PREDICTORSOF TREATMENTOUTCOME:A LONG-TE RMFOLLOW- UP STUDt OF BEHAVIOU RALTREATMENT FOR AGORAPHOB IA
BY
C JOHNDONOHUE
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ABSTRACT
Out c ome and predict ors of long -te rm prognClsi swe re invest i g ated in27agoraphobi c patient s whowere reasse sse d 1 to5 years fo llowing espc eure- bee e d trea t men t. The outc ome mea s ur es us e dinthe origina l tri a l swere repeated by enass es s o r whoalsointe rv iewed the pl!lt i en t s. Ove r all, impr ove ment sattained duri ng tr ee.tme nt we r e maintaine d at follow-up. Highly sign if icant (p<.00 0 1 )improveme nt swere observedon all cli nical mea s ur e s betweenpretreatmentand long-termfollow-up. The patternof improvementwas similar to that observedin previou sstudies: treatmen t gainswer e maintained, but pa tientsgenerallydid notdisplay significant co nt i nued imp r ov emen t during the fo llow- up per iod.
f'orty-tdqht perc e nt of follow-up clients achi e ve dthe a prio ricriteriafo r high endstatefun ct ioning. The var lsbles which gave the greate s t co ntributionto the varia nce in outcom ewere social phcb te , Belf- eff icacy , behavi o ura l avoidan c e , and lat erin treatment , agora phObi c sev erl t yand cognit i v ereacti vity . Di s cri minan t funct i o n an a l ysesof thesevari a bl e sres ul tedinove r eO\ co r re ct;
predi ct i o nsof outcome groupat long-termfo llow-u p. Onthe otherhan d, themod e of phobia onset, levelof depress ion, attitudetowardtr e a t men t, and social suppo rt were poor pre dict or s of tonq-e ernoutcome. possible reasonsfor and implication s of these findings are discus sed.
i i
ABSTRACT . . . List of Tables
Table of Contents
ii vi
xiv xii List of Figures
List ofAppe nd i c e s
INTRODUCTION. . . . Long-termOutcome ofaenevtcurerTreatment for
Agoraphob ia . . . . . . Statis t icallysignificant Outcomefo r
Agoraphobia . . . . Cl inic a ll y signifi can t Improvement in
Ago r aphob i a • . . . . The Inc idenceof Relapseand/orFresh Symptom
Emergence During Long-term Follow-up 15 Summary of Long-termEffective ne ssof
Behavi ouralTreatmentof Agoraphobia PrognosticIndicatorsof TreatmentOu t c ome
Demographicand His toricalvariables Pretreatment ClinicalMeasures Attitude toward Treatment . . . . . ResponseProfile . . . . . Familial and Interpersonal Variables Conclus ion . . . . .
The Current Study
METHOD . . . . Treatment programme
iii
;:!o 21 22
2.
30 32 37
,.
45 505.
ClinicalAs s e s s ment Mea s ur e s •. . . • . . ~1 Subjects . . . • .. . •• . .. • • . S8 Measures cc e c ernedwithPredict i onofOUt c o me s 58 Modeof PhobiaOnset • . • . . . 58 Measure s of At tit udesTf'lward Tr eatment 61
Measuresof aeepcnecProfile 64
Heasuresof SocialSupport 67
RESUL'I'S . •. . . 73
Treatment MCo mp l e t e r s"ve r s us MNo n- Co mplete r s· 73 Long- termOutcome •. . . •. • . ••. 74 Predict i o n of "End s t a t e Functioning- . . • . . 65
Demographic I His tor i c a l variables, Mod e of
Onset . • . . •. . . 65
Clinical AssessmentMeasures 65
Attit ude towa r d Treatment 94
Response Profile • • • • . • 97
SocialSuppor t • . •. . . . 98
Exploratory and Post-hocAnaly se s 99
Predict i ng TreatmentPreference 99
Relat ions hipeeevee nMode of Phobia Onsetand Response Profile . . . • . . . 100 Interrelationshipsbetween Outco mePredict ors 101
DISCUSSION •. • . . . . • . •• • • •• . •• 10 2 Lo ng - t e r m Outcomeof Be ha vi o ura l Treatment for
Agor a pho bi a . • . . . •• • • •• . Va riab lespred ic t i ng Tr e atment Outcome
iv
102 103
Modeof Phobia Onset • • • 104
Clini cal Measures • • • • 105
Att i t ude Toward Tr eatment 108
Re s p on s e Profile. • • • • 110
Social Supp ort • • • • • • 112
Strengthsand Weak nesses of theCurrentSt udy 115 SUb je c t Se lecti on and TheFollow-upSample. \16 Desi gnof the St udy andSelecti o nof Measures 116
Summar y andFutu reDi re ctio ns 118
FutureDirections 120
Refe rences • • • • • • • 234
140 Listof Tabl es
Tabl e 1: Summar y of prog no s ticBeha vio ural Tr ea tmen t Studi es for Ago r a phob ia • • . • . . . 124 Table 2:Descripti ve Summa ryof Subjects Who Compl e ted
Tre a t me nt . . . •. . . •• 139 Table 3:Pretreatment ClinicalScores of Treatment
Completers (n• 35) . . . •. •. . Tab l e4: Chi -square Co mpa r is onofTreatms nt
"Complete rs"versus "Non-c omple t ers" on
De mog rap hicvcrre b t es . • . . . 141 Ta bl e 5:Chi- s qua r e Comparisonof Treatment
"Co mpleter s· versus "No n- c o mp l e ter s" onHis tor ic al vari abl e s . . . • . . . •. . . . 142 Ta b le 6: T'-t e st Compa r isonof Tr e atment "Co mplet ers·
vers us "Non- comp leter s"on Pr e t re a tmen t Me a s ures 143 Table 7: T'-testcompari sonof 'rce e emeneCompleter s
versus"Non- compl ete rs"onRe sp o nse Profile Me a s ures . •• ••. . . • . . . 144 Ta t::' e 8:Chi-squareCo mpa r i s o n of TreatmentCo mpleters
versus "Non-completers"on Pre -t reatment Soc ia l supportVariables . • . . . 14S Table9: Dir ect Discr i mina nt FunctionAnal ys e s
predicting Tr e a tme nt Dr op- o ut Using' Me as uresof Phob iaSever i ty as Pr e dic tors . . . 147 Table10 : DirectDiscri mina nt Fun ction Analyses
Predi ctingTreatmentDrop-ou t us ingHellosures of Mood/Depres s ionll.S Predictors . •. . . . .. . 148
vi
Tl!ible 11:Chi-square Comp a r 1s01l of CHentsFollowed-up versusNot Followed -upon Demographic and
Histori calVariable s . . . •. . . 149 Table12:T-testCo mpa r i s o n of Clients Followed-u p
versus Not Followed -upon Demographic and
Pretreatment ClinicalVariables . . . • 15 0 Ta b l e 13: T-test Comparisonof ClientsFollowed -u p
varsua Not Followed-upon Mid-treatmentClinical Measures . . . . • • . . . • . •. . 151 Table 14: T-test Comparisonof Clients Followed-up
versus Not Fo ll owe d - upon scsu-ureaemen c Cli n i c a l Measures . . . • . . . 152 Table15:T-testComparisonof Cl ie nt s Followed- up
versus NutFo ll owe d- up on Clini calMeasures at 6- monthFo llow- up • . •. . . • 153 Table 16: Summaryof Follow-up Int e r v i ew Data . . 154 Tab le17: Repeated-Meas uresANOVA's of Clinical
Me a s ur e s for AllFollow-upSubjects (n• 27) 155 Ta b l e 18: Chi-squareCompar isonof HEFvers us LEF
clientson Demographic Variab les • . •• • • 156 Table 19: Chi-squareComparison of HEF versus LEF
Clie ntson Historica l Variables . . • • •• 15 7 Tab l e 20: T-test Comparis on of HEF versusLEFClients
on pc e t.reatment. ClinicalVariables . •• . . . . 158 Table21: T- t e s t Comparisonof HEFve r s us LEFClients
onMid- t r e atme nt Clinica lVariables •• • . . . 159 Table 22: T-t e s t Comparisonof HEF versu s LEYClients
onPo st - t r eat me nt Clini c al Variables •• •. • • 160
vii
Table 23:T-test ComparisonofHEFver s us LEF Clients on Clinicalvariables at 6-monthFollow-up. . . 161 Table24:DirectDi s c ri mi n a nt Func tionAnalysis us i ng
Pr\!treatmentMeasures of Phobia Severit y to Predict End stateFunctioning . . . • . • . . . 162 Table 25:DirectDiscriminantFunctionAnalysisusing
Mid-t reatment Me a s u r e s of Phobia Severity to Predictzndst et;e Function ing . . . 163 Table 26: Direc t Discrimi nantFunctio nAnalysisusing
Post-treatmentMeasures of Phobia Severityto Predict EndstateFunc t i o n i ng . . •. • • . . . . 164 Table 27: Direct DiscriminantFunctionAnalysis using
Measures of Phobia severity at 6-monthFollow-up toPre d i c t EndstateFunctioning . . . 165 Table 28: Comparison ofLEY and HEFGr o u ps on Phobia
severity: 2(groups) X 3 (assessment phases) Repeated-MeasuresANOVA . . . •. . . 166 Table29: Di rectDiscriminantFunctionAnalysisusing
Pretreatmen t MoodMeasures to PredictEndstate Functioning . . . •. . . 168 Table30: Di r e c t Discr imin ant Functio nAnalysisusing
Mid-treatmentMood Measures to Predict Endstate Functioning . . . • . : . . . • 169 Table31: Direct Discrimina ntFunction Analysis us i ng
Post-treatmentMood Measures toPredict Endstate Functioning . . . • •. . •. . . 170
viii
Table32: Direct Discri mina ntFun c tionAnalys is using HoodMeasures at 6- monttoFollow- up to Predi c t Endstate Func tioni ng •• • . .• • • . • • • • 171 Tab le33: COlll pariso nof LEE'end HEFt;r/)u p s onHood
Measu res: 2 (g r o ups )"13(a ssess mentphases ) Repeated-Mea s ure sANOVA • • •• • • . • •• • 172 Tabl e 34:DirectDi s cri mi nantFunct i onAn41 YGls using
theAttitude sQues t ionnaireSub-scal es toPr ed i c t Endsta teFunctioning. • • • •• • • • • • • • • 173 Table 35: T-testComparison of HEF versus LEYClients
on Treatment Attitude variables • . • • • •• • 174 Table 36 : T-teat comparison of HEF versus LEF Clients
onSymptom Que s t i onna ire Sub- sca l es • • • •• •• 175 Table37: DirectDiscriminan t Function Analysis using
PretreatmentSQSub- s c a l e s to PredictEndetate Funct ioni ng • • •• • • • • • • • • • • . • • • • 176 Ta bl e38 : Direct Diecri mina nt Fu nctio n Analysis using
Hid-trea t ment SO sc b- ece tee toPredi ctEndstate Funct i on ing • •• • . • . . •• • • • • • • • • • 177 Tab l e39 : DirectDi s crimina ntFunctionAnalys isusing
Post -treatl1lentSQ Sub - s c al e s to PredictEndstate Functioning • • • • • • • • • • • • • • •• • •• 178 Tab l e40:Direct Discri minant FunctionAnaly s i s using
sQ Sub-scales at 6.monthFollow-upto Pred i ct Endstate Functio ning. . • •• • • •• • • • •• 179 Tab le41: T-test Comparisonof HEF versusLEF onBDI
Sub- s c al e s • • •• • • • . • • • • •• • • • • . 180
lx
• •. ISS Table42:Direct O:acriminantFunction Analysisusing
1SSB Sub-scalestoPred i c t EndstateFunctioning 181 Table 43:T-test Comparison of HEF versusLEF Clients
on SocialSupport Measures . . . 182 Table 44: Ch i -squa r e Comparison of HEF versus LEF
Clients on Pretreatment Social Support Variables 183 Table 45:Standard MultipleRegress io nsof Pretreatmen t
Clinical variables onClients' Preference for Psychologicalversus DrugTreatments. . . lS4 Table 46:Standard Multip leaegressions of Mid-
treatmentClinical VariablesoncjIenee ' Preference forPsychological versus Drug Trea tments. . . .. . . . Table 47:Stendard Mult ipleRegressions of Post-
treatmentClinicalVariables onClie nt s ' Prefer ence fo i.' Psychologica lversusDrug
Treatments• . . . .. . •• . lS6 Ta ble 48:StandardMultipleRegressionsof Clinical
Variablestakenat6-mo nt hFoll ow-ll P on Clients' Preference forPsycho logicalve rs us Drug
Treatments •• . • . •• • . . • . . . • . 187 Table 49:St a ndardMul t i p l eRe g r e s s i ons of Current
Clinic a l Varia bles onClients' Prefer e nce for Psy ch ological versus DrugTrea tments . , . , . , 188 Table so:Ch i-squ are Compa risonof Cla s s i c a ll y-
ConditionedversusCognitive Learning Clientson Histori calVariables . . . • . . •. . 189
Table 51: r-ee eecomparison of Classically-Conditioned versusCog n itive Lea r n i ng Clients onSQ Sub - sca l es. • . . . . .. . . • . . 190 Ta b l e52: T-t e s t Compa ris on of Classically-Con di t ioned
...erGUS Cognit i v e Learningclients onBO! sub- scales. . . .. . . •. . . 19 2 Table53: Direct Discri minant Function Post- ho c
Analys is us ing Pretreatment Measur esto Predict EndstateFunctioning. . . . •. . •. . . • 194 Table 54: DirectDiscriminantFunctionPos t- ho c
Analysi s usingMid-treatmentMeasures to Predict End s ta t e Funct ioning . . •. . . . .. . . .. . 195 Table55 : Di r e c t DiscriminantFunctionPost-hoc
Analys is using Post-trea t mentMeasuresto Predict EndstateFunctioning . . . . •. • . •• • • 196 Ta b l e S6: Dire c t DiscriminantFunction Post-hoc
Analys i aua i ng 6-monthFollow-up Measures to Predi c tEndstate Functioning . . • .. • . . . 19 7
xi
Lis t of Figures
Figure1Follow-up subjects' scores on FQ-AGOR 77 Figure2Follow-up subjects' scores onFO-TOTAL . 78 Figure3Follow-up subjects' scores on FO-SOCIAL 79 Figure4Follow-up subjects'scores on FO-INJURY 80 Figure 5Follow-up subjects' scores on FO-INCAPACITY 81 Figure 6Follow-up subjects' scores on Self-efficacy
82 Figure7Follow-up subjects' scores on FO-FEEL . . . 83 Figure 8Follow-up subjects' scores on BDI . . . 84 Figure9HEF versus LEF clients' performance on FO-AGOR from pretreatment to current follow-up. . •• • . . . . 87 Figure10 HEF versus LEY clients' performance on FO-TOTAL
from pretreatment to currentfol l ow- up. 88 Figure 11HEF versus LEF clients' performance on FO-SOCIAL
from pretreatment to current follow-up. 89 Figure 12HEF versus LEF clients' performance on FO-INJ URY
from pretreatment to currentfollow-up. 90 Figure13HEF versus LEF clients' performance on
FO-INCAPACITYfrom pretreatment to current fo!low-up.91 Figure14 HEF versus LEf clients' performance on CAN_DOfrom pretreatment to current follow-up. •. . . . •. . 92 Figure15 HEF versus LEF clients' performance on CONFIDENCE
from pretreatment to current follow-up. 93 Figure 16HEF versus LEF clients' performanceon lo'O-FEEL
from pretreatment to current follo....-up. 95
xii
Figure17 HEFversu sLEY cl i ents' pe r f o r man c eon 80 1from pretrea t ment to curre ntfollow+up . • •• • • • • • 96
xiii
AppendixA:Tables
List of Appendicefi
123 AppendixB: Letter to Prospective Follow-up Clients 198
AppendixC: Fear Questionnaire . . . 199
Appendix0:Ratings of Self-efficacy •• . •. . 201 AppendixE: Beck Depression Inventory . . . . •. 202 AppendixF: Out line of Semi-structuredFollow-up
Interview . . . •. • • • 206
AppendixG:Test of Model •• • •. • . . . . 210 AppendixH:Atti tudesQuestionnaire . . . • • 215 Appendix I:Inventoryof Socially Supportive
Behaviours. . . • . . . . 227
xiv
Agora phobiarepresentsthe 1Il0stfreque nt ly tre ate d o!
phobicdisorders , and isgenerallyconside re d to bethemost dif ficu lttotreat. Agor a phob i abee beentreatedfor ov er thirtyyearsut U izing expo s ure-ba s e d treatments alone , as we ll as incombina~ionwith other tr eatmentappro a che s , includingfamily the r a py (e,g.,Ar no w, Ba r r -Tay l o r, Ag r as , , 'ret c h, 1985; Ba r l ow , O'Bri en, &Last, 1984; Ce rny, Ba rl o w, Craske, , Himadi, 1987 ; Mathews, Te a s da le , Hunby, Johnston, , Shaw, 1977;Hunby , Jo hnst on, 1980) ,psycho thera p eutic suppo rt (e.g.,Roberts, 1964 ), psyc hotrop i c medication s (e.g., Hafne r &Ma r ks, 19 7 6;Mavi s sakalian sMi ch elson , 19 8 3 ; Mi c he l s on , Mavis sak a li an, &Hemi nger, 1983;Milton&
Hafner , 19 7 9 ),relax ationthe ra py (e. g. , Perse on, Nord l und, 1983; Mark s,Gray , Co hen , Hill, Mawson, Ramm, &Stern, 1983), and cogniti ve rest ru ct uring(e .g., Barlowet al., 1984;vermil yea , Boice, &Barlow , 1984) , among others. It ha s genera ll ybee nfound thatin vi voexposur e te chnique s areth etre a t ment ofchoicefor phobic disorde rs , res ulting inred uct ions in agorapho bic sympt omsuptosix mont hs fo llowi ngtre a t me nt (e.g ., Bar low ' wo lfs , 1981; Emme1 k amp, 198 2; Hand, Lamontag ne, , Marks, 1974; Marks , 197 9;Mathews et aI., 1977;Jan s s on' Ost,19 82 1Si nnot t, Jone s, Sco t t - Ford ham,, Woodwa rd,198 1). Ne vert he l es s, the re isalsoa great deal ofva ri abi lityinout come of behaviour a l treat mentfor ago ra phobia (Gra y&McP he rson,198 2 ; Jan sson&
t)st , 19 8 2 ).
There hasbeensome disagreement among res e a rche r s rega r d ing theimpor t a nc e of spo ntan e o uspan i c att a ckswit hin theag orapho bicsyndrome. Themos t recent editionof the Oil/gnosticand Statisti cal Manu al fo r MentalDiso r d er s COSH
III-R; APA, 198 7 )of f e r s three possiblesubtypes of agoraphobiaand punlc disorder: (a) panic disorder with agoraphobia,(b) panicdis o r d erwit hout agoraphobia, or (c) agorap hobiawi thouthistory ofpanLc di s order.
Unfortunately,mos ttreatmentoutcomestud ie s ha venot differentiatedbetween these subtype s. Thus, for the purposesofthe pre sent rev i e w,~a gorll. p h o bia~ wi ll refe r to a pattern ofagoraphobicavoidance,regardlessof the presenceorabs e n c eof spontaneous pan ic atta c ks. Barl ow (198 8) has reported th a tthe vast ma jor ity of agor a p h obics whopresentthemsel vesfortrea tmen t ,experiencesymptoms which meet the criteriafor panicdi sorder . Thus , i tis likely that the majority of these clientswouldhave been more accurately clas sif iedas exhibi t ingpanic diso r d e r with agoraphobia.
Thisreview addres sestwoissuesrelated to outcome of behaviouraltr e a tm en t for ag o r apho b i a . First, thelong-term effectiveness of exposu re-basedtreatmentsforagor a p hobi a isevaluated for statistical andcli nicalsignificance ,as well asthe inc i d enc e ofre l a ps e and/ or fresh symptom emergence followingtreatment. Sec ond , a revi e w of the lit e r a t ur e predicti ng lo ng- t e rm(i. e., ~ 1 year)outcome of behavioural tr e a t ment s for agoraphobia is presented . Fi ve broad categories of predictorsare di scussed : (1) demographicandhistoricalva riab l e s, (2 ) pretreatment clinical measures, (3) client atti tudes toward treatment , (4)re spon s epro fi l e measures,and, (!'I Ifa mil i aland interpersonalver Iebree .
Long-term Outco meof Behavioural Treatlllent for Agoraphobia
In discussing the long-termvalue of exposure-based treatments for agoraphobia, two general questions shouldbe addressed. First, does treatment actually result in empirically verifiable improvementsover the long-term;>
Second, if so, are these improvements personally meaningful for the client;>
Statis ticallySignificant Outcome for Agoraphobia
Nume r o us studies have demonst ratedthat systematic pro grammesof expo s ur e resultin reductionsin agoraphobic symptomsup to sixmonthsfo llowi ngtr e a t ment (e.g. , Ha nd et al., 1974 ; Mathewset al., 1977; Jansson& ljst, 1982 ; Sinnottet al., 1981). There are fe werstudieswhichverify the long-termefficacy of these treatments, but the avail able evi d en c e shows that statistically significant treatment gains are maintained for periods of up toni ne years (Burns,Thorpe, &Cavallaro, 1986). On the whoJe, pa ti e nt s cont inue to functionat approximatelypost- treatmen t leve l s throughout the follow-upperiod, but do not demonstrateany further improvement.
Forexampl e , Marks (1971) conducteda fo ur year fo l Iow- up of 65 phobicpatients,approximately half ofwhomwe r e agorap hobic. On measures of the main phobia,other phobi a s , dep r e s s i o n , andsocial adjustment, there was substantial impr o ve me nt from pre- to post-treatment. Thesebenefits
we r e maintainedat fol low-up,but littlefur t h erpro gress tookpla ce during thefo llow- up period.
Similarl y , Emmc lka mpand Kuipers (1 979) reported that 75\ of the i r agoraphobicpa tients had maint ai n ed their tre atmen t gains over a 3- to 5-year follow- up per i o d.
Seventy of the original81 pa t i e n t swere locat edan dtes t e d.
r-e eeee compar ing post-t re a tment andfol l ow-up scor es rev eal ed tha t improvement sweremai nt ain edon allmea s ure s, with slight imp r ov eme ntson depr e s s i on andgl o ba l phob ia . Unfo r tunately , th eas se s smen t s consist edon ly of si mpl e, mail-inself- r a t i ng s.
McPh e r s on , Brougha m and act.eren (1980) report edtha t treatmentga i ns were maintained , altho ug hno fur t hor imp r o veme nt s occur red In56 agor ap hobic s between post- tre a tme nt anda 3- to6-year follow-up. Meas ure son ceagain inc ludedonly sel f -ra t edsca l es. It isalso unfort u nat e that onl ytreatme nt su c ce ss es wer eincl ud ed inthe follow-u p sample.
Hunb y and Johns t o n(19 8 0) ret e s ted 63of 66ag o r ap ho bi c patie nt sat fou r to nineyears followi ng tr eatmen t. T-te s ts rev ealed significan t diffe r e n ce s betwee n pr et re a t me n tand fo l l o w-up accrea on near ly allse l f - and clini cian-rated me a s uresof anx ietyandde p r ess i o n. Li k epr evious st udies , few furtherimpr o ve mentswereobservedbe twee npost- treatmentand follow-up.
Inanot h e r series ofstudie s , a grou p of 40agoraphob ic clientswer-erea s sessed at two- (Cohen, Monte i,r os xarx e, 1984) and fiveyear s (Le ll iott, Marks , Mont e i r o!Tsak.i r i o, &
Nos hirvan i, 1987 ) followingtreatment. High ly signifLce nt;
(p( .001 ) Lmpr-ov e mentawereobs e r vedbetweenpretreatment andeac h fol low- up on all meas u res (HarksandK':I.thew's [1979] Fea r Questio nnaire (FQ] , clinician-rat ed &everityof phoblot, WakefieldOepre s sionInVe ntory ,HamiltonDepression sc a l es, self- ra tednon- p h obi c anxi e t y,frequency of spo nt aneo uspani cat tacks). As inprevious stud i es, £ollow- up score sdid not differ si gnific a nt l yfrom those obtained immediat e ly fo ll owingtr e a t me n t , with theexceptionof a slight, but statistical l ysig nificantrel a ps eat s-yeaceon clinic ian-andsel f- r ate d fear hier a rchi es.
xevreseke f re n and Michelson(1986B), usinga mo r e thor o ughassessme nt batte ry,also de mons t r a t ed that impr ovements were maintainedupo n a- y ear follow-up.
Mea sures inc l uded clinica l ra t i ngs of globa l phobiaand phobiaseverity , se lf - r a t i ngs of phobia, depressionand anxiety,and perf ormanc e on a behavioura l avoidancetest (BAT). The 25 patients....eretr e a t e d wi thexposure ,plu s eitber imipra mineor pla c e bo. Aga i n , the va s tmajority of improveme nt s were realized be t ....eenpre- andpost-treatment, whi chwere mainta i ne d at 6-month, 1- , and 2- yea r foILow-up s,
Burns eta1. (1986) als oused a variety of outcome measuren in ana-yeer follow-upstUdy of 20ago r a phob i c clients. Statisticallysignificant improvell'en tswere observed between pretreat mentand follow-up on all cu eccme measures (BAT , Agorap hob iaQuestionnaire, SocialAvo ida nce and Distress, Fe a r of Negati ve Evaluationscales). No further improvementa too k placebetwee n1- and a-year
follow-ups . Theseres ult s must be read with some caution, sinceonly half ofthe originaltre a tme nt samplewas reassessed, ana there were biases infavour of th e fol low-u p sampleonsome measures at post-t reatment. Sti l l , this study providesevidence that patientsmaintain their treatment gains upto 8 years after treatment on a variety of outcome measures, includinga direct behavioural assessment of agoraphobic avoidance, althoughno further impr o v eme nts occurredduring thefollow-upphase.
Finally, Franklin (1989) conducteda 6-year follow-up of eight agor aph obi cs . Treatmentconsistedof respiratory retraining , relaxation, cognitivetherapy,and imaginal exposurein a mul tiple-baselineformat. At post-treatment, treatmentresultedin improvementsona BAT, sel f- and clinic i an- r a ti ngs of avoidance, anxiety, work, marital , and sexual adjustment, and , SymptomChecklist-90 (SCL-90R ) scores. All of these gains were maintained over the 6-yea r follo....-up, and afe w individualclients experienced continuedimpr ove mentdu r i ng thefo llow- up period .
For c}"'vious ethical reasons,none of the above studies inc l ud e d"no treatment" or pl acebocontrol groups with which to compare treatment outcomes. There is a paucity of data on the outcome of agorap hobiawhenle f t untreated,but the ava ilab l e evidence sugges tsthat the rate of spontaneo us recov ery is quitelow. For example, in arevi ew of beha v i o ur al treatment studies of agoraphobia, .r.aneecn and
~st(1982) reviewe dseven studieswhichusedeither wait- lis t or attention-placebocontrolgr oups . In none of the s e
groups did significant improvementsemerge between pr e- and post-treatment. Furthermo re, Marks (1985) showed tha t a mixed groupof chronic phobicsdidnot improvewhen left on a wa i ti n g list for pe riod s of upto one year. Finally, the av a il a b l e data on the natural historyofagoraphobiaalso showsthatthe rate ofspontaneous recoveryis very low (Agras, Chapin&Oliveau, 1912; Ha r ks &Herst, 1970) .
Su._ary Exposure -basedtreatme n t results in statistica l ly significa ntimprovementswhi c h are maintained for pe riod s of up to nine years, Lo ng- ter m follow-upstudieshave generally shown that treatme nt ga i nsar e maintained throughout the follow-up pe r i od, i!l.lthonghpat i e nt s ge ne r a ll y do not demonstrateany further improvement.
Cl inica llySignificantImp roveme ntin Agoraphobia
Although theabove results are encouraging, the finding thatclients' scores change to a statistically significan t deg reedoesnot addr essquestions rega r dingindividual va riabil i tyof treatmentoutcome, or th eclin ical significa nceof thosecutcomee, Ar.y "significant" cha nge should als o consider the clients ' overallendstate level of fu nctio n ing , Until rec en t ly, evaluat ing theclinical si gnificance of change in ago rap ho bia trea t me nt re sea r c hwas secondaryto compar ingthe effec tsof one treatment vereus another . For examp l e , onl y 26\ of patients (0"'963) Iin one
13 1 \ receivedbehaviourthe rapy.
study stated tha t thetr e atmen t the y hedrece i vedwas "v ery uee fu L'' (Bur n s&.Thorpe, 1977). Asa r-eauLt;,quest ions remain about the personal relevance of the cbenqe, Outcome studies have prov idedmixed in f o r ma t i on about clinical relevanceof theout come following expc suce- beeed treatment foragora phobia. HoweverI it appears tha t mostresear chers havebeen overlyop timls tic regardingthe clinica l signlfico nce of their treat ment s. Onlya few at u d i es have app lied objective cri te r ia to evaluate the signi f i c anc eof improv e me nt.
For examp l e, Roberts (196 4 ) reportedthat 1 to 16 years follo....ing treatmentat an inpatie nt psychiatricsetting, 27 of 38 "ho us ebound house wives"werera t ed bythecl inicianas either <r ec ov e r ed" or"i mp r ove d. · Ho wev er, clo se r examinat io nofthe ind i vid ua l outcome s reveals that many of th e"Lmp rcv ed"pat ients were st i ll extremely limited in mobil ity, and coul dnot beconsideredtr e a t ment success es by any standard. Only7(18t) of the 38 patientswere symptom freeatfollo w-u p.
Mark.s(1971 ) si mila r l yre p o rt ed that only 3 of 6S patients had lost all of theirphobicsymptomsat; follo ....-up:
[Theot h ersJhadimp r oved duringnr e etmeut to the point where they werefunctio ning mor e activein the communityand avoidingtheir phobicsituations signi ficantlyless. However, they retainedmeny symptoms, alb eit at lesser seve r ity . (p. 697)
Like wise, McPherson eta!. (1980) foundonl y a small sub-g roupof patients (18\) to be symptomfree at3- to6- year follow-up. Nonetheless, many of their clients ha d made meaningfu l gains, even 1fthe ywe r e not completelycuredat follow-up. For example,at pretreatment 21 of 56 clients wer e unableto workbecause of thei ragoraphobicsymp toms, whi l e none of the patients reported thisprobl emat fo llow- up. The authors concludedth at:
the ma j o r ity (66\) reportedthat theirsympt oms ha d stabi lized at a levelwhic h , whileoc casio nall y caus ing them slight diatress,co uldeasily be toleratedand affected theirlives onlyslightly. (p,15 1)
Burns et a!. (198 6) describedsome remarkab le Lnd Lv IduaI improvements infunc tio n ing 8 yearsfollowing trea tmen t. Duringa semi -structu redinterview, some clie n ts report edlevel s of functionin gwhich, whe n compared to pret reat mentlevels,wo u l d be considered clinicall y mean ingfulbyany standards. Nonetheless, the majori tyof client s still repo rtedat leastsome area s of co nti nued difficul ty .
Mavissakalianand Michelson(19868) reported tha t 41%
of the ir sample still conside redagoraphobia a problemat 2- yearfoll o w-up. Si xof41 patients were una bl e towork beca useof agoraphobia, while8subjectshadexperie nced at tee e c one panic attackduring the weekprio r to thei r foll o w-up eeeeeemene. Fur t he r mor e, 12 subjects(3D') had
10 receive d so meint erim treatmentfor agoraphobia, and 8 patients st ill used al c oh ol or anxi olytic med i c a tio n before enterin g into ph ob i c situations.
Finally,at 5-year follow-up, Lelliott etei . (1987) reported that themajorityof clientshad significant and lasting gains, and rated themse l ve sdSeithermuchimproved (30 \ ) orimproved (52\) from pret.r-eatae nt;levels . However , lesstha n one-third (28%) of pat ie n t s rated themse l vesas 0 or 1 on a scaleofglobalphobia (ato 8). Furt her mo r e, less tha none-fifth (18%)had bee n consistentlywell throughoutthe ent irefollow-upperiod: 5of 40 patients were consideredtoha ve had marked fluc tua t i ons in their agoraphobiaduringthe fi veyears followi ngtreatment, reportedby their fa mily phys icia ns .
Objective Definitio nsofClioically SignificantOutco~. A fewaut.ho r-e haveuse d objectivedefini tionsof "c linic a lly significantoutcome.· Twowa y sin whichthis has been at t e mpte din the lite ratu re are: (a)use of statistica l criteria base don normative populati onme a nsand standard errorofmeas urement,and (b ) use of a prioricut-offs to indicatetr e at me nt successandfa i l ur e.
Statistical Definitions Ina meta-analysisof 11 agora phob iaoutcomestudies, Jacobson,Wilson, andTupper (1988) reported that outcome SCOI'eaof 60\ofsubjects had improvedto ast a ti st i c a lly significant degreeover precre e tmene levels offuncti o ni ng. However, only34\
11 perc entof subjects ha dattai ned the crite ri a fo r clinically si g ni fi c a nt improvement. ·Clinicallysignificant improv ement- was defin ed as a poat-tre a.tl"ent scor-ewhi c h fa ll sbel ow the mid-way point betwe e nag oraphobicand no rll'l41 popula t i o n norllls j tha t is, when the sc o rewa sclo s e r to the no r mal (versusagora p hobic) populationmean. For measu res onwhicbncr meIpopulationnorms were una v ailable, the criteriafor clinic a llysign if ica ntimpro ve me nt wa s a 2 standar d deviati o n imp ro v e me nt fr ompret reatmentlev els . Finally, a reduct i on of 2 pointsona 0to6 scale, or 1 point on a0 to58":41e was uti l ized for sel f-an d clinic ian-ratedscales of phobia sever ity.
Arrin dell , Emmelka mpandSa nderman (1986) report ed that 69\ ofthe i r sample had experienced ·clini ca ll ysi gnifi c ant and rel iable improvement ,·using Jacobs on, Folletteand Reve n storf's (198 6 ) statistic al cri t er i a . Overa ll , the clien ts experie nc ed adr op of 17pointsfrom pr e- topos t- treat men t onagorep hob i a scaleof the FO(FO-AGOR) . Significant gainswere also reported on measure s of anx ious mood, dep r e s s i on, soci al fears , as we ll eaon perfo rmanc e on a BAT .
Fina lly, Tr ull , Nietz e l , and Hain (1988)assessed the clini ca l sign if i c an c e of 19 behaviouraltreatment out c ome stud ie s ,all of .,.,hich eval uated out.come usingthe FO.
"Cli nic al significance"wa sde fi ned asscoringwi th in 2 sta nda r d de v i at ion s of thenorma l population meanonFO-AGOR and total phob i a (FO-TOTAL)sub-s cal es. Overa ll , treat ment re s ul t ed in clinica ll ysi gn ificantimprov e ment. As comp a r ed
12 to normal popu lat ionmeans, overallpatients' sc o r e s dropped from the 97.3 percentile at pretreatmentto 68.0at post- tre4tment and 65.5at follow-up. The resul t s were less encouragingwhen compa r e d to collegenorms(9 9.9 , 98.7,and 98.2respec t ive ly) .
APr iori Definit i ons ofsneaeeee Fun c t i oning The above efforts represent8signi f icant impr ov e me nt from more typicalapproac hesto ass e s si ngtreatmenteffectiveness, whi c honly considerthesta t is ti c a l si g ni f ica nc eof the tre a t ment effect. However, any defi n ition of clinically significa nt cha ng eshouldal so include acri t e ri a for adequate "e nds tatefun ction ing " :a prede termi nedcriteria for the client s' overalllevel of fun ction ingfoll owing t.r e a t ment . That is,what minimal criteria shoul d con st i t ut e treatme ntsuccess?
Jans s o n and[jet (1962 )reviewed iJexposur e - based treatmentstudiesfor agor aph ob ia, all of whichutilized impr o ve me nt s inclin ici a n's rating s ofphob i a sev erity as e.
measureof treatment suc ce s s. Their cri te r i a forclinic a ll y significantimp r o ve ment were: (1 ) at least50\ reductionof phobiasever ityratings ,and, (2) an outcomescore of 3 or less on a scale of 0 to6. Usingthese criteria ,10 of the 18 stud iesyielded clinicallysignifican t overall res ultsat post-treatmen t . Fo r seve n stud i e s which include d assessmentsof patients atleastsixmonth safter treatment, four had clinica llysignif icant follow-upresults . Ho we ve r , it is interestingtha t the one lo ng - ter mfollow-u pstudy
13 included in the analysis (Munby , Johnston, 1980) failed to meet theircriteria for clinically significant change.
Cohen et e L, (1984) found that clinician-ratingsof phobi a severitydropped froman average of 6. 6 at pre t r e a t me nt (marked fear, usually avoid situations) to3.2 at 2-year follow-up (some fear, minimal avoidance)on a scalefr om 0 to B. Emmelkamp and Kuipers (1979), McPherson et81. (1980), and Munby and Johnston (1980) reported similar gains at long-termfollow-up .
Others (e.g.,Barlow,19 88;Himad! et 81., 1986) argue thata composite of several variables is more desirablethan a singleglo ba l variable inmea s ur ing endsta te func tio n i ng . Acomposite criteriaofferstheadvantage of assessing multipledimensions treatment-inducedchange. Chambless (1990) notedthat overly optimistic re s ul t s can be attained by using simplemeasures ofthe treated symptoms, and excludingcriteriarepresentingmultidimensional definitions of treatment outcome. Un f o r tunat e ly, fe w studies have subjectedtheir treatmen tstori go r o us evaluation of clinica l significanceof outcomes. Most studies have op ted for simple, global , self-ratedcriteria of outcome functioning. Other s have relied almostexc l u s i v e l y on anecdota levidence toassess theclinical significance of theirtreatments.
Mavissaka lian andcolleagueshaveusedacompos ite de fi ni t i o n of endstate functioningin evaluating the effectiveness of theirtr e a t me nt prog rammes atpo s t- tre atmentand short-termfollow-up(Mavissakalian, 1986;
14 Mavissakalian, Hamann, 1981; Mavissakal ian&Michelson, 19 83 ; Michelson, Mavissaka lian, &Marchione, 1985,1988;
Michel s o n, Mav issakal ian,Marchion e, nencu , , Greenwald, 1986) . Their crite r i a for "high endstatefunct ion ing "(HEF) includ e dac h i e v i ng at leas t thre eof the following: (8) a score of 2or less ona 5-pointclinician-rated scaleof severityof phobia ; (b) asc o r e of2or lesson theglo bal self-rat ingof se v e rit y on theFO(FQ-I NCAPACI TY); (0) a sc o reof2or lesson Watson and Mark's (1971 )self-ratings of the pat i ent'smo s t severephob icsituations (0 to 9);
and , (d) completion of a st a nd a r d i z e d and ind i vidualizedBAT withminimal or noanxiety . These criteriahavenot yet been usedin a long-term (L e . , i!:1year) follow- up. At pos t-t r eat me nt and 6-monthfollow- up, the authorshave consistently repo r tedthat ap prox i ma t e l y 50 to65 \ of their patient s ac h i e v e th is cri t eriaforHEF.
Ba r low and colleagues (Cerny eta1., 1987; Craske, Burton,&Barlow, 19 89 ; Hima d i,Cerny, Barlow, Cohen, &
O'Brien,1986) have uti li ze d asim ilar compo s i tedefinition of treatmentoutcome, To achieve HEF, clien tsmu athavemet threeof the followingconditions: (a) a sc ore of20 or less (0 to 100) on a personalizedfe a r hierarchy ; (b ) spouses ratingof 20 or le s s on fear hierarchy; (c) comp l e t i onof all items on a BAT withminimal self-ratedanxiety ; (d)a scoreof2or lesson FQ-INCAPACIT Yiand, (e) score of 2 or less on clinician'S0 to8rating scale of phob i cseverity . At f-yeer follow-up , 35\of clients treated withspou s e s , 18\ of those treated wi thoutspouses, had echLe vedthis
15 cr i teria forHEF (Ce r ny et aI, 1987). The s e perce ntages had impr ove d to47% and27\, re s p e ctive l y, by a-yearfollow-up.
SWIIlD4ry Ane cdo ta l ev idencesugge sts that manypatients experienceper ecneLty sign ificant gains, if not complete re c o ver y. Noneth eles s, a great numbe r of patients experience incomplet e recovery , and onlyave r ysma l l minorityare sympt om free at follow-up. Obj ective a priori compositecriteriafor succes sfultreatmentoutcomeare especially importantineval ua ti ng treatment effec tiveness, althoughonly asma ll minority ofstudies have utilized such criteria . The proportion of clients who exper ience clinicallysi g nif i ca nt outcomes is reportedat 35% to 65%, dependingon the definition of clinical si g n if i c a nc e .
The Incidenceof Relapseandlo r Fr e s h Symptom $mergence DuringLong-termFo ll o~
Mostresearchershave concl udedthat exposure-based treatment results inlasting improveme nts inagoraphobia, withrelatively few relapsesor complications (e.g . , Emmelkamp, 1980; Emmelkamp& Kuipers, 1979;McPherson et 801. , 1980; Munby&Johnston, 1980). The notion of symptom substitutionisgene r all y rejected inthebe ha vio ur al literature. However, the availableev idencedoes no t support such an optimistic conclusion. Fo r example, in a meta-analytic re view of agoraphobiafo llo w-up studies, tist (1989) reportedthat theme a n rate of relapsewas 24 %, whi le
\6
33'<Jf pat ient shadso ug ht further troa t ment at Bornetimo duri ngthefoll ow-upperiod. The fo llowingreview will demonetre c ethat re se a rc hersin thisare a ha ve notbeen cri t i c alenoughof the long-termoutcomesofthe i r treat me nt pro gramme s. On the contu ry , they seemcontentto emphas ize their treatment suc ces ses, and to demonstratethattheir tr ea t me nt isst at i s ti ca lly superiorto ano the r treatment.
For exa mple,atfour years after treatme nt, Marks (1971 ) conc ludedtha t hiesa mp l e "remeLn e dillpredominantly phobic one and didno t developanyothe r kindofne ur o t i c syndrome- (p• 686). However,this co nc l usio nwa s not support edby the informationg~theredduringfollow-u p int e rv i e ws. Appro ximatelyone-quar terofthe sa mp l e reportedsexual dis orders(e.g., frigidity ), while one- qua rterwerenot ed to have dist urbedworkand leisure adj u s tmen t. It is also note wo r t hy that during the follow-up period.11\of this samp l e hadbeen hospitaliz ed for depressi on, while another4\were treatedfo r depres sion as out pa ti ent sI•
Munbyand Johnst o n (1980) si mila rly stated that they failed to find evide nce of ne w symptom s or rel apseintheir sample of 63 agoraphobics. Thisconclu s ion iscontradi cted by the fact tha t 31(49\)of theirpatientshad sought furthe r treatment, and 37 (59\) hadre cei ve d psychotropi c dr ugs atsometi medur ing the follow-upperiod.
1 Harks stated that -ma ny-of thepatient s had been treat ed for depress i on beforethey entered int o treatment, but providedno baaeHne data.
17 Furthermore, 21 (33l)pa t i e n t s reported that they had experienceda period of severe relapse, la s t i ng atle a s t one month. Nonetheless , clientswho functionedbest at the6- month follow-up had generally con tinuedto do well during therest of the foll ow- u p perio d. This inform a tion is significant sincei t is the oppositeof what would be expected in a symptomsubstitution model. That is, theoretically, the most improvedgroup shouldbe most prone to relapse or symptom substitution .
Marks et a1. (1983) reported that 15 of 45 patientshad further contact wi th the therapist during the six months fo ll owi ngtr ea t me n t , 10 (22\) of whom had received antidepressants. Howe v e r, patientswho rec eivedfurther treatment were initiallymostde pr e s s e d at pr etrea tment. Two years after treatment9 of 40 follow-upclientshadbeen referred to psychiatristsat some timedur i ng the follow-up (Cohenet al . , 1984). Finally, at 5-yea rfollow-up (n=40 ), 23patients had sought furthertreatment for agoraphobia, 10 ofwhomwe r e still onps ych o t r o p i c medications (Lel liottet aL, 1967). Onceagain, at each follow-u p, patientswho werewor se-of f at previousassessmentswe r etho s ewho sough t furthertreatment.
Ma vi s s a ka lia n andMichelson(19664) reported tha t 30\
of their sample hadreceivedinterimtreatmentspec ifica lly fo ragoraphobia, and 15\ for othermental hea lt hproble ms during the 2 yearsfollowingexposu re tr e atme nt . Twen ty- fou r percentof patientshadrec eivedeithe r anxiolyticor antidepressantmedication duringfollow-up, 17\ had interim
18 depressive episodes, and 12% met the criteria for major depressionat the time ofthe fo llow-up. Theinc i d enc eof dep ression inthissample is noteworthy, since the authors reporte dlytook extremecere toexcl udeanyonefromth e study wi t h8.histo r y ofpri mary af fectivedisor der.
Si milar ly , in the Burns et al. (1986) B-year fo Lkcw-u p study, new mentalhealth problems had emerged in 3 of 20 clients, 4 had receivedaddit iona l treatme ntfor agoraphobia, and 11peoplewe r e stillusingmedicationat the time of follow-up to helpthem cope....lth anxiety. Fra nklin (1989) repor t ed that five of Beven patients experienced·partial but temporaryrelapses· during the six yearsfollowingtreatment. Unfortunately , he provides no fur t her definitionof"p a r t i a l , - ftt empo r a r y ,"or "re Lapee",
EmmelkampandKuipers (1979) statedthatthe y found no evidence of fresh symptomeme rg e nc e four years af t e r treat ment, although13 of 70clie ntshad re c e i ve dfur t her treatment duringthe follow-upperiod. Similar l y,McPhe rson et et.(198 0) reportedthat theyfo und noev i d e nc eof symptomsubstitution, although 5 of 56 clients received furthertreatment becauseof a relaps e intheir agorap hob ic symptoms. Unfortuna tely ,bothstudi es used onl ysimple mall-inassessments, making it unl i ke l y thatanynew symptomato logy wo u ld have been uncovered.
Inan early study, Hafner (1976)reported that two- thirdsof patients (na39) had met the criteria for fo.eah symptomemergencein the 12 monthsfoll owi ng exposu re treatment. "Fr e s h s}'mptomemerg e nce-was definedas an
19 increase onmo r eth a n one scaleof theMiddelsexHospital Questionnaire or FearSur ve y Schedule (F5S ) over pretreatment levels . Kafner classifiedsubjects into thirds, representingthose who experienced(6.) negligible, (b) small-ta-moderate, and (c) moderate-to-largeamount cf fresh symptom emergence. The top third responded well to treatment on all of the criteria (main phobia, global phobia, self-satisfaction, Maudsley Hospital Questionnai re). In contrast, the bottom groupresponded well only on the main phobia; onth e othe r measures, theywere actual ly worse-off at follow-upthan they were before treatment. Hafner concluded that treatment had an overalladverse effect on one-thirdof hissample.
However,Hafner'sstudyhas been widely criticized (e,g ., Emmelkamp&VanOe r Hout, 1983 ; Marks, 1981;
Monteiro,Marks&Rarnm,1985; Stern, 197 7; vandereycken, 1983) because it is not known how many increases in the FSS and MiddelsexHospital Que s t i o nn a i r e Bub-scales couldbe attributedto chance. Furthe rmore, the occurrenceof fresh symptomemergence could notbe attributed to phobia remov a l, since allthree groups improved equallywell in phobia severity. Thus, increases In non-phobia measures could no t be considered symp t om subs titution followIngphobia improvement.
SWIUllary Thereis no doubt that a sub-group of agoraphobic clientscontinue tohave significant difficultiesfollo wing behaviou r therapy. The incidenceof relapse, use of
2.
ps yc ho t r op i c medications. and/o r seekingfur t h ertreat ment in the literature 18 usually repo r t ed at33\to66\.
Unfortunately, the rigorousne ssofass e ss me ntanddegree of detail reported for these datave r Iee grel!ltly betw e e n studies.
Thos ewhoinitially respond we ll to trea t ment appe a rto mainteo in the irbe ne fi t s during follow-up. The no t ion of symptOIll Buhstitution isgenerall y not supporte dinthe behavioura l lit erat ur e . Prololems dJr ingfollow-upusually foll owpoor initiel respo nse totr eatment, ra therthan symptomsubst i t ut i onfollowing success f ul treatment.
SUID:pa ryofLong -termEffec tive nessof Be ha v i o uralTreatme nt ofAgoraphob i a
Theevidence Buggests thatbe ha viou r a l tre a tmentsfor agoraphobia re s ul t in long -l astingilllprovement forper i od s of upto nine ye ars . Overall , treat tle nt gainsare mainta ine d fr o m post-treatment tofollow-u p, 81 tho ugh furt he r improvement duringfollo....-up does not appe a r to
No ne t heleu,despiteove r a llstatistically significan t imp r ovements ,onlya small minority ofclie nts are completelysymptom fre eat follo....-up. A sig ni fi c a nt number ofpa t i e nt s experi encerelapse and/ or incompl eterecovery. Researchers havenot been cri t i c a l enoughof thelo ng - t e r m outcome sof their treatmentprogrammes, con t e nt to emphasize treat mentsucc e s s e s,andtodemonstra t e thattheir tr e a t ment
21 isst a t i s t ica lly superior to another tr eatment. With few exceptions, there has been a failureto apply reasonabl e cri teria to dec ideonthe number ofclie ntswho are functioningat a satisfactory le v elatfo llow- u p.
Noneth eless, thenotionof symptom substitution is gene rally not suppo rtedIn thebehav iourall i te r a t ure , astho s e who init i a llyre spond well to tre a tment ge nera llyma intaintheir benefit s during follow-u p; prob lems dur ingfollow-up us uall y fo ll owpoor initia l res ponse totreatment,ra ther than sympto m sUbstituti o n foll owingsuccessfu l treatmen t.
prognos t icInd i catorsof TreatmentOutcome
Give n thata significantnumbe r of pat ients experience relapseand /orinc omp le t erec o veryfollowi ng behaviour a l tr e a tme nt ofagoraphobia , it wo u ldbeuseful to be able to pr ed ict whichpa tie nts benefitfromtreatment., whicb pat i entswill experience relapse,and whichwilldrop-o utof tre atmentpremat urely . Table 1 (App endixA)presents de t a il s of 17 studieswhicbhave exami nedthe utili t y of differ e nt variable s inpredi cting lo ng-te rm(I. e ., z 1 year ) out come following expos ur e-bas e dtrea tme ntofagoraphobi a . Includedin thisrevieware studie swhi ch exami ne d th e relat i onsh ipbetwee n variou s patient variabl e s and long-term outcomefo r behav i oura l treatmentofago r a pho b i a. ThUS, studies were notincluded ....hich ....ere concernedsolely ....ith comparingthe effecti vene s s oftr e atment A vers us treatment B, did notexp li citly ma keus e of a beh avioural (i.e.,
22 exposure-bAsed) treatment, or, had a follow-up period of Les s than 1 year. The review is organized under five general categories of patientvariables~ (a) demographic and historical variables, (b) pretreatment clinictll measures, (c) patient attitudes toward treatment, (d) response profile characteristics, and, (8)interpersonal and famIlial factors.
pemographic and Historical Variables
Demographic and historical variables are generallypoor pre:.lctorsof treatment outcome for agoraphobia. In only three of nine studies were demographic variables sIgnificantly predictive of any measure of treatment success, while historIcalvariables yielded slmilorly poor results (2 of 7 studies). Furthermore,the fe.... positive findings have typically revealed only very ....eak associations between these variables and treatment outcome. One historical variable, the mode of phobia acquisition, is a theoretically important variable, but no long-term outcome research bee been done to empirically demonstrate Lt ' s importance.
Delllographic Variable s Cohen et ei , (1984) found no relationship between sex, age, or marital statue and clinicians' ratings of phobia severity, improvement, and relapse during the two years following treatment. Treatment consisted of self-exposureplus either imipramine or
23 placebo , and relaxat ion orguidedexposure . Monteiro at ef, (1985) similarlyfound no relationshipbetween marital statusand outco meon a varie tyof se lf-ratedmeasuresof phobia anddepres sion . Le l lio t t et et . (1981) reported no eff e c t of age and sexonout c ome at five yearson self-and clin i cianrati ng sof trea tmentoutcome.
Hafner (198 3 )li ke wi s e reported tha t therewere no sig ni fi c an t differencesbetweenmalesand females in overall phobic sev e ri t y 12 mont hsaf tertreat ment. However , Hafner did find thatfemales expe r i e ncedsignificantly gre a ter frequencyof panic and were moredependent on ot hers 12 monthsafter treatment. He als oreported that men we remore likelyto ha ve refus ed treatmen t or to have dropped-out prematurel y, although these latter trends were not stat is t i c a llysi g nif i c a nt.
Histor icalVariable l; Historicalvariable s ar e also ineff e ctivepredi ctor sof treatm entoutcome. Emmelkamp and Kui pe rs (1979)found thatdurat ionof phobia was unrelated to amo untof impr ovementreported on self-ratingsofit ems onpersonalized fe arhierarchies . Cohen eta1. (1984) reported that durationof phobilll was unr e lat e d to clinician ratings of phobia se ve ri ty , improvement, or relapsetwo ye a r s fallowing self-exposuretreatmentplusimipramine or placebo and relaxation or guided exposure. Fi na lly , Lelliot t at d . (1987) found that durationof illne s s was unrelatedto a number of differe ntclinici an-and self- ratingsof phobiaseve rit y.
24
Mode of Onset One historical variable, the type of phobia onset, is a theoreticallyimportant determinant oftr e atme nt outcome,althoughlittle research has beendone to verify its' prognostic value. Rachman (1977) and Wolpa (19 81) have proposedtha t phobias maybe acquiredbyme a ns of one of two mechanisms: classical conditioning, or cognitivele a r n ing. Cl a s s ica lly- c o nd i t i o ned phobias are acquired through pairing withone or more direct or vicarious ne ga t i v e experiences, leading to a "generalized maladaptive response" . conversely , cognitively-basedphobias are acquiredthrough misinformation and/or social le a r n i ng. A key characteristic of cognitively-learned phobia aisthat patientsdo not recognisethat their fears are unrealistic. In these cases, cli en t s believe that the dangeris real,and that their fears are thereforewarranted. Michelson (1984) we nt onto suggestthatphysiological and behaviouralcomponents ar e les s important in maintaining cognitively-learnedfe a r s , compared tocog ni t i ve components such as appraisa ls , attributions and expectationsof danger. tlst (1985) reportedthat the majority (89\) of agoraphobics acquire their phobias via class icalconditioning.
Unfortunate ly , no long-term empirical research has been done to test whether differe ntmodes ofacq u is i tio n are associat edwithlo ng- t e r m outcomefor agoraphobiafollowi ng beh a v i o ur al treatment. Roberta (1964) conducted the only long-term study to examinethe relationehipbetween the circumstances surroundingagoraphobia onset; and treatme nt
25 outcome. He found th at patients who had a"s u dd e n"pho b i a onsetwere moreli k e ly to be classified as"un impr oved" at 1.5-to 16-yea rfollow-up, whil eth o s e in the "i mp rove d"
group were evenlydividedbetween Budden and "g r adual"
onset. Roberts also foundtha t an older age at the onset of thedisorderpredictedpoo re r prog nosis at1.5 to 16years fo llowI n g treatment.
Li d d e ll and Acton (1988) tested whetherthe misi nformationand erroneous beliefs associatedwith cognitively-basedagoraphobiawoul d interfere wit hthe patient'sability to understand the behaviouralmodel of phobia tr e a t ment. A24- i te m multip le - choic etestwas administeredat pre- and post-treatment. Thistest assessed thepa t i e nts' knowledgeof thebeha v i o u r a l modelof etio logy andtr e a t ment of agoraphobic sympt oms. Contrarytothe hypothesis, therewa s nodif f e r e nc e in test performance be tw e en patientswith cognitive and cond i tion ingonsets.
These findings suggestthat acquisitionoffe a r isnot pr e d i c t i ve ofthepat i e nt s ' abilityto understandand accept the behavioural model of trea tment.
Summary Demographicand historica l variables are generally poorpredi c torsof treatment outcome for agoraphobia. The few positive findings have revealed onlywea k associations between these vuri.ab l ea and treatment out.coee . The mode of acquisitionofphob i a is a theoretica lly1mportantvariable, but ver y little research has beendone to demonst rateit·5 importance.
"
PretreatmentClinicalMe a s ur e s
Emmelkampand Van Der Hout (1983)concludedthat pretreatment,clinica l meas ureswere not useful in predicting treatmen t outcome foragoraphobia. Although many studies have been conductedsincethat time, on the whole, this observationremai ns true. Fur t hermo r e , in studieswhIch have reportedapositive relationship between pretrea tment cli nicalmeasures and tr e a t me nt outcome, these measures generallyaccount for onlya small percentage of the variance in outcome. Thereis some evidence that clinical measures gain predictiveutili ty6S treatment progresses, although the y do not attainusefulpredictivepower unt il late in treatment.
?bobic Severity The studies reviewedin Table 1 show that, overall, pretreatment meas uresof phobia severity (o11nici an-, andself-ratings of phobia seve r i t y, standardized paper..~-pencilmeasures,personalizedfear hiera rchies , diaryrecordsof self-exposureactivity) are poorpredictorsof long-termtr e a t me nt outcome, rela t i ng to lo ng-term treatmentoutcomeinonly12of 29 occas i ons. However, the avail a bleevidence also suggests that these same measuresbecome moreuseful pred i ctorsof long-te r m outcomeas treatment pr og r e s s e s (e.g. , LelBo t t et e L,, 198 1i Munby&Johnston, 1980; Roberts , 19 6 4 ) .
For example , Ro b e r t s (1964)rep o r t ed that the clients'
"mcbLlLt.y"at pretreatmen t (Le. ,ability to leave the
27 house )was only weakly as sociatedwith their mobilityat 1.5-to 16-year follow-up, whilemobility at 6-mo nthfo11o...- up was stro ng lypredic t i ve ofoutcome at lo ng-t e r m £ol1ow- up.
Munby andJoh n s t o n (1980) simila rly reportedthat ra t i ng sof phobiaseverity at QUtreatment were poor pr e di.. tors of 5- to 9-year outcome,but that thesame ratings taken sixmonths~trea tment were significantly related to ratings at long - t e r m follow-up. Measures incl udedclinicians ' ratings of phobia seve r ity, the FSS, and a personalized fe a r hierarchy. Thesame patternemerged for diary measuresofti me spe nt out of house: long-term ou t co me wasweaklycor r ela t e d with diarymeasurestakenat pretreatment(r...04)I but the same measures takenatpce c - tr e atme nt we r e strongly predictive of long-termoutcome
(r = .45) . However, these latter correlationswere not
statisticallysignificantbecause of the small sample size (n ..12) fo r thllt meaaure ,
Fina lly , Lelliottet a!' (1987 ) found thatclientswho sought furthertreatmentduringthe five yearsfo ll owi ng treatme ntdi dnot differ on any of the four pre t reatment variables (clinicial'l- andself-ratingsof fear hierarchy items, FO, self-ratingof global phobia). Ho we ve r, those whosubseq uentlysought fur t he r tre atmentwereworse-of fon al l meas uresof phobia severityat post-treatment.
MoodI Depression , General Psychopathology Ot he r symptoms associated with agoraphobiainclude depression,gc.neral1zed
2.
anxiety,depersona lizat ion, hypochondriacalfears, int e rpe r s o na l depende nce,and decreasedsexual functioning.
Someauthors (e.g.,Chambless' Goldste in, 198 0 ; De Moor, 1985)ha velIrguedthat behaviourtherapi st stake too na rrow avi e w oftheago ra pho b i csynd r ome, focu si ng on l y on the most pr ominent feature s (i.e., ago r a phob i c avo i d a nce andthe -f ea r of fear- ). De Moor (1985) went onto suggesttha t progress in exposure-based , ·phobi a removal-treatmentis hamp e red i fthese add i t i o na l pr ob l e msar e not addr essed.
This notion is partia llysupported by theavaila ble evid ence ; Inthe 18 cases in Ta b le 1 in whi c h measures of gene ralpsyc hopathologywe r e used aspredictors of long-t e r m treatment outcome, 7re s u l t ed in statist icallysignificant relationships. However, instudies in which po sitive effects were found,th e s emeas ur e s generallyaccounted for onlya small pe r c enta g e in the varia nce in out c ome .
Cerny et at , (198 7) cond uctedmultiv aria t e andyeesto predict outcomeatl-y e a r follow-up in73ago r a p hobic patients. Theauthorsused several mea s u resof phobia severity tosel e c t the highes t (n..9) and lo wes t (n "11 ) functioning pat i e nt s at follow-up. Univariatestatistical testsdid not different iatethe groupsonany pret r eatment measures of generalpsychopa t hology (BoI , Middelsex Hospital Question naire,Subjectivesymptom Scale). Howev er, mu l ti va r iateana l yses re ve a ledtha t clien ts wi thpoo r outcomesc oredlower (i.e.,poore r) on thesemeasures .
Marks andco l l ea g u e s (Harks et al., 1983; Co he net al., 1984 ) also reported that neither scoreson clinician-
"
(Hamilton Oeprenlon Scal e)nor self-rated (Wa k e f ield nepre earonInve nto ry)depression scaleswerepredictive of pho bia seve rity at1- or 2-yearfollow-up. However, clients who scoredhigheron depression were mor e like ly tohave receivedadditionaltreatme ntduringthe firs t year foll owingtre at ment, and high scoreson the Hamilt on nep r eeefcnScalewerepredict i ve of trea t mentdro p-out.
Fur t he rmore, highe r pret r ea tmentdepression and non - pho b ic anx iet yat pre treatment:predicted greater phobia sev er i t yat s-ye er follow- up (Le lliott et al., 19 B7).
Finally,EmmelkampandKuipers (1979 ) reportedthat neitherpr e tr e at men t me a su resof Boclalanxiet y (Social Anx i e ty Sc a l e )nor depres sio n (ZungDepres s i o nScale) were reb,ted tose ve ri ty ofphob i aat 3.5- t.o5-yea rfollow- up .
Suma4ry Pretreatme ntmeasur es of pho bia severlt y ha ve gene rall ynot been effective predi c t o rs of treatment outcome. In studiesir?whi c h positive effectswere re po r t ed , th e s eme asur e s accoun tedforonly a small per c e nt a ge of theva riance inoutc ome . Cl i n i cal me asures beco mebetter predictors astreatment proqreseee, but do not attain use f u lpredictive power until late inthe trea t me nt process. So meaut hor sha vestres sedthe impo rtlm c e of general psychop atho logyand persona lityinthema i nte nance of agoraphobia . Measure sof depressionwerenot consistentl ypredic tiveof treatment outcome,although inc r e a s e d depre s s i o nwa s as s oc i a ted withpoorerpr ognos is in a few stu d ie s.
30 Atti tude toward'f r e at me n t
Few studies have assessed the long-termeffect of agor a p h'Jbi c s' attitudes toward treatmentontreatment outcome. -Atti t u d e s toward treatment "r-e Eeru to the clients' motivationfor treatment, expectationsfor what will tnnspire in treatment, expectations fOI: therapeutic gain, and, the irlellr n i n g and accept i ngofthe therapeutic rationale. The available findings suggestthat an optimistic attitudetoward the treatment offer-edmay predict a positive outcomeat post-treatment,but is unrelatedto outcome at1-or 2-year follow-up (PerE;son " Nordlund, 198 3;
Marks et al.,198 3 ; Cohenet aL, 1984). 'rnere isa1eo Borne evidence whichsuggests: that clientswho havo better understood thebehavioural therapeutic model ha v e superior outcomeon BOlte measures (Liddell&Acton, ll188),
Persson and Nordlund(19 8 3)treated 103 phcbfce!with self-direc tedexposure, anxiolyticmedications , plus one of relaxation , supportive therapy,prolonged exposu r e ,or no additional ther ap y, At pretreatment ,threeattitudinal variableswe r eas s e s s ed byquestionnaire: (a) expectationof therapeuticgain, (b)goals for treatmen t, and, (c)client's wishesregardingthe therapist's roleduring treatment.
·Cong r uent· tr ea t me nt go als and expectations for the therapists' role wereassociatedwi th decr-eased phobic symptomatology at post-treatment, For example, clientswho rece i v ed guidedex p osur e showed betterImp z cveme ne at post-
I including 61 agoraphobics
31 treatmenti fthey entered into treatment with the desire to receive"ed vdce and guidance-from the therapist.
Alternatively, those who had received supportive therapy were more improved if they wanted the therapist "to help discover tbecaUSt18of the disorder." However, these variables were no longer associated with outcome at 9-month follow-up.
Marks and colleagues (Cohen et a1., 1984; telBott et a1., 1987;Marks et a1., 1983) reported thatthe therapists' ratings of treatment compliance were not related to treatment outcome at 1-, 2-, or 5-year follow-up stages. Therapists' pretreatment ratings of clients' motivation for treatment were also not related to phobia severity at 1- or 2-year follow-ups, although a positive pretreatment attitude toward treatment was predictive of positive outcome at 5- year follow-up (Lelliott et a1., 1987).
Finally, Liddell and Acton (1988) found that clients who had acquired a batter understanding of the behavioural model at post-treatment had also attained greater improvements on 2 of 4 outcome measures. A 24-item multiple-choice"test of the behavioural model-was administered to 42 agoraphobics at pretreatment. The test was designed to assess the degree to which patients understood a behavioural model of the etiology and treatment of anxiety. The test was re-adrninistered at post-treatment to the 29 clients who completed the programme. Clients who demonstrated greater understanding of the model at post- tre.:.tmentalso showed decceeeedphobic incapacity (FO-
32 INCAPACITY) and increasedse l f-eff i c acy . These clients experiencedno greater i.mprovement on 2 other measures (FO- AGOR, aDI).
Summary Fewlo ng-t e r m studies have eeeeeeee the relationship betweenattitude toward treatmentand treatment outcome, and the few available findingshave not been cons i s t ent . The availableevidencesuggests that an attitude congruent with the treatment offeredis associated with immediate (i.e., post-treatment )outcome, but that attitudestow,\rd treatment are not associated....ithoutcome at longer follow-ups (1to2 years). Also, therei~
evidence which suggests that pBtientewho have better learned and understood the therapeutic model ha ve superior out c o me , at least at post-treatment.
Response Profile
La ng (1968) conceptualizedanxiety as three loosely interwovendimensions: cognitive, behavioural and psychophysiological. "Re spo n s e stereotype"refers tothe strengt hsof physiological, behavioural, and cognitive reactionsduringexposure situations. Researchers hove measu redresponse stereotypes in the hopes that theywould help improvethe reliability and validityof classification, and a.ssist in tailoringtreatment to the unique
characteristics of the client.
33 The results of several pos t-treatment andsh ort-term follow-upstudies suggestthat re s pons eprofile characteristicsare usefu l in predictingtreatmen t outcome (e.g., cxeexe, Sanderson, &Barlow,1987 ; Mackay&Liddell, 198 6 ; Mavissakalian &:Michelson, 1983: Mict.elaon, 1986 ; Mi che l s o n &Mavisgakalian, 1985: Mi chelson , M8vissakalian,&:
MarC hione, 1985, 1988; Michelson, Mavissakallan , Marchione , Ulrich, Marchione , &:Testa , 1990:Stern&Marks, 1973 ; Vermilye a et a1., 19 8 4; Watson&Harks,19 7 1 ). However,no lo n g-te r m (Le.•.l!;1year) follow-upstudies havebeen done toindi c a t e the usefulness of theseva riab le sin predicting long-term out come.
PhysiologicalArousal Some theoristshave suggested that high physiolog ical reactivityearly in the treatmentprocess is indicative of"e mo t i onal processing"of the"fe a r stru cture~;thus,physiological arousal duringexposure should be as so c iat e d withbe t t e r treatmen t outcome in agoraphobics. Three studies have presented evide nce which sug gests that highph y s i ol o g i cal re s p o nsiv e n e s s is predictive of improved outcome at post-treatment (Ster n &
Marks , 19 7 3;Vermilyeaet a1., 1984; Wa t s on &Marks , 1971) . One other studyreportedsuperioroutcome at 6-month fo llow- up for high physio logical respon ders (Craskeet al., 1987 ) . However, nolo n g- t e r m follow-up studies havebeen done to te s t the hypothesis tha t hi gh physio logica l respo nsiveness duringexposu reis associatedwi th improved treatment outcomein agoraphobics.
Bebavioural Avoid ance Mavissakalianand Hamann(19 8 6 ) suggestedtha t performanceon behavioural avoidance tests (BAT) areof limi tedvalue inas s es sing agoraphobics,si nce unlikesi mple phobia s, the essential fear in agoraphobia is a fear of panic, rather than the fearof external objects or situat ions. There areno long-term outcomestudiestotest the valueof behaviou ra l performance in predicting treatment out come for agor ap hob i cs. Nonet he le ss, the literature suggest s that good be ha vi o ural performance onin vivoBATs isco n sis te n tly relatedto positiveshort-term out c o me (Craske et al. , 198 7; Cerny et al. , 19 87; Ma viesakalian &
Hamann, 19B6; Mavis sakalian,Michelson, 1986b ;Michelson , Mavissaka lian'Marchione, 1988).
Subjective AnXi ety Inaddit ionto phys iologicaland be ha v i o ur a l symptoms,agoraphobiais cha racterhedby subject ivefeelings ofan xiet y , catastrophic thoughts, dysfunctionalbellefs, andmi s a p p r a i s als of internal and externalcues. sender-son andBe c k (1969)empha s izedthe impo rtanceof the s e symptoms inthedevelopment of the "fe u of fear." ucvever , there is littleempirical supp o r t for the notionthat strength of cognitive reactivity is a predictor of short-termoutcome of behaviouraltreatmentof agoraphobia(Barloll/et a1.,1984; cr e e ke, Burton& Barlow, 1989;Hafner' Marks, 1976; Mavia sakalian, Hamann, 1986 ; Havissakalian&Michel son, 1986; Michelson' Mavissakll1ian, 1985; Watson'Marks, 197 1). Onceag ai n, no long- term
35 studies have been doneto determinethe usefulness of cognitivereactivity in predictinglong-termtreatment outcome. Nonetheless, there is some evidence which suggests that ear lyimprovements in subjective anxiety during ex posu repredict betteroutcome at short-term (1 month) follow-up (Mavissakalian " Michelson,1983).
lle.p0II.S8Syrll~:broDYI Desynchrony The somatic, behavioural,
and cognitive systems may chenqeor improveat different rates du ring tr e a t me nt. Response "synchronyI dssynchrony"
ref e rs to the degreeof ccvarfence amongst thethree systems overtime (Rechmen&Hodgson,197 4). The r e are no studies to test the relatio nship be tw e en re s po n s e synchrony during treatmentand lo ng- t erm treatment outcome. In two short- term studies, parallel improvementin behavioural, physiologica l, and cognitive response systems was associated with superio routcome on at lea s t oneout c omemea s ur e (Vermilyea et al., 198 4; Mi c he l s on et al., 1990 ). Athird study failedto show any ou tcome superiority for clients wit hsynchronous improveme nt(Craske et al., 1987).
ft• •poas. Concordance I Discordance Response·conco rdanceI discordance"refers to agreement inthe relative strengths of the th reeresponse systems. Unli ke the synchrony I des ynchronydimension, whichrefersto unityof changesin the differentra s pon s e systems over time, concorda ncerefers tothe relative strengthsofeach ofthe respo nse systems at one poi nt in time. Vermilyea et a1. (1984) suggested that
