i n g even s l i g h t l y h i g h e r treatment success w i t h very much more emphasis on c o r r e c t i n g c o g n i t i v e 123 m i s i n t e r p r e t a t i o n s than on i n t e r o c e p t i v e exposure. There i s no doubt t h a t the a d d i t i o n of these techniques t o exposure alone has done much to improve treatment outcome. As had been p r e d i c t e d , t h e r e 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 on the e f f e c t t h a t e i t h e r i s l i k e l y to have on i t s own. For example, w i t h i n the realm of panic d i s o r d e r , two s t u d i e s have r e c e n t l y been s e t under way to assess the e f f e c t of a p u r e l y c o g n i t i v e i n t e r v e n t i o n ( J . Magraf, p e r s o n a l communication, March, 1990; P.M. S a l k o v s k i s , p e r s o n a l communication, A p r i l , 1990) with promising r e s u l t s . Van den Hout (1989) has a l s o used i n h a l a t i o n of C0 2 over e i g h t i n t e n s i v e s e s s i o n s as a way of exposing s u b j e c t s to sen s a t i o n s very s i m i l a r t o t h e i r own n a t u r a l l y o c c u r r i n g p a n i c a t t a c k s . While they became very much l e s s anxious about the i n d u c t i o n , the e f f e c t d i d not g e n e r a l i z e to n a t u r a l l y o c c u r r i n g p a n i c , opening up some s p e c u l a t i o n as to what are the l i k e l y s t r e n g t h s and l i m i t a t i o n s of such a treatment. I t i s c e r t a i n l y no l e s s t i m e l y than i t was at the time the study was i n i t i a t e d , to c o n s i d e r how an a b b r e v i a t e d form of these two approaches would f a r e w i t h the more s i t u a t i o n a l l y cued p a n i c and anxiety e v i d e n t i n c l a u s t r o p h o b i a . The main focus i s i n e v i t a b l y on the i n t e r o c e p t i v e and c o g n i t i v e approaches s i n c e so l i t t l e i s known about t h e i r e f f e c t s . I t would go a g a i n s t the g r a i n adopted i n t h i s study to t r y and work out whether the c o g n i t i v e or the 124 i n t e r o c e p t i v e approach was the more s u c c e s s f u l . T h i s would i n any case imply a range of assumptions t h a t have not been t e s t e d , such as that both would be as l i k e l y to be showing an e f f e c t a f t e r the same l e n g t h of i n t e r v e n t i o n and a f t e r so s h o r t a time p e r i o d . I t would seem j u d i c i o u s to keep the s p o t l i g h t o f f such a comparative emphasis. D i s c u s s i o n w i l l s t a r t with the r e s u l t s from the four experimental q u e s t i o n s . The r e s u l t s of q u e s t i o n 1 set the fo u n d a t i o n f o r the study. One of the r e c e n t f e a t u r e s of the treatment of phobias (Ost, 1989) i s the i n c r e a s i n g speed w i t h which treatments are c a r r i e d out. I t i s thus not s u r p r i s i n g , t h a t i n under 90 minutes of e x p l a n a t i o n and experience, those i n the exposure group should have undergone such a c l e a r r e d u c t i o n i n t h e i r f e a r to a t l e a s t t h i s e n c l o s e d s i t u a t i o n . Without, examining thoughts or d e c r e a s i n g s e n s i t i v i t y to s e n s a t i o n s , i t was p o s s i b l e t o b r i n g about a c l e a r r e d u c t i o n on a b a t t e r y of assessment measures, as compared wi t h the c o n t r o l group. In the case of the l a t t e r , t h e r e was some r e d u c t i o n i n the f e a r of some i n d i v i d u a l s , but f o r a g r e a t e r number, scores remained r e l a t i v e l y unchanged. The r e s u l t s of the "benchmark" groups were thus very much as expected. The f a c t t h a t r e p o r t e d f e a r and pa n i c were both s i g n i f i c a n t l y reduced by e n t i r e l y c o g n i t i v e procedures i s something of a m i l e s t o n e . As r e c e n t l y as 1987, i n a major review, Last was w r i t i n g o f f the r o l e of c o g n i t i o n s i n the 125 treatment of any phobias. These r e s u l t s would suggest t h a t t h i s i s too hasty a judgment. Not only were these f e a r r e p o r t s reduced, but a f t e r only t h i s b r i e f c o n t a c t with the s t i m u l u s , confidence i n t h a t group was running h i g h , w i t h a s s u r e d p r e d i c t i o n s being made about the g e n e r a l i z a t i o n c l o s e t , evident from the r e s u l t s of q u e s t i o n 4. Thus, though i t was s t r i k i n g t h a t t h i s i n t e r v e n t i o n had the a n t i c i p a t e d e f f e c t on r e d u c i n g the r e p o r t s of panic, i t would be wrong to assume t h a t t h i s was an i s o l a t e d e f f e c t . Barlow (1990), among o t h e r s , has warned t h a t "measures of the percentage f r e e of panic as the c e n t r a l measure of outcome may prove to be an o v e r l y o p t i m i s t i c gauge of t h e r a p e u t i c success". Whether c o g n i t i v e components to treatment can be used to speed exposure i n the treatment of c e r t a i n phobias, or t o make i t more e f f i c i e n t , w i l l have to be e s t a b l i s h e d , but the door to such r e s e a r c h i s now f i r m l y opened. A d i s a p p o i n t i n g f e a t u r e was the l a c k of support f o r the n o t i o n of c o n t i n u e d improvement over time as a r e s u l t of a c o g n i t i v e i n t e r v e n t i o n . I t i s e v i d e n t from the data on q u e s t i o n 2 t h a t one may have to be c a u t i o u s i n assuming that the e f f e c t s of a c o g n i t i v e i n t e r v e n t i o n w i l l i n v a r i a b l y improve over time. F a c t o r s that make t h i s more and l e s s l i k e l y w i l l have to be i s o l a t e d . I t i s important to note the measures not j u s t on which the c o g n i t i v e i n t e r v e n t i o n d i d e x e r t an e f f e c t , but on those on which i t d i d not. There has been 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 procedures would r e s u l t i n b e t t e r coping i n the face of a s t r e s s o r , or very much l e s s a n x i e t y even i n i t s a n t i c i p a t i o n and approach. The lack of change on q u e s t i o n 1 on both h e a r t r a t e and p r e d i c t i o n of f e a r , would suggest that f o r a t l e a s t a number of s u b j e c t s , t h e i r improvement d i d not come about b e f o r e the second exposure, at the approach to which t h e i r f e a r l e v e l s and h e a r t r a t e were s t i l l h igh. T h e i r p r o g r e s s , at l e a s t as expressed i n t h e i r own p r e d i c t i o n s of f e a r , was thus made d u r i n g t h e i r re-exposure to the f e a r e d s t i m u l u s , which l i n k s w i t h the r e s u l t s from q u e s t i o n 3 d i s c u s s e d below. In the i n t e r o c e p t i v e group, the s t a t i s t i c a l l y s i g n i f i c a n t decrements i n r e p o r t e d s e n s a t i o n s and c o g n i t i o n s on q u e s t i o n 1 were not matched by e q u i v a l e n t r e d u c t i o n s i n r e p o r t s and p r e d i c t i o n s of a n x i e t y and p a n i c . Study of the l a r g e standard d e v i a t i o n s i n t h i s group pro v i d e s a l i k e l y e x p l a n a t i o n : t h i s was an e f f e c t i v e s t y l e of i n t e r v e n t i o n f o r some but hot f o r o t h e r s ; more than i n the other two groups, some people responded l i t t l e or not a t a l l to t h i s i n t e r v e n t i o n . While C l a r k ( p e r s o n a l communication A p r i l , 1990) and o t h e r supporters of the c o g n i t i v e approach have w r i t t e n o f f i n t e r o c e p t i v e exposure as a d e c i d e d l y i n e f f i c i e n t way of changing thoughts and so a n x i e t y , there i s enough change shown here f o r i t to warrant f u r t h e r study. In p a r t i c u l a r , i t may prove that l o n g e r exposure to s e n s a t i o n s w i l l have more e f f e c t . 127 While the r e s u l t s of q u e s t i o n 1 are q u i t e c l e a r c u t , l i t t l e emerges from q u e s t i o n 2. The r e d u c t i o n i n the t o t a l N from 48 to 36 e f f e c t e d by the e t h i c a l l y n e c e s s a r y e x c l u s i o n of the c o n t r o l group at follow-up, has severe e f f e c t s on s t a t i s t i c a l power. This i s the more n o t a b l e when one i s s e a r c h i n g f o r d i f f e r e n c e s between the t h r e e groups as they move bro a d l y i n the same d i r e c t i o n . One must, then, be p a r t i c u l a r l y wary of making any ded u c t i o n s from the p l e t h o r a of n e g a t i v e r e s u l t s . What one can take from these data are, however, important e f f e c t s i z e s f o r f u t u r e r e s e a r c h , s i n c e i t i s from the f u r t h e r study of group x time i n t e r a c t i o n s t h a t much w i l l be lea r n e d . There are, too, s e v e r a l p o i n t s which emerge which can be l i n k e d . The f i r s t i s that the c o g n i t i v e group, f a r from improving over time, had higher scores at follo w - u p than at p o s t - i n t e r v e n t i o n on measures such as r e p o r t e d f e a r . Secondly, averaged a c r o s s a l l groups, w h i l e p r e d i c t i o n s of f e a r were reduced between pos t -i n t e r v e n t i o n and follow-up, scores were h i g h e r on both r e p o r t e d f e a r and heart r a t e . These p o i n t s are i l l u s t r a t i v e of the f a c t t h a t there was an u n u s u a l l y h i g h p r o p o r t i o n of " u n d e r p r e d i c t i o n s " at follow-up. While one might expect a " r e t u r n of f e a r " i n r e p o r t e d f e a r , t h i s would u s u a l l y a l s o be expected i n scores of p r e d i c t e d f e a r . A combination of the confidence gained d u r i n g the i n t e r v e n t i o n and at the second assessment, f o l l o w e d by, i n most cases, continued avoidance of f e a r e d s e t t i n g s , l e d to i n a c c u r a t e p r e d i c t i o n s 128 of f e a r . A way appears to have been a c c i d e n t a l l y found of boosting the n a t u r a l i n c i d e n c e of u n d e r p r e d i c t i o n s . T h i s i s an area of some t h e o r e t i c a l i n t e r e s t , and may encourage s p e c u l a t i o n as to what makes u n d e r p r e d i c t i o n s more l i k e l y , s i n c e there i s i n c r e a s i n g evidence to suggest t h a t the c l i n i c i a n should t r y to a v o i d t h e i r occurrence (Rachman & Bichard, 1988; Rachman & E y r l , 1990). This leaves the r e s u l t s from q u e s t i o n 3 to be di s c u s s e d . These f e l l very much a c c o r d i n g to what had been hypothesized, w i t h the f e a r p r e d i c t i o n s i n the exposure group f a l l i n g g r a d u a l l y , the l a r g e s t r e d u c t i o n t a k i n g p l a c e at the longest s e s s i o n of exposure. In the c o g n i t i v e group i t was necessary to have the experience of the second exposure before p r e d i c t i o n s of an x i e t y were reduced. T h i s r a i s e s a number of i s s u e s . Though i t i s not r e f l e c t e d i n reduced s c o r e s , there i s c l e a r l y some l e a r n i n g t a k i n g p l a c e to a l l o w such a r a p i d r e a p p r a i s a l . I t . i s not c l e a r what t h i s l e a r n i n g i s , and p r e c i s e l y how t h i s i n f o r m a t i o n i s l i n k e d to the experience of exposure. An obvious i m p l i c a t i o n i s that the amount of exposure r e q u i r e d c o u l d be g r e a t l y reduced with a s u i t a b l e c o g n i t i v e p r e p a r a t i o n . T h i s may be p a r t i c u l a r l y u s e f u l where i t i s d i f f i c u l t , expensive, or takes too much t h e r a p i s t time to set up frequent exposure s e s s i o n s . Of i n t e r e s t , too, i s t h a t the p a t t e r n of r e d u c t i o n of a n x i e t y 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 to the c o g n i t i v e r a t h e r than the exposure group. These p o i n t s w i l l 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 to the q u a l i t a t i v e r e s u l t s a f t e r some o b s e r v a t i o n s have been made about what took p l a c e d u r i n g the running of the four groups. CONTROL For the most p a r t , those i n the c o n t r o l group were as anxious the second time as the f i r s t . I t had been made c l e a r to them that as p a r t of the study they would be asked to go i n t o the c l o s e t on two separate occasions and f i l l out the necessary forms. T h i s was framed as p o s i t i v e l y as p o s s i b l e , by saying t h a t t h i s was the only group i n which p a r t i c i p a n t s d i d not have to wait e i g h t weeks to f i n d out the p r e l i m i n a r y f i n d i n g s of the study, and to get the s o u g h t - a f t e r i n f o r m a t i o n a t the d e b r i e f i n g . In s e v e r a l cases, one i n p a r t i c u l a r , the i n i t i a l experience was not n e a r l y as a v e r s i v e as had been a n t i c i p a t e d , and scores on a v a r i e t y of measures were reduced on the second o c c a s i o n . The most dramatic change i s worth r e c o r d i n g i n d e t a i l . In t h i s case a phobia of t h i r t y years d u r a t i o n , with profound s o c i a l i m p l i c a t i o n s , was e r a d i c a t e d by the f o u r minutes of assessment. The p a r t i c u l a r s u b j e c t even had the c o u r t e s y to telephone to say what an enormously s u c c e s s f u l i n t e r v e n t i o n . i t had been! On the f i r s t o c c a s i o n she had spent the e n t i r e two minutes w i t h her hand d i r e c t l y over the buzzer, her eyes shut, and she had counted slowly ( t r y i n g t o b l o t out the nagging thought of what would happen i f she was s t i l l c o u n t i n g at the end of two minutes). She a r r i v e d on the 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 but no more co n f i d e n c e . As she en t e r e d the c l o s e t , she d e c i d e d not to count, to keep her eyes open and to ignore the buzzer. A f t e r some seconds had passed, she began to f e e l the w a l l s and d e l i b e r a t e l y turned her back to the door, making any chance of e x i t more d i f f i c u l t . When the t r i a l ended she was brimming with c o n f i d e n c e , and s e t o f f a f t e r the s e s s i o n to c a r r y out a number of long-avoided a c t i v i t i e s . I t i s c l e a r from t h i s a t y p i c a l example t h a t i t i s p o s s i b l e f o r people to engineer t h e i r own f e a r r e d u c t i o n with minimal a s s i s t a n c e . EXPOSURE T h i s i n t e r v e n t i o n was the most s t r a i g h t f o r w a r d to c a r r y out w i t h 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 were s u r p r i s e d at the speed a t which t h e i r f e a r was reduced and needed l i t t l e encouragement t h a t t h i s was a u s e f u l path to pursue. The only doubts expressed were the common ones t h a t w h i l e they might be p r o g r e s s i n g a t a g i v e n l e v e l , they doubted i f they c o u l d make s i m i l a r progress at h i g h e r p o i n t s on 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 to note the d i f f e r e n c e i n speed a t which i n d i v i d u a l s ' f e a r was reduced and t o ponder on the i m p l i c a t i o n s of t h i s . There was some i n d i c a t i o n that those who a d j u s t e d very q u i c k l y to the c l o s e t may have shown l e s s g e n e r a l i z e d improvement, appearing not to process t h e i r f e a r r e d u c t i o n as e f f e c t i v e l y . There were a l s o two ins t a n c e s where f r i g h t e n i n g thoughts not evident i n the i n i t i a l assessment emerged 131 d u r i n g the i n t e r v e n t i o n . N e i t h e r c o u l d be t a c k l e d and were weakly e v i d e n t at the second assessment. For the most, however, i t was s t r i k i n g how the c o g n i t i o n s disappeared without being s p e c i f i c a l l y examined. I t i s not p o s s i b l e to say whether evidence was found to ch a l l e n g e them, or whether they were simply l e s s l i k e l y t o a r i s e once a n x i e t y had been reduced. The q u e s t i o n remains an open one, too, as to whether exposure works s o l e l y through c o g n i t i v e means as C l a r k 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 of the t h e r a p i s t was t h a t p a r t i c i p a n t s would r e p o r t h i g h l e v e l s of a n x i e t y without obvious s u p p o r t i n g c o g n i t i o n s . T h i s turned out to be u n n e c e s s a r i l y 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 d u l y r e p o r t e d , but p a r t i c i p a n t s had l i t t l e d i f f i c u l t y i n seeing the r o l e they played i n f u e l l i n g , i f not n e c e s s a r i l y c r e a t i n g , t h e i r f e a r s . P i l o t work had l a r g e l y been c a r r i e d out w i t h students which was adequate p r e p a r a t i o n f o r only some p o i n t s that arose. A s i m i l a r i t y with the student p o p u l a t i o n was t h a t t h e r e was evidence of a c l e a r d u a l b e l i e f system. Almost a l l of these c l i n i c a l v o l u n t e e r s r e c o g n i z e d that the degree of b e l i e f i n the thoughts t h a t had come to mind i n the c l o s e t , was g r o s s l y i n f l a t e d i n comparison with what they b e l i e v e d i n d i s c u s s i o n or on r e f e c t i o n l a t e r . The d i f f i c u l t y was i n 132 g e t t i n g the same reas o n i n g to operate a t the higher l e v e l of a n x i e t y . T h i s task was s p l i t c l e a r l y between thoughts which were r e l a t i v e l y easy to c h a l l e n g e and thoughts which were not. In the f i r s t category were thoughts which were l a r g e l y based 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 had never c o n s i d e r e d how much a i r one would need to s u r v i v e i n an enclosed space, and were i n t e r e s t e d to make an estimate b e f o r e c a l c u l a t i n g the r e a l i t y (a rough estimate was that they were w e l l over a hundred times out i n t h e i r e s t i m a t e s ) . They d i d not know how to work out i f a space was a i r t i g h t . They d i d not know t h a t f a i n t i n g r e s u l t s from one's h e a r t going slower and so c o u l d not happen i f one's heart was pumping from a n x i e t y . Such i n f o r m a t i o n was u s e f u l and q u i c k l y and e a s i l y r e c e i v e d . What had not been a n t i c i p a t e d was t h a t there would be a second s e t of c o g n i t i o n s i n some i n d i v i d u a l s t h a t proved to be very much more stubborn. In many cases they were f a r from random, but came from t h e i r p e r s o n a l experience or that of others c l o s e to them. C l a r k has suggested t h a t one must t a c k l e " i d i o s y n c r a t i c evidence", but has perhaps underplayed the s i g n i f i c a n c e of the circumstances under which t h i s may have been l e a r n e d . In s e v e r a l cases, i t came as a s u r p r i s e to s u b j e c t s to r e c a l l i n c i d e n t s which had l e d them to b e l i e v e the p r o b a b i l i t y of a c e r t a i n occurrence. To understand the b a s i s f o r the b e l i e f was h e l p f u l to them. A second p o i n t was that w hile i t was r e l a t i v e l y s t r a i g h t f o r w a r d to h e l p them to come up w i t h c o n v i n c i n g 133 counterarguments d u r i n g the i n t e r v e n t i o n , t h e i r concern was whether they would be able to summon such thoughts when they were back i n the c l o s e t . The t h i r d s e s s i o n was spent speeding up t h e i r responses and making them e a s i e r to access. However, a t h e r a p e u t i c concern was that i n some cases, the f r i g h t e n i n g thoughts were never accessed at a l l ; c oping statements were used-almost l i k e a mantra. While t h i s seemed u s e f u l i n the short-term, i t seemed u n l i k e l y to be b e n e f i c i a l i n the long-term. The c l i n i c i a n at t h i s p o i n t might have encouraged s u b j e c t s d u r i n g t r a i n i n g to imagine t h a t they were i n the s i t u a t i o n , to b r i n g on the f r i g h t e n i n g thoughts and then, and only then, to t r y and d i s p u t e them. However, i t was f e l t t h a t such i m a g i n a l exposure could be i n c o n f l i c t w i t h the i n t e g r i t y of the way the i n t e r v e n t i o n was to be conducted. I f coping statements were being used i n t h i s manner, and s u b j e c t s were being d i s t r a c t e d from t h e i r t y p i c a l thoughts, then t h i s may h e l p to e x p l a i n why t h i s c o g n i t i v e group d i d not continue to improve over time: they were being d i s t r a c t e d from t h e i r key c o g n i t i o n s r a t h e r than l e a r n i n g to c h a l l e n g e them. I t would be expected that at a l a t e r p o i n t , t h e i r more u s u a l , even almost automatic thought p a t t e r n s , would r e t u r n . 134 INTEROCEPTIVE There has been almost not h i n g w r i t t e n on the p r a c t i c a l problems of g i v i n g i n t e r o c e p t i v e exposure. I t was at some p o i n t s the most d i f f i c u l t i n t e r v e n t i o n to a d m i n i s t e r . While i t was not hard to convey the r a t i o n a l e , not a l l i n d i v i d u a l s f e l t c omfortable engaging i n these e x e r c i s e s , and, f o r example, expressed awkwardness or embarrassment d e s p i t e e f f o r t s to put them at t h e i r ease. Though the main e x e r c i s e used i n p a n i c d i s o r d e r i s h y p e r v e n t i l a t i o n , b r e a t h i n g through the straw proved more s i m i l a r to s e n s a t i o n s that had been e x p e r i e n c e d i n the c l o s e t , was e a s i e r to b u i l d up a t o l e r a n c e t o , and appeared to b r i n g about more change. T h i s may mean t h a t there i s a q u a l i t a t i v e d i f f e r e n c e i n panic i n and out of an enclosed space. I t i s s t i l l q u i t e u n c e r t a i n as to what the mechanism of change might be. I t c o u l d be t h a t one i s a t l e a s t doing something not p r e v i o u s l y t r i e d , and which a t l e a s t appears to make sense. I t could be t h a t one i s g e t t i n g l e s s s e n s i t i v e to a p a r t i c u l a r p h y s i c a l s e n s a t i o n . I t c o u l d be t h a t the e x e r c i s e s f o s t e r c o g n i t i v e change. I t i s i m p l i c i t i n c o g n i t i v e theory that panic can be reduced by e i t h e r r e d u c i n g t r i g g e r i n g s e n s a t i o n s or changing i n t e r p r e t a t i o n s about them. I t i s s t i l l an open q u e s t i o n as to whether the i n t e r o c e p t i v e i n t e r v e n t i o n might operate, a t l e a s t i n some 135 cases, by the former mechanism, i n s t i t u t i n g change and reducing a n x i e t y without a c c e s s i n g or changing c o g n i t i o n s . T h i s would need to be e s t a b l i s h e d , as i t would whether t h i s would be a l e s s powerful, or at l e a s t l e s s g e n e r a l i z a b l e , way of change. I t remains an i n t r i g u i n g p o s s i b i l i t y that the i n t e r o c e p t i v e techniques are not j u s t a d i f f e r e n t method to c o g n i t i v e ones, but operate through d i f f e r e n t mechanisms. CLAUSTROPHOBIA AND THE CLARK MODEL A s t a r t i n g p o i n t f o r t h i s r e s e a r c h was the success of p s y c h o l o g i c a l i n t e r v e n t i o n s with panic d i s o r d e r . C l a r k ' s model of treatment (1987) has aroused much p r o f e s s i o n a l a t t e n t i o n , and i t was of i n t e r e s t to note how e a s i l y i t cou l d be t r a n s f e r r e d to the s o r t of panic that can be observed i n c l a u s t r o p h o b i a . At the ou t s e t i t should be s a i d t h a t one would not expect a mirror-image t r a n s f e r . Panic d i s o r d e r , by i t s DSM-III-R d e f i n i t i o n , i n v o l v e s a s t a t e of a n x i e t y without obvious cause. T h i s makes f o r a group that have proven to be i d e a l l y s u i t e d to 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 of t h e i r s e n s a t i o n s . I t has not, and would not, be claimed that a c l a u s t r o p h o b i c or s i m i l a r l y cued panic occurs u s i n g the same mechanism. There are i n s t a n c e s where there i s complete ov e r l a p , but these are not the r u l e . For example, a r o u s a l 136 brought about f o r a v a r i e t y of reasons i n an e n c l o s e d space can indeed be m i s i n t e r p r e t e d as a s i g n of l o s i n g c o n t r o l , l o s i n g a i r , or some o t h e r f r i g h t e n i n g c a t a s t r o p h e . However, p e r c e p t i o n s of t h r e a t i n c l a u s t r o p h o b i a are l e s s l i k e l y to a r i s e 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 than the misreading of e x t e r n a l cues. I t i s c l e a r t h a t common c o g n i t i o n s t r i g g e r i n g a n x i e t y such as t h a t one might be trapped, might become crushed, or might be a t r i s k from some n a t u r a l d i s a s t e r are u n l i k e l y to be t r i g g e r e d by i n t e r n a l s e n s a t i o n s . Such a change i n emphasis to the m i s i n t e r p r e t a t i o n of e x t e r n a l t r i g g e r s poses no c o n c e p t u a l l e a p or d i f f i c u l t y f o r the theory. A second p o i n t i s t h a t while c o g n i t i o n s may p l a y a r o l e i n the genesis of the f e a r , there i s evidence t h a t they may not be so important i n i t s maintenance. In an unpublished paper, Lopatka and L e v i t t (1988) proposed the n o t i o n of a secondary phase of f e a r i n g the d i s c o m f o r t t h a t has become a s s o c i a t e d w i t h a f e a r . Thus, f o r example, w h i l e the f e a r of b e i n g crushed might i n i t i a t e the f i r s t p a n i c , t h i s might set o f f a high degree of a r o u s a l i n other e n c l o s e d spaces which need not be m i s i n t e r p r e t e d to be found very unpleasant. At p r e s e n t Clark s t i c k s r e s o l u t e l y to the n o t i o n t h a t there must be continued m i s i n t e r p r e t a t i o n on every o c c a s i o n on which there i s a panic. 137 Whether c l a u s t r o p h o b i a p r o v i d e s the grounds f o r non-c o g n i t i v e panic opens more c o n t r o v e r s i a l areas. What can be s a i d i s that c o n d i t i o n i n g a t the very l e a s t p l a y s a very much more prominent p a r t than has been apparent i n pa n i c d i s o r d e r . One can s t a r t w i t h an example i n which c o g n i t i o n s are i n i t i a l l y apparent but then weaken or disappear. One s u b j e c t i n t h i s study became very uncomfortable at a packed f o o t b a l l game. A woman s a t down beside her wearing overpoweringly s t r o n g perfume, and i t suddenly seemed as i f she was br e a t h i n g j u s t perfume and was not g e t t i n g enough a i r . She f e l t t e r r i b l e and wondered i f she would throw up, f i n a l l y becoming panicky and l e a v i n g . The smell of perfume i n any crowded p l a c e i s now s u f f i c i e n t i t s e l f to b r i n g on a p a n i c , even though there i s now no re p o r t e d c o g n i t i o n . Her concern when she co n s i d e r e d j o i n i n g a treatment group t h a t f o l l o w e d the study, was not of the a c t i v i t i e s t h a t might be demanded, but whether any of the other women might be wearing perfume. Con s i s t e n t with the r o l e of c o n d i t i o n i n g i s th a t i t seems as i f i n t e r n a l scanning p l a y s a l e s s prominent r o l e i n c l a u s t r o p h o b i a than i n uncued p a n i c . I t i s the e x t e r n a l s i t u a t i o n , whether or not 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 b r i n g s on the sensat i o n s which i n t h e i r t u r n can a l s o be m i s i n t e r p r e t e d . Though some s u b j e c t s have hi g h ASI s c o r e s , i t i s much more remarkable t o note t h e i r v i g i l a n c e f o r e x t e r n a l cues: the no i s e from above i n the e l e v a t o r , the 138 change i n engine tone i n a p l a n e , which are e i t h e r c o n d i t i o n e d t r i g g e r s or open the door to unwelcome c o g n i t i o n s . One could go a stage f u r t h e r and sp e c u l a t e t h a t i n some i n s t a n c e s there may have never been a c o g n i t i o n . There c e r t a i n l y does seem to be an i n t r i g u i n g n o n - c o g n i t i v e n a t u r e to entrapment. An item on one q u e s t i o n n a i r e t h a t i n v i t e d h o r r o r from many was being i n a s t r a i t j a c k e t . Even i f they were accompanied by a t r u s t e d f r i e n d who was not so r e s t r i c t e d and who c o u l d have looked a f t e r t h e i r s a f e t y , they p r e d i c t that they would f e e l very uncomfortable. The d i f f i c u l t y they have i n e x p r e s s i n g the foundations f o r t h i s d i s c o m f o r t make i t d i f f i c u l t to see how t h i s can be f i t t e d i n t o neat c o g n i t i v e terms. An important o b s e r v a t i o n i n t h i s study, however, and i n t e r e s t i n g l y C l a r k (1990) has r e p o r t e d the same wit h agoraphobics, i s t h a t the thoughts so prominent i n panic d i s o r d e r , are o f t e n f l e e t i n g when there i s the degree of avoidance as i s e v i d e n t here. The f a c t t h at the thoughts were so c l e a r l y r e p o r t e d i n the c o g n i t i v e c h e c k l i s t may g i v e a m i s l e a d i n g impression of t h e i r s a l i e n c e . A t t e n t i o n f o r the most p a r t was very o f t e n not on these b a r e l y c o n s c i o u s thoughts, but i n s t e a d on wanting d e s p e r a t e l y to get out of the s i t u a t i o n . Subjects have to engage almost i n a change of mental set i f they are to focus not on t h e i r anxious 1 3 9 f e e l i n g s , but on the u n d e r l y i n g thoughts which f u e l them and about which they might be very much l e s s aware. The q u e s t i o n can be posed that i f one has to educate people as to what i s f u e l l i n g t h e i r f e a r , then t h i s would seem an u n l i k e l y rock on which the f e a r i s founded. On the other hand, one i s f a c e d with the c l e a r data from t h i s study that a p u r e l y c o g n i t i v e i n t e r v e n t i o n , without doubt not administered to i t s optimal e f f e c t and f o r a very s h o r t time p e r i o d , was a b l e to b r i n g about s u b s t a n t i a l e f f e c t i n anxiety r e d u c t i o n . What one i s l e f t w i t h i s that there are, f i r s t l y , n e g a t i v e thoughts and, secondly, sets of behaviours t h a t prevent i n d i v i d u a l s from t e s t i n g out t h e i r b e l i e f s . These are r e q u i s i t e s f o r a c o g n i t i v e i n t e r v e n t i o n and i t i s u s e f u l to know th a t they are so c l e a r l y e v i d e n t i n t h i s phobia. T h i s study suggests that a d d r e s s i n g c o g n i t i v e elements i s l i k e l y to be a u s e f u l adjunct to mere exposure, but t h i s w i l l need to be t e s t e d . A v a r i a n t of the model f o r panic d i s o r d e r may w e l l be t r a n s f e r a b l e to t h i s f e a r and, at l e a s t as i m p o r t a n t l y , c l a u s t r o p h o b i a may w e l l provide i n the f u t u r e a t e s t i n g ground f o r the C l a r k model. One t h a t comes to mind i s to provide very s h o r t p e r i o d s of exposure which g i v e o p p o r t u n i t i e s to t e s t c r i t i c a l n e g a t i v e b e l i e f s . I f these prove to be s u p e r i o r to longer p e r i o d s of exposure not s p e c i f i c a l l y t i e d to n e g a t i v e thoughts, then C l a r k ' s model and i t s emphasis on c o g n i t i o n s would indeed be demonstrated to be a p p r o p r i a t e f o r g e t t i n g to the r o o t of t h i s f e a r . 140 CLAUSTROPHOBIA AND THE BARLOW MODEL I t would be m i s l e a d i n g to s e t Barlow up as being i n o p p o s i t i o n to C l a r k , s i n c e the s i m i l a r i t i e s i n t h e i r approaches are more s t r i k i n g than the d i f f e r e n c e s . Moreover, most of t h e i r r e c e n t a t t e n t i o n has fo c u s e d on panic d i s o r d e r and i t i s I, r a t h e r than they, who have t r a n s f e r r e d t h e i r approaches to a simple phobia. N e v e r t h e l e s s , the f a c t t h a t Barlow has g i v e n a s l i g h t l y d i f f e r e n t emphasis i n h i s work does p r o v i d e a d i f f e r e n t s l a n t f o r d i s c u s s i o n . One c h a r a c t e r i s t i c of Barlow's approach has been h i s enthusiasm f o r the i n t e r o c e p t i v e model. Though a l o t of qu e s t i o n s remain as to the mechanism of i t s e f f e c t , the i n t e r o c e p t i v e e x e r c i s e s d i d make an impression on some important a s p e c t s of t h i s phobia. C o g n i t i v e t h e o r i s t s w i l l no doubt argue t h a t t h i s e f f e c t was brought about through c o g n i t i v e means. The f a c t t h at the straw was by f a r the most e f f e c t i v e of the set of e x e r c i s e s , would be ex p l a i n e d as t h i s b e i n g the one which was most l i k e l y to b r i n g about c o g n i t i v e change. At t h i s p o i n t , the q u e s t i o n cannot be answered w i t h any degree of c e r t a i n t y . But even i f t h i s i s the mechanism of change, then i t must be seen as an e x e r c i s e l i k e l y to produce change f o r at l e a s t some people. There are many areas i n which i t i s d i f f i c u l t or expensive to get exposure ( f l y i n g , 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 the 141 very l e a s t these e x e r c i s e s are l i k e l y to h e l p p l u g such gaps; i f they work through mechanisms other than the c o g n i t i v e , then a whole new approach w i l l have been opened up. I t was of note t h a t f a l s e alarms as Barlow d e s c r i b e d i n panic d i s o r d e r a l s o occur i n c l a u s t r o p h o b i a . The numbers i n each group are too s m a l l to be even s u g g e s t i v e of trends, but p r e d i c t i n g the success of an i n t e r o c e p t i v e treatment on how the f e a r was l e a r n e d could open up new avenues of t h e r a p e u t i c assessment. I f i t t r a n s p i r e d t h a t the experience of f a l s e alarms was p r e d i c t i v e of success from an i n t e r o c e p t i v e treatment, then i t might open the door to c a t e g o r i z i n g phobias and other f e a r s not by the s p e c i f i c o b j e c t f e a r e d , but by how, f o r example, the f e a r was l e a r n e d . 142 AN ANALYSIS OF CLAUSTROPHOBIA A model s p e c i f i c a l l y a ddressing c l a u s t r o p h o b i a can g a i n from borrowing ideas from t h e o r i s t s such as C l a r k and Barlow. However, i n the f i n a l a n a l y s i s an understanding of t h i s f e a r must be b u i l t around the f a c t s p e c u l i a r to i t . There are p o i n t s about the f e a r t h a t run i n p a r a l l e l with other f e a r s , and others that make i t stand a l o n e . Elements of both c a t e g o r i e s have i m p l i c a t i o n s f o r the study of other a n x i e t y d i s o r d e r s . I t has become c l e a r e r as to what c o n s t i t u t e s t h i s f e a r . The s i n g l e most important theme i s escape from an enclosed space, hence the predominant c o g n i t i o n of entrapment. Other themes i n p a r t stem from t h i s , s i n c e they tend to be r e p o r t e d only when e x i t s are cut o f f . These i n c l u d e thoughts r e l a t i n g to a i r , such as those concerning s u f f o c a t i o n , which are c h a r a c t e r i s t i c of t h i s f e a r , but by no means always pr e s e n t . Since they r a r e l y occur i n the absence of entrapment, i t may be b e s t to t h i n k of. c l a u s t r o p h o b i a as a f e a r of entrapment w i t h or without s u f f o c a t i o n . L i t t l e l i g h t i s shed on the n o t i o n of entrapment i n t h i s study. The s t r u c t u r e d i n t e r v i e w s o n l y s e r v e d to confirm t h a t t h i s element of the f e a r does seem to have a non-c o g n i t i v e element which i s not e a s i l y e x p l a i n e d . When c l a u s t r o p h o b i c s are asked 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 d i s c o m f o r t such as low c e i l i n g s i n underground p a r k i n g , they are q u i t e unable to l i n k t h e i r f e a r to any p a r t i c u l a r thought. There are, too, m u l t i p l e examples of r e p o r t s of be i n g unable to remove t i g h t c l o t h i n g or r i n g s which are s i m i l a r , i n as f a r as t h a t t h e r e i s no c l e a r c a t a s t r o p h i c outcome t h a t they can i d e n t i f y . One n o t i o n that has been advanced i s that such f e e l i n g c o u l d r e p r e s e n t another form of entrapment i n t h e i r l i v e s : trapped, f o r example, i n a job or i n a marriage. There i s l i t t l e evidence to support t h i s . The s i n g l e r e l a t e d f i n d i n g i n t h i s study was t h a t one member of the c o n t r o l group l o s t much of her c l a u s t r o p h o b i a ( a f t e r the study but b e f o r e d e b r i e f i n g ) when a d i v o r c e settlement was reached t h a t gave her f i n a n c i a l independence. Though she r e p o r t e d t h a t she f e l t very much l e s s trapped on he a r i n g of the s e t t l e m e n t , and a t t r i b u t e d her reduced avoidance to t h i s f e e l i n g , there are a l t e r n a t e e x p l a n a t i o n s such as a r e d u c t i o n i n her ge n e r a l l e v e l s of s t r e s s . There are other, more l i k e l y , e x p l a n a t i o n s of entrapment than some form of symbolic s i g n i f i c a n c e . The f i r s t i s t h a t i t i s , at l e a s t i n p a r t , a v e s t i g i a l f e a r . Preparedness, as d i s c u s s e d i n the review of the l i t e r a t u r e , i s c e r t a i n l y a f a c t o r i n oth e r common phobias, and a l i n k to c l a u s t r o p h o b i a would not be i n c o n s i s t e n t i n t h a t entrapment c o u l d a l s o be seen as a t h r e a t to e a r l y man: a mechanism to a v o i d s i t u a t i o n s from which escape would be d i f f i c u l t would 144 c e r t a i n l y have had s u r v i v a l v a l u e . A c l e a r e r understanding of preparedness seems the most l i k e l y route of an improved understanding of t h i s a p p a r e n t l y n o n - c o g n i t i v e aspect to the f e a r . A second p o s s i b i l i t y i s t h a t the f e e l i n g of entrappedness i s e a s i l y l i n k e d to e a r l y n e g a t i v e emotional experience. In three cases the f e e l i n g of entrapment reminded p a r t i c i p a n t s of when they had been sep a r a t e d from t h e i r parents as c h i l d r e n . The panic of being u t t e r l y on t h e i r own, of f e a r i n g o n e s e l f abandoned, was what i t was l i k e f o r them to be trapped. I t i s u n c e r t a i n whether they a r e merely d e s c r i b i n g a s i m i l a r f e e l i n g or may be p o i n t i n g t o a p o s s i b l e mechanism of l e a r n i n g . A theme t h a t had not been p a i n t e d as b e i n g as prominent i n c l a u s t r o p h o b i a , was the f e a r of being seen to l o s e c o n t r o l of one's emotions. While t h i s i s by no means p e c u l i a r to t h i s f e a r , t h e r e are i n d i c a t i o n s from both the s t r u c t u r e d i n t e r v i e w s and the I n v e n t o r i e s , t h a t i t may p l a y an u n u s u a l l y important r o l e . T h i s may help to e x p l a i n why the presence of o t h e r s o f f e r s so l i t t l e support and why some p a r t i c i p a n t s , indeed, expressed a preference to b e i n g on t h e i r own i f they were to f i n d themselves trapped. With r e g a r d to who p i c k s up the f e a r , t h e r e do seem to be a host of v u l n e r a b i l i t y f a c t o r s i n c l u d i n g c h i l d h o o d e x p e r i e n c e s , s t r e s s , s e n s i t i v i t y to b r e a t h i n g d i f f i c u l t i e s , and a concern about l o s i n g c o n t r o l p a r t i c u l a r l y i n f r o n t of 145 other people. These t y p i c a l l y i n t e r a c t with a p a r t i c u l a r s a l i e n t experience. T h i s i s most commonly a short p e r i o d of entrapment i n a s i t u a t i o n t h a t i s not o b j e c t i v e l y dangerous such as a door jamming or an e l e v a t o r stopping between f l o o r s . A r e s u l t of the b r e v i t y of such experiences i s th a t many c l a u s t r o p h o b i c s have never a c t u a l l y had a c l a u s t r o p h o b i c panic. They have always managed to get out " j u s t i n time", and so are l e f t w i t h t h i s nagging and fearsome doubt of what would have happened had they not been abl e to le a v e . 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 of se n s a t i o n s l e a d i n g to a p a n i c , i t seems more ac c u r a t e to say th a t they h o l d assumptions about what they f e e l would happen i f they c o u l d not make good t h e i r escape. These assumptions may be t i e d to the sen s a t i o n s t h a t they have a l r e a d y s t a r t e d to experience but t h i s i s not n e c e s s a r i l y the case, p a r t i c u l a r l y i n those who have had the b r i e f e s t experience of entrapment. T h i s l a c k of f a m i l i a r i t y with p a n i c i s a f e a t u r e t h a t appears to set c l a u s t r o p h o b i a apart from those w i t h panic d i s o r d e r . There i s no reason to suggest t h a t t h i s makes the f e a r any l e s s i n t e n s e . What may l i n k the two d i s o r d e r s i s that i n n e i t h e r does i t now appear l i k e l y t h a t the core i s as simple a matter as a change i n a p h y s i c a l s e n s a t i o n b e i n g g r e a t l y o v e r i n t e r p r e t e d : an i n c r e a s e i n h e a r t beat, f o r example, l e a d i n g t o a b e l i e f such as t h a t one may be about to have a h e a r t a t t a c k . Apart from the f a c t t h a t t h i s i s an extremely 146 uncommon a s s o c i a t i o n , i t ignores the f a c t t h a t such m i s i n t e r p r e t a t i o n s are not random. I t has been s t r i k i n g i n t h i s study t h a t the c r i t i c a l c a t a s t r o p h i c b e l i e f s are o f t e n stubborn because i n some way they are based on e x p e r i e n c e . The nature of that experience may, a f t e r r e f l e c t i o n or d i s c u s s i o n , be e a s i l y e x p l a i n e d i n other terms, but the i n d i v i d u a l uses some i n f o r m a t i o n from an event i n t h e i r p a s t , o f t e n not c o n s c i o u s l y , to i n t e r p r e t t h e i r c u r r e n t s i t u a t i o n . T h i s c o g n i t i v e l i n k appears to be p a r t i c u l a r l y l i k e l y t o a r i s e at a c e r t a i n l e v e l of a n x i e t y , the reasons f o r which one can as yet only s p e c u l a t e . T h e r a p i s t s have, f o r the most, ex p l o r e d p e r s o n a l e x p e r i e n c e s that may l e a d to i d i o s y n c r a t i c n e g a t i v e b e l i e f s , o n l y as an a i d to s e t t i n g up a p p r o p r i a t e experiments f o r c l i e n t s t o t e s t t h e i r assumptions. While i t i s important f o r the c l i e n t t o be aware of the c o n d i t i o n s under which any b e l i e f was formed, l e s s a t t e n t i o n has been g i v e n to the mechanism through which such thoughts come to be h e l d . While i t can o f t e n be s t r a i g h t f o r w a r d to take t h e r a p e u t i c advantage of c l e a r p e r s o n a l examples whose meaning has i n some way been d i s t o r t e d , i t i s s t i l l not c l e a r why c e r t a i n e x p e r i e n c e s seem more l i k e l y t o have been so i n f l u e n t i a l i n the f i r s t p l a c e . An example was a p a r t i c i p a n t who f e a r e d t h a t she might f a i n t who had, on one o c c a s i o n , f a i n t e d as a c h i l d . 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 to examine t h i s i n c i d e n t and to see how i t i n f l u e n c e d her 147 present concerns i n a n x i e t y - p r o v o k i n g s i t u a t i o n s . On the other hand, much l e s s i s known about why c e r t a i n i n c i d e n t s seem to t r i g g e r b e l i e f s . T h i s i s s u r e l y no l e s s worthy a t o p i c of r e s e a r c h . Even some more complex examples such as a s u b j e c t who f e l t t h a t she was l o s i n g c o n t r o l and d r i f t i n g i n t o a s t a t e of madness every time t h a t she had a c l a u s t r o p h o b i c p a n i c , c o u l d o f t e n be t r a c e d to p a r t i c u l a r p e r s o n a l e x p e r i e n c e s . Here again, though, i t was not c l e a r why t h i s e xperience should have a c e r t a i n e f f e c t at even moderate l e v e l s of a n x i e t y i n p a r t i c u l a r s i t u a t i o n s . With r e g a r d to the treatment of the f e a r , t h i s study was a b l e to draw not only on the s h o r t i n t e r v e n t i o n s , but on treatment that took p l a c e a f t e r a l l the r e l e v a n t data had been c o l l e c t e d . A l l c o n t r o l s u b j e c t s , and those who had made l e s s progress than they wanted i n the hour f o l l o w i n g the 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 of therapy u s i n g a l l t h ree strands of therapy together, r a t h e r than one e x c l u s i v e l y . As one would have p r e d i c t e d , most made r a p i d , dramatic and d u r a b l e progress. There was a subgroup who made much slower p r o g r e s s , i t s e l f an i n t e r e s t i n g area f o r i n v e s t i g a t i o n . E i g h t of these formed a group which met once weekly f o r s i x weeks. At the end of t h i s time, only one was unable to face the i n i t i a l l y u n t h i n k a b l e g o a l of the group, namely to be i n an e l e v a t o r w i t h the power turned o f f , stuck between f l o o r s . Impressions from t h i s group were that c o g n i t i v e and i n t e r o c e p t i v e elements d i d indeed hasten 148 p r o g r e s s , and o f f e r e d u s e f u l options when the e f f e c t s of exposure alone appeared to be f a l t e r i n g . One i s s u e r a i s e d i n t h i s group was t h a t of s a f e t y s i g n a l s ; perhaps something can be s a i d about the nature of a f e a r from the s a f e t y s i g n a l s used to defend a g a i n s t i t . On the f i r s t day, group members s h e e p i s h l y admitted to a range of m e d i c a t i o n , t o r c h e s and even s c r e w d r i v e r s s e c r e t e d i n t h e i r handbags. T h i s was c h a r a c t e r i s t i c of the l a r g e r group many of whom had r e p o r t e d u s i n g s i m i l a r a i d s . The most common one, as w i t h so many of the a n x i e t y d i s o r d e r s , i s c a r r y i n g around some form of medication. Perhaps because the f e a r i s so very p r e d i c t a b l e that one does not have to make so many p r e c a u t i o n s , they appeared to be l e s s commonly used than w i t h some o t h e r f e a r s . The range, however, was somewhat g r e a t e r as i t was not l i m i t e d to t r a z n q u i l l i z e r s but was at l e a s t as l i k e l y t o i n c l u d e s l e e p i n g t a b l e t s , t r a v e l s i c k n e s s m e d i c a t i o n , or some other such m i l d s e d a t i v e . Other p a r t i c i p a n t s commonly looked f o r h e l p w i t h o r i e n t a t i o n (such as a t o r c h ) , s a f e t y , and ease of b r e a t h i n g (decongestant sprays) a p a r t from p a r t i c u l a r coping s t r a t e g i e s such as a v i g i l a n c e f o r and i n s i s t e n c e on open doors, open windows and c l e a r access to e x i t s . / Though i t i s not unusual f o r phobias t o have i n d i v i d u a l i z e d p a t t e r n s , there seems to be p a r t i c u l a r b readth and v a r i e t y i n the case of c l a u s t r o p h o b i a . Whereas 149 i n panic d i s o r d e r , r e c e n t emphasis has been on the r o l e of c o g n i t i o n s i n g e n e r a l and m i s i n t e r p r e t a t i o n s i n . p a r t i c u l a r , t h i s i s only one p a r t of c l a u s t r o p h o b i a . There can be such m i s i n t e r p r e t a t i o n s of s e n s a t i o n s , but there are a l s o other c o g n i t i v e elements such as f e a r of l o s i n g c o n t r o l or a c t i n g f o o l i s h l y . Entrapment and d i s o r i e n t a t i o n are l e s s c l e a r l y , and sometimes not a t a l l , c o g n i t i v e f e a t u r e s of the f e a r . F u r t h e r , there i s the much more prominent r o l e of c o n d i t i o n e d f e a t u r e s i n c l u d i n g s i g h t s , sounds, and smel l s . Indeed i t i s o f t e n d i f f i c u l t to c a t e g o r i z e something such as d i s o r i e n t a t i o n as c o g n i t i v e or c o n d i t i o n e d , s i n c e i t may have elements of both. One f i n a l d i s t i n c t i o n i s between pa n i c and a n x i e t y . The re c e n t c l i n i c a l emphasis on panic should not c l o u d the f a c t t h a t panic i s not a necessary f e a t u r e of c l a u s t r o p h o b i a . As has a l r e a d y been mentioned, many wit h the f e a r have never a c t u a l l y panicked and, f o r some, t h i s i s not t h e i r worst c a t a s t r o p h e . The sheer d i s c o m f o r t of a n x i e t y alone should not be minimized and may w e l l be s u f f i c i e n t t o cause and perpetuate avoidance. C l a u s t r o p h o b i a may be a u s e f u l way of examining panic, but the two should not be equated: c l a u s t r o p h o b i a i s . p r i m a r i l y a phobia i n which p a n i c can occur under c e r t a i n c o n d i t i o n s . 150 DIRECTIONS FOR FURTHER RESEARCH I t seems almost i n e v i t a b l e i n such p r e l i m i n a r y r e s e a r c h t h a t many more q u e s t i o n s have been r a i s e d than answered. There are no fewer avenues which now beckon f o r a t t e n t i o n . One c o u l d choose to f i n d out more about c l a u s t r o p h o b i a , more about the i n t e r v e n t i o n s and instruments used i n t h i s r e s e a r c h , or use the model of c l a u s t r o p h o b i a to f i n d out more about f e a r . With r e g a r d to c l a u s t r o p h o b i a perhaps one of the most i n t r i g u i n g aspects l e f t unsolved i s the i s s u e of entrapment. C l a u s t r o p h o b i a does seem to be on the brid g e between c o g n i t i v e and n o n - c o g n i t i v e f e a r s , and f u r t h e r e x p l o r a t i o n of entrapment may l e a d t o an improved understanding of what d i f f e r e n t i a t e s the two. There would seem to be much value i n i n v e s t i g a t i n g f u r t h e r the i n t e r v e n t i o n s used i n t h i s study. The i n t e r o c e p t i v e techniques could be used f o r a much lon g e r p e r i o d on a g r e a t e r v a r i e t y of a n x i e t y d i s o r d e r s , t o e s t a b l i s h c l e a r e r c o n c l u s i o n s as to t h e i r u t i l i t y . The c o g n i t i v e techniques c o u l d be expanded with , f o r example, the i n t r o d u c t i o n of i m a g i n a l exposure to get more e f f e c t i v e c o g n i t i v e r e h e a r s a l . There i s c o n s i d e r a b l e scope a l s o i n t e s t i n g d i f f e r e n t c o g n i t i v e techniques ( p r o v i s i o n of i n f o r m a t i o n a g a i n s t more e x p e r i e n t i a l l y o r i e n t e d techniques, 151 f o r example) to explore Barnard and Teasdale's (1990) work on l e v e l s of meaning. At a l a t e r p o i n t i t w i l l be w e l l worth i n v e s t i g a t i n g how both i n t e r o c e p t i v e and c o g n i t i v e techniques i n t e r a c t w i t h exposure. The c l e a r i m p l i c a t i o n from the data on the t i m i n g of change i s that exposure treatment, even i n phobias, c o u l d be speeded up by the a d d i t i o n of these methods. There i s a l s o much scope f o r developing the measures used i n t h i s study. Perhaps those most u r g e n t l y i n need of a t t e n t i o n are the c o g n i t i v e measures. The pschometric p r o p e r t i e s of the Negative C o g n i t i o n s C h e c k l i s t must be e s t a b l i s h e d i n l i g h t of the changes made to s u i t a c l a u s t r o p h o b i c r a t h e r than an agoraphobic p o p u l a t i o n . L i t t l e i s yet known about the e f f e c t of combining the frequency of b e l i e f s with the degree to which they are b e l i e v e d , and how t h i s might compare w i t h the most s i n g l e c r i t i c a l b e l i e f , frequency of b e l i e f s , d u r a t i o n of b e l i e f s , or other s c o r e s t h a t have been used w i t h s c a l e s s i m i l a r to those adopted here. I f ways c o u l d be developed to measure c o g n i t i o n s o u t s i d e a n x i e t y - p r o v o k i n g s i t u a t i o n s , t h i s , too, would be very u s e f u l . 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 at l e a s t a s t a r t i n t h i s d i r e c t i o n . Even the t i m i n g of measurement must be taken i n t o c o n s i d e r a t i o n . The g r e a t e s t / impact of the assessment was d e l a y e d i n f o u r p a r t i c i p a n t s . One, f o r example, had to t u r n on the heater i n the c a r park to s t o p h e r s e l f shaking i n a warm summer day, w h i l e another 1 5 2 had to p u l l o f f the road to stop h e r s e l f t r e m b l i n g . These are j u s t 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 . I t would be i n t e r e s t i n g to know, too, of the c o g n i t i v e r e a c t i o n s on a long e r t i m e - s c a l e . The model of c l a u s t r o p h o b i a seems a u s e f u l one f o r i n c r e a s i n g our o v e r a l l understanding of f e a r . There are q u e s t i o n s r e l a t e d to the t i m i n g of f e a r through the l i f e -span. In t h i s study i t was s u r p r i s i n g , f o r example, that so l i t t l e f e a r was r e p o r t e d i n adolescence. One would have thought that t h i s i s the very time of l i f e when one might very w e l l be pressed to do t h i n g s , o f t e n i n the absence of s a f e t y s i g n a l s , and when there might be very p a r t i c u l a r concerns about s o c i a l embarrassment. Instead, what was found was evidence of the f e a r i n c h i l d h o o d and then a g a i n i n adult h o o d . Whether t h i s i s a re-emergence of the e a r l i e r f e a r , o r whether the two are d i s t i n c t i s u n c e r t a i n from these d a t a . C l a u s t r o p h o b i a a l s o seems a good way of st u d y i n g the du a l b e l i e f system (the f a c t t h a t b e l i e f s are so d i f f e r e n t when i n the s i t u a t i o n as opposed t o f a r removed from i t ) , slow and non-responders to treatment, and the p r e d i c t i o n of what groups of people w i l l respond to what s o r t s of treatment. There i s no reason why the c l a u s t r o p h o b i c model should be confined to the l a b o r a t o r y format used i n t h i s study. Medical techniques such as magnetic resonance imaging 153 (Quirk e t a l , 1989) a l l o w a broad scope f o r r e s e a r c h i n t o t h i s f e a r , and f o r use of the f e a r f o r f u r t h e r i n v e s t i g a t i o n . / 154 CONCLUSION One task of a c o n c l u s i o n i s to put p a t t e r n s and meaning on to a s e t of data. T h i s i s p r e c i s e l y what those with the f e a r t r y to do w i t h the i n f o r m a t i o n a t t h e i r d i s p o s a l . One must be on guard f o r there i s a r i s k f o r the r e s e a r c h e r , too, that a s i m i l a r path can be f o l l o w e d on which only c e r t a i n items of i n f o r m a t i o n are used, others are d i s c o u n t e d , a t the same time one i s unaware of yet other f a c t o r s . The f i r s t s t e p i s to c o n s i d e r the sample. A major important e x c l u s i o n a r y c r i t e r i o n i s t h a t t h i s i s a sample screened f o r i t s good h e a l t h . I t i s very p o s s i b l e t h a t t h e r e i s a whole subset of c l a u s t r o p h o b i c s who have been excluded, the f a t e f o r example of three with Meuniere's d i s e a s e who were not i n c l u d e d i n t h i s study. They are s u r e l y even more l i k e l y t o m i s i n t e r p r e t sensations and to be s e n s i t i v e to any changes i n t h e i r p h y s i c a l s e n s a t i o n s . They are a group that m e r i t study. Acknowledging t h a t t h i s i s a p r e - s e l e c t e d sample, and t h a t r e s e a r c h v o l u n t e e r s may have c e r t a i n d i s t i n g u i s h i n g f e a t u r e s from the wider c l a u s t r o p h o b i c p o p u l a t i o n , i t was yet p o s s i b l e to broaden and d e t a i l our u n d e r s t a n d i n g of the f e a r . F i r s t l y , t h e r e were the r e s u l t s of the phenomenological study. I t i s unusual to g i v e so much focus to d e s c r i p t i v e data, but t h i s seems an important s t e p i n l e a r n i n g more about t h i s f e a r . Though i t may sometimes have been seen as t r i v i a l from a c l i n i c a l p e r s p e c t i v e , t h i s i s a f e a r which can have profound s o c i a l , h e a l t h and even o c c u p a t i o n a l i m p l i c a t i o n s . I t i s not merely t h a t i t i s a nuisance to have to c o n t i n u a l l y monitor one's e x i t s and pl a n one's i t i n e r a r y , but, i n the more extreme cases, many t r a v e l and s o c i a l o p p o r t u n i t i e s , and i n some cases even jobs, are turned down because of the f e a r . Not only are many options r u l e d out, but many p a r t i c i p a n t s i n t h i s study p o i n t e d out the e f f e c t on mood and s e l f - e s t e e m when t h e i r f e a r s have been at t h e i r worst. C l a u s t r o p h o b i a i s not a simple f e a r to c a t e g o r i z e . There seems to be g r e a t v a r i a b i l i t y to the emotional experience of being t r a p p e d and i n some cases t o the accompanying s e n s a t i o n s . I t s nature i s not easy to p i n down. With a wide range of c o n d i t i o n i n g h i s t o r i e s and accompanying c o g n i t i o n s , there i s huge v a r i a b i l i t y i n the s i t u a t i o n s t h a t are avoided and i n outcomes that are f e a r e d . What i t does have i n common with o t h e r phobias i s that i t i s a t l e a s t p r e d i c t a b l e , u n l i k e p a n i c d i s o r d e r and to a l e s s e r extent agoraphobia. T h i s can be a t t r i b u t e d to the very much more powerful c o n d i t i o n e d f a c t o r s which are such a f e a t u r e of the phobia. 156 With regard to the experimental study, a major f i n d i n g was t h a t a p u r e l y c o g n i t i v e procedure d i d reduce both r e p o r t e d f e a r and panic, and l e d to more c o n f i d e n t p r e d i c t i o n s of a second e n c l o s e d space, i n r e l a t i o n to a c o n t r o l group. The i n t e r o c e p t i v e i n t e r v e n t i o n was not as s u c c e s s f u l i n t h a t i t e x e r t e d an e f f e c t on a s m a l l e r p r o p o r t i o n of p a r t i c i p a n t s i n t h a t group. N e v e r t h e l e s s , the t i m i n g of change was s i m i l a r i n both groups, the power of each i n t e r v e n t i o n being maximized by even the b r i e f e s t p e r i o d of exposure. I t i s i n t h i s combination of c o g n i t i v e and i n t e r o c e p t i v e techniques w i t h exposure that much i n t e r e s t w i l l l i e . There would seem much to be gained from broadening exposure techniques and making them both q u i c k e r and more e f f e c t i v e by such a d d i t i o n s . There i s ample evidence from the data of t h i s study that t h i s would be p r o f i t a b l e with c l a u s t r o p h o b i a ; f u r t h e r r e s e a r c h w i l l be n e cessary to see i f t h i s i s an avenue that would be u s e f u l w i t h other phobias. 157 REFERENCES Agras, W.S., S y l v e s t e r , D., & O l i v e a u , D. (1969). The epidemiology of common f e a r s and phobia. Comprehensive  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 . (1987). D i a g n o s t i c and s t a t i s t i c a l manual of mental d i s o r d e r s (3rd ed.. r e v ) . Washington. DC: Author. Bandura, A. (1977). 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New York and London: Plenum Press. van den Hout, M.A. (1989) C02. panic and treatment g e n e r a l i z a t i o n . Unpublished manuscript, U n i v e r s i t y of Ut r e c h t . van den Hout, M.A., van der Molen, G.M., G r i e z , E. , & Lousberg, H. (1987). S p e c i f i c i t y of i n t e r o c e p t i v e f e a r to p a n i c d i s o r d e r s . J o u r n a l of Psvchopathology and B e h a v i o r a l assessment. j), 99-106. Vermilyea, B.B., Barlow, D.H., & O'Brien, G.T. (1984). The importance of a s s e s s i n g treatment i n t e g r i t y : An example i n the a n x i e t y d i s o r d e r s . J o u r n a l of B e h a v i o r a l Assessment, £, l - l l . V e rmilyea, J.A., B o i c e , R., & Barlow, D.H. (1984). Rachman and Hodgson (1974) a decade l a t e r : How do desynchronous response systems r e l a t e to the treatment of agoraphobia? Behavior Research and Therapy. £1, 615-621. W i l l i a m s , S.L., & Rappoport, J.A. (1983). C o g n i t i v e treatment i n the n a t u r a l environment f o r agoraphobics. Behavior Therapy. 11, 299-313. Wilson, G.T. (1986). P s y c h o s o c i a l treatment of a n x i e t y d i s o r d e r s . In B.F. Shaw: Anxiety D i s o r d e r s . P s y c h o l o g i c a l and 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 . (1958). Psychotherapy bv r e c i p r o c a l i n h i b i t i o n . 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 . Wolpe, J . (1981). The dichotomy 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 Behavior Therapy and Experimental P s y c h i a t r y . 12, 35-42 . Zajonc, R.B. (1980). 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 no i n f e r e n c e s . American 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 experiences from your c h i l d h o o d ? Can you d e s c r i b e it/them i n as much d e t a i l as p o s s i b l e ? 2. Do you remember being f e a r f u l l y c l a u s t r o p h o b i c as an adolescent ? 3. What has been the course of t h i s f e a r : Has i t remained s t a b l e , spread, reduced e t c . ? 4. Do you f e e l t h a t there was a s i n g l e event i n your 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 experiences ? If yes, choose 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 through your mind at your most anxious, what was the worst you thought might happen 6. C u r r e n t l y what do you a v o i d doing/where do you a v o i d going ? ( S p e c i f i c a l l y ask about e l e v a t o r s , planes and under water) . 7. Do you have or have you had dreams/nightmares about c l a u s t r o p h o b i a ? 8. What i s the most f r i g h t e n i n g s i t u a t i o n t h a t you c o u l d r e a l i s t i c a l l y envisage ? 10. In g e n e r a l , what are the c o n d i t i o n s t h a t i n c r e a s e your f e a r s i n enclosed spaces (prompt: time, r e s t r i c t i o n of movement, others present, l i g h t / d a r k . . . . ) . 11. In the past have you found any coping s t r a t e g i e s h e l p f u l ? 12. Have you/do you use or 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 used a l c o h o l or 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 of coping w i t h your f e a r ? 13. When you are i n an e n c l o s e d space do you reach your peak l e v e l of f e a r immediately or does i t take some time ? ( I f not immediately) How long ? 14. Do y^ ou know anyone e l s e who has these f e a r s (prompt: f a m i l y members/friends) ? 15. Do you see a common theme ( f o r example, 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 term would you see as a c c u r a t e l y d e s c r i b i n g your f e a r , entrapment or s u f f o c a t i o n , or both ? Do you t h i n k that s u f f o c a t i o n / a c c e s s to 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 spaces ? I f yes, 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 whether l o o k i n g back you see the 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 being g e n u i n e l y dangerous or j u s t that they are very unpleasant ? 18. Do you have your own theory which e x p l a i n s your c l a u s t r o p h o b i c f e a r s ? 19. Is the f e a r g e t t i n g b e t t e r , worse or remaining about s t a b l e ? 20. Do you t h i n k t h a t t h i s i s a f e a r that c o u l d be changed, or i s i t with you f o r l i f e ? 21. Have you ever sought treatment f o r c l a u s t r o p h o b i a ? ( I f yes with what r e s u l t ; i f no, was i t ever c o n s i d e r e d ?; what sparked the c u r r e n t enquiry ?) 22. What are the s o r t of t h i n g s you would most l i k e to be a b l e to do i f t h i s f e a r was reduced ? 23. Panic: How f r e q u e n t l y have you experienced p a n i c i n a 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 you experienced p a n i c i n any o t h e r s i t u a t i o n ? How f r e q u e n t l y have you experienced panic out of the blue ? 24. Are there p o i n t s you would l i k e to make t h a t we have not y e t d i s c u s s e d ? 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 a little some much very 2. When I cannot keep my mind on a task, I worry that I might be going crazy. • 4. It scares me when I feel faint. little 0 I. It is important to me not to appear nervous. 0 - 0 — -3. It scares me when I feel "shaky" (trembling). — 0 0-5. It is important to me to stay in control of my emotions. 0 6. It scares me when my heart beats rapidly.—.-- 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 breath.— 0 11. When my stomach is upset, I worry that I might be seriously ill. 0 12. It scores me when I am unable to keep my 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. - - - 0 - - -16. It scares me when I am nervous. 0 - - -2 3 2-2-2-2-2-2 2 •2 •2 3 • 3-3-3 •3-•3-•3 •3 •3 much 4 ... 4 - -4 ... 4 ... 4 ... 4 ... 4 ... 4 ... 4 --- 4 --- 4 2 3 4 171 APPENDIX C: PREDICTION OF FEAR INITIALS TRIAL* DATE 1. At i t s peak, how f e a r f u l do you think you w i l l be i n the t e s t room? (place a mark on the l i n e below) Extremely f e a r f u l Not a t a l l f e a r f u l 172 APPENDIX D: REPORT OF FEAR/REPORT OF PANIC INITIALS TRIAL# POST-TRIAL ESTIMATES 1. At i t s peak, how f e a r f u l were you i n the t e s t room? (p l a c e a mark on the l i n e below) Extremely • Not at a l l f e a r f u l f e a r f u l 2. Did you panic? Yes No IF NO Did you come c l o s e to p a n i c k i n g ? Y e s _ No. 173 APPENDIX E: NEGATIVE COGNITIONS CHECKLIST INITIALS TRIAL* Please check o f f any of the f o l l o w i n g thoughts or ideas you experienced w h i l e i n the t e s t room. DID YOU THINK THAT % BELIEVED 1. ...you were going to pass out? 2. ...you were going to a c t f o o l i s h l y ? 3. ... you were going to have a h e a r t a t t a c k ? 4. ...you had been f o r g o t t e n i n the room? 5. ...the w a l l s were c l o s i n g in? 6. ...you might s u f f o c a t e ? 7. ...you were i n danger? 8. ...you were going to l o s e c o n t r o l ? 9. ...you were going to choke to death? 10. ...you were going to run out of a i r to breathe? 11. ...you were going to f a l l ? 12. ...you were trapped? 13. ...Did you think of u n r e l a t e d f r i g h t e n i n g events (such as h o r r o r s t o r i e s ) ? D e s cribe b r i e f l y . . . . 14. ...Other thoughts (please i n d i c a t e ) 174 APPENDIX F: PHYSICAL SENSATIONS CHECKLIST INITIALS TRIAL # Please check o f f any of the items that d e s c r i b e how you f e l t w hile you were i n the t e s t room. 1. Shortness of breath 2- Choking or smothering s e n s a t i o n s 3. Too warm 4. T i g h t e n i n g muscles 5. P a l p i t a t i o n s or a c c e l e r a t e d h e a r t r a t e 6. Dry mouth 7. Relaxed 8. T e a r f u l 9. Headache 10- Chest p a i n or di s c o m f o r t 11. Sweating 12. F a i n t n e s s 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 d i s t r e s s , or any form of nausea 15. D e p e r s o n a l i z a t i o n or d e r e a l i z a t i o n 16. Numbness or t i n g l i n g s e n s a t i o n s 17. _ F l u s h e s , hot f l a s h e s or c h i l l s 18. Trembling or shaking 19. Other ( p l e a s e i n d i c a t e ) % Unpleasant 175 APPENDIX G: GENERALIZATION TEST GENERALIZATION Instructions for this part of the assessment should be clearly presented in the following order: 1) The subject i s invited to make a set of predictions about how anxious they think they would feel i f they were to stay in the generalization closet. It is emphasized 2) that this closet is soundproof (in answer to any queries state only that there i s enough air for their needs, rather than getting drawn into discussion of whether i t is airtight or not); 3) that the time period i s no longer exactly two minutes but can now be between two and four minutes, this number being randomly drawn from a set of ten second intervals; 4) that there is 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 is presented, explain that the door w i l l not be locked in these practices since no difference will be fe l t or heard). The predictions should be made on a scale from 0 - 100 where 0 denotes no fear and 100 signifies terrifying fear. The situations are as follows: 1. Outer door open, inner door open , light in room on. 2. Outer door closed, inner door open, light in room on. 3. Outer door closed, inner door open, light off. 4 . Outer door closed, inner door closed, light in room on. 5. Outer door closed, inner door closed, light in room off. 6 . Outer door closed, inner door locked, light in room off. Fear predictions Willing to experience for two seconds (Y/N) 1. 2. 3. 4-. _/ 5. 6 . N / A No of situation chosen 1 7 9 APPENDIX K : TREATMENT INTEGRITY In any comparative treatment study, the q u e s t i o n of treatment 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 there has been a grave r i s k of c o n f u s i n g the d i f f e r e n t s t r a t e g i e s , and i t has been imperative to show that no such b l u r r i n g took p l a c e . In p r a c t i c e , i t d i d not t u r n out to be d i f f i c u l t to demonstrate i n t h i s study. The three 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 from l i s t e n i n g to the tapes. In only the exposure group were p a r t i c i p a n t s taken back to the assessment c l o s e t to work though a h i e r a r c h y of elements they f e a r e d . In only the i n t e r o c e p t i v e group were p a r t i c i p a n t s taken through a range of e x e r c i s e s to b r i n g on s e n s a t i o n s s i m i l a r to those they experienced while anxious. In only the c o g n i t i v e group d i d they examine f e a r f u l thoughts and l e a r n how these c o u l d be d i s p u t e d . The only ambiguity t h a t arose was when those not i n the c o g n i t i v e group expressed c o g n i t i v e change and sought 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 not i g n o r e d or d i s m i s s e d , but n e i t h e r were they encouraged or taken f u r t h e r . What seems to have been a more important i s s u e i s one t h a t cannot yet be answered: treatment e f f i c a c y . At t h i s p o i n t i t i s not known whether 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 should 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 important i t i s that they examine t h e i r own experiences which may have c o n t r i b u t e d to some of t h e i r common c o g n i t i o n s , and how important a f f e c t may be i n c o g n i t i v e change. There are s i m i l a r grey areas i n r e l a t i o n to the i n t e r o c e p t i v e techniques. I t i s simply not yet known whether the e x e r c i s e s should be p r a c t i c e d i n s h o r t or long 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 m o d e l l i n g . Much i s l i k e l y to emerge over the next years t h a t w i l l h e l p to e v a l u a t e the extent to which these i n t e r v e n t i o n s were o p t i m a l l y a d m i n i s t e r e d . / 180 APPENDIX L : ADJUSTED MEANS AT POST-TEST (PRE-TEST COVARIED OUT) FOR QUESTION 1 Observed mean Adj u s t e d PREDICT FEAR C o g n i t i v e 49.83 50 . 18 Exposure 2 5.00 24 . 91 I n t e r o c e p t i v e 51.33 51.83 C o n t r o l 67 .33 66 . 58 REPORTED FEAR C o g n i t i v e 21.00 21.52 Exposure 15 . 92 15 . 48 I n t e r o c e p t i v e 34.42 34 . 14 C o n t r o l 52.58 52 . 78 REPORTED PANIC C o g n i t i v e 2 .75 2 .85 Exposure 2.92 2 . 94 I n t e r o c e p t i v e 2.50 2.39 C o n t r o l 2.25 2 . 24 NEGATIVE COGNITIONS C o g n i t i v e 29 . 50 31.79 Exposure 18 .83 3 .29 I n t e r o c e p t i v e 81.33 101.51 C o n t r o l 251.00 244.08 UNPLEASANT SENSATIONS C o g n i t i v e 58.33 54 . 37 Exposure 34 . 67 46 . 37 I n t e r o c e p t i v e 106.17 107.44 C o n t r o l 284.92 275.91 HEART RATE C o g n i t i v e 90.83 89 . 56 Exposure 79 . 50 81 . 16 I n t e r o c e p t i v e 87.75 89.23 C o n t r o l 97 . 08 95.21 PREDICT FEAR C o g n i t i v e 23.92 23 . 04 Exposure 18 . 67 20 . 86 I n t e r o c e p t i v e 20.42 21.80 C o n t r o l 25.33 22 . 64 

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