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.The review of psychosocial treatments presented here willfollow this tradition, beginning with treatments for agoraphobia.AgoraphobiaInitial treatments for agoraphobia were developed in the 1960s and 1970s.These mainly consisted of systematic desensitization, with little attentiongiven to panic attacks [6].Systematic desensitization involves imaginalexposure to the feared situation, simultaneously accompanied by musclerelaxation.This technique was used primarily because it was thought thatactual exposure to feared situations would be too overwhelming foragoraphobic patients.However, studies evaluating the use of systematicdesensitization for treatment of agoraphobia have found the technique to beineffective [7,8].Around the same time, some researchers began success-fully treating people with agoraphobia using in vivo exposure [9], wherebypatients were encouraged to venture away from safe places and entertheir feared situations.Since then, in vivo exposure has become the mostwidely studied psychotherapy for agoraphobia.Basic Components of In Vivo ExposureIn vivo exposure begins with the construction of a hierarchy of situationsthat the agoraphobic individual fears and avoids, arranged from least tomost frightening.Common items on a fear and avoidance hierarchy include driving alone on the highway , eating at a crowded restaurant , shopping at the mall and riding on the subway .Patients are thenencouraged to repeatedly and systematically enter the situations on theirhierarchy and remain in the situations for as long as possible, often with theuse of coping strategies learned in session.Although the presence of thetherapist during in vivo exposure may be necessary for it to be effective withseverely agoraphobic individuals [10], those with mild to moderate levels ofagoraphobia are usually able to engage in exposures on their own or with afriend or family member serving as a supportive coach [5]. PSYCHOTHERAPEUTIC INTERVENTIONS FOR PHOBIAS: A REVIEW ___________ 181Efficacy of In Vivo ExposureResearch has consistently supported the efficacy of in vivo exposure fortreating agoraphobia.By the mid-1980s, studies revealed that 60 70% ofagoraphobic patients who completed in vivo exposure treatment showedsignificant clinical improvement, with follow-up assessments indicatingthat treatment gains were maintained for four or more years [11 17].Theseresults were replicated in several controlled studies, which used no-treatment or placebo control groups [18 20].In vivo exposure for agoraphobia has been the subject of more recentresearch as well.Fava et al.[21] completed a long-term follow-up study of 90patients who received 12 sessions of graduated, self-paced exposuretreatment, conducted biweekly over a 6-month period.At post-treatmentassessment, 87% were panic-free and much improved on global clinicalmeasures.The authors used survival analysis to predict the probability thattreatment responders would remain in remission, and they determined that96% of treatment responders remained panic-free through the first two years,77% through five years, and 67% through seven years.Predictors of relapse inthis study included the presence of residual agoraphobia and comorbidpersonality disorders; this finding emphasizes the importance of thoroughlytreating all vestiges of avoidance before termination.A number of studies have shown that other cognitive-behaviouraltechniques combined with in vivo exposure are no more effective for thetreatment of agoraphobia than in vivo exposure alone [22 24].On the otherhand, one study by Michelson et al.[25] showed that the addition ofcognitive therapy to situational exposure can be significantly beneficial topeople with agoraphobia and panic, especially when compared to exposuretreatment plus relaxation training.Other controlled studies have shownthat relaxation or breathing exercises confer no treatment advantage over invivo exposure [26 28].A study by Schmidt et al.[28] suggested that patientswith panic disorder and agoraphobia receiving breathing retraining tendedto have lower end-state functioning at follow-up when compared to patientsnot receiving breathing retraining.These findings suggest that breathingretraining and relaxation training may put patients with panic andagoraphobia at risk for relapse, perhaps because the exercises teach patientsto minimize and distract from physical sensations during situationalexposure, with breathing and relaxation becoming safety behaviours [5].Combined In Vivo Exposure and PharmacotherapyA number of studies have studied the efficacy of in vivo exposure combinedwith tricyclic antidepressants, with most studies showing that the combined 182 __________________________________________________________________________________________ PHOBIAStreatment is superior at the post-treatment assessment [29 31].However, atthe follow-up assessments, after the tricyclic antidepressant is discontinued,the benefits of the combined treatment tend to disappear [32 34].Similarly,Marks et al.[35] found that alprazolam plus in vivo exposure was equallyeffective as either treatment alone at post-treatment, but those who hadreceived the combined treatment showed significantly higher rates ofrelapse at six-month follow-up, after the alprazolam had been discontinued.More recent studies have examined the addition of selective serotoninreuptake inhibitors (SSRIs) to in vivo exposure for agoraphobia.De Beurs etal.[36] found that the addition of fluvoxamine to situational exposurereduced avoidance significantly more than exposure alone at post-treatment.However, at two-year follow-up, the treatment gains wereequivalent for both groups [37].These studies indicate that although theaddition of pharmacotherapy confers a short-term treatment advantageover situational exposure alone, this advantage disappears in the long term,after the medication has been discontinued.Methods of In Vivo Exposure DeliveryAfter the efficacy of in vivo exposure for agoraphobia and panic wasestablished, researchers turned their attention to discovering the mosteffective methods of delivering in vivo exposure to patients.First, massedexposures, or exposures conducted during long, frequent sessions, havebeen compared to spaced exposures, or shorter exposure sessionsconducted weekly or biweekly.While earlier studies found that massedexposures lead to greater attrition [38,39] and relapse rates [15,40],Chambless [41] found no detrimental outcomes associated with massedexposure in a study comparing massed to spaced exposures [ Pobierz całość w formacie PDF ] |
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