Dianne L. Chambless

Efforts to increase the practice of evidence-based psychotherapy in the United States have led to the formation of task forces to define, identify, and disseminate information about empirically supported psychological interventions. The work of several such task forces and other groups reviewing empirically supported treatments (ESTs) in the United States, United Kingdom, and elsewhere is summarized here, along with the lists of treatments that have been identified as ESTs. Also reviewed is the controversy surrounding EST identification and dissemination, including concerns abou research methodology, external validity, and utility of EST research, as well as the reliability and transparency of the EST review process.

A scheme is proposed for determining when a psychological treatment for a specific problem or disorder may be considered to be established in efficacy or to be possibly efficacious. The importance of independent replication before a treatment is established in efficacy is emphasized, and a number of factors are elaborated that should be weighed in evaluating whether studies supporting a treatment's efficacy are sound. It is suggested that, in evaluating the benefits of a given treatment, the greatest weight should be given to efficacy trials but that these trials should be followed by research on effectiveness in clinical settings and with various populations and by cost-effectiveness research.

The development of the Mobility Inventory for Agoraphobia (MI), a 27-item inventory for the measurement of self-reported agoraphobic avoidance behavior and frequency of panic attacks, is described. On this instrument, 26 situations are rated for avoidance both when clients are accompanied and when they are alone. These two conditions were found to be only moderately correlated and are thus analyzed separately, as is the item on frequency of panic attacks. Studies are reported which support the reliability and the concurrent and construct validity of these three measures, using comparison samples of agoraphobic, socially phobic and normal Ss. The MI appears to be a sound instrument, with which a broad range of situations troublesome to agoraphobic clients can be surveyed, and should prove useful for treatment planning and research.

Two studies were conducted to further psychometric research on the recently developed Beck Anxiety Inventory (BAI). In Study 1 the test-retest reliability and internal consistency of the scale were examined with a sample of 40 outpatients having anxiety disorders. The BAI proved highly internally consistent (cronbach's alpha = .94) and acceptably reliable over an average time lapse of 11 days (r = .67). Study 2 was conducted to assess the convergent and discriminant validity of the BAI vis á vis anxiety and depression and in comparison to the widely used trait Anxiety measure from the State-Trait Anxiety Inventory. Seventy-one outpatients with anxiety disorders completed the revised State-Trait Anxiety Inventory, the Beck Depression Inventory, and daily diary ratings of anxiety and depression in addition to the BAI. The BAI fared better on tests of convergent and discriminant validity than did Trait Anxiety. The correlation between the BAI and Diary Anxiety was significantly higher than that between BAI and Diary Depression, and, compared to Trait Anxiety, the BAI was significantly less confounded with depression as measured by the BDI. Scores for STAI-Y Trait Anxiety were highly confounded with measures of depression, but results for the STAI-Y State scale were more positive.

The authors review the existing models for understanding agoraphobia and suggest a more complex behavioral model which includes a combination of necessary and sufficient factors for its formation. This model is presented as a framework allowing classification of agoraphobic-like symptoms with implications for treatment planning and research efforts.

The efficacy of cognitive-behavioral therapy (CBT) for anxiety in adults is well established. In the present study, the authors examined whether CBT tested under well-controlled conditions generalizes to less-controlled, real-world circumstances. Fifty-six effectiveness studies of CBT for adult anxiety disorders were located and synthesized. Meta-analytic effect sizes are presented for disorder-specific symptom measures as well as symptoms of generalized anxiety and depression for each disorder, and benchmarked to results from randomized controlled trials. All pretest-posttest effect sizes for disorder-specific symptom measures were large, suggesting that CBT for adult anxiety disorders is effective in clinically representative conditions. Six studies included a control group, and between-groups comparisons yielded large effect sizes for disorder-specific symptoms in favor of CBT. Benchmarking indicated that results from effectiveness studies were in the range of those obtained in selected efficacy trials. To test whether studies that are more representative of clinical settings have smaller effect sizes, the authors coded studies for 9 criteria for clinical representativeness. Results indicate an inverse relationship between clinical representativeness and outcome, but the magnitude of the relationship is quite small.

A meta-analytic comparison of studies testing cognitive behavior therapy (CBT; n = 12) and exposure treatment (n = 9) for social phobia indicates that the treatment modalities are equally effective. Compared to exposure, CBT did not lead to greater pretest-posttest or pretest-follow-up improvement on self-report measures of social anxiety, cognitive symptoms, or depressed/anxious mood. Length of treatment was generally unrelated to outcome, although a larger number of exposure sessions produced better results on measures of social anxiety at posttest.

Statistical methods designed for categorical data were used to perform confirmatory factor analyses and item response theory (IRT) analyses of the Fear of Negative Evaluation scale (FNE; D. Watson & R. Friend, 1969) and the Brief FNE (BFNE; M. R. Leary, 1983). Results suggested that a 2-factor model fit the data better for both the FNE and the BFNE, although the evidence was less strong for the FNE. The IRT analyses indicated that although both measures had items with good discrimination, the FNE items discriminated only at lower levels of the underlying construct, whereas the BFNE items discriminated across a wider range. Convergent validity analyses indicated that the straightforwardly-worded items on each scale had significantly stronger relationships with theoretically related measures than did the reverse-worded items. On the basis of all analyses, usage of the straightforwardly-worded BFNE factor is recommended for the assessment of fear of negative evaluation.

Proposed in this paper is an expansion of the concept of fear of fear to include fear of other emotions (anger, depression, and positive emotions). In Study 1, initial evidence of the reliability and validity of a questionnaire designed to measure this construct, the Affective Control Scale, is provided. In Study 2, an analogue experiment of susceptibility to panic disorder was conducted. The ability of fear of anger, depression, and positive emotions to predict fear of laboratory-induced bodily sensations in a population with no history of panic attacks was demonstrated.

Response to cognitive-behavioral group therapy for social phobia was assessed at posttest and 6-month follow-up in a sample of 62 clients (41 generalized subtype, 21 nongeneralized). Predictors assessed were depression, expectancy, personality disorder traits, clinician-rated breadth and severity of impairment, and frequency of negative thoughts during social interactions. Outcome measures included self-report questionnaires and behavioral tests of dyadic interaction and a public speech. Although no predictor was related to outcome across all domains of measurement, higher depression, more avoidant personality traits, and lower treatment expectancy were each related to poorer treatment response on one or more outcome criteria. Cognitive change was consistently associated with change on self-report symptom measures, but, contrary to expectation, lower rates of negative thinking at posttest did not predict better maintenance of treatment gains at follow-up.

The reliability and validity of the Yale-Brown Obsessive-Compulsive Scale were examined according to a multi-trait multi-method approach in a sample of 54 outpatients with obsessive-compulsive disorder (OCD). Internal consistency was acceptable but was improved by deletion of items concerning resistance to obsessions and compulsions. Inter-rater reliability was excellent, but test-retest reliability over an average interval of 48.5 days was lower than desirable. The YBOCS demonstrated good convergent validity with most other measures of OCD, but divergent validity vis à vis depression was poor. Analyses of new items assessing avoidance and the duration of obsession-free and compulsion-free intervals indicated that only the avoidance rating added meaningfully to the full scale score. In future research the authors recommend deletion of the resistance items and inclusion of the avoidance item to yield a revised 9-item YBOCS total score.

Recent studies in social psychology have found that the frequency of certain words in people's speech and writing is related to psychological aspects of their personal health. We investigated whether counts of "self" and "other" pronouns used by 59 couples engaged in a problem-solving discussion were related to indices of marital health. One spouse in each couple had a diagnosis of obsessive-compulsive disorder or panic disorder with agoraphobia; 50% of the patients and 40% of their spouses reported marital dissatisfaction. Regardless of patients' diagnostic status, spouses who used more second-person pronouns were more negative during interactions, whereas those who used more first-person plural pronouns produced more positive problem solutions, even when negative behavior was statistically controlled. Moreover, use of first-person singular pronouns was positively associated with marital satisfaction. These findings suggest that pronouns used by spouses during conflict-resolution discussions provide insight into the quality of their interactions and marriages.

Abstract Psychologists in independent practice ( N = 591) were surveyed regarding their approach to treatment decisions, specifically the use of research on empirically supported treatments (ESTs) to inform practice. All participants received a case study of a patient with panic disorder, and half were randomly assigned to receive a research summary on evidence‐based treatments for panic disorder (cognitive–behavioral therapy and pharmacotherapy). Practitioners reported that they rely primarily on clinical experiences to inform treatment decisions, although they often consult EST literature. Those who received the research summary were significantly more likely to report they would use an EST. These results indicate that providing information about ESTs can impact practice. Although this sample was more positive about EST research than clinicians are often depicted to be, this study indicates an enduring research–practice gap in clinical psychology. © 2007 Wiley Periodicals, Inc. J Clin Psychol 63: 267–281, 2007.

A review of studies of cognitive-behavioral therapy (CBT) for generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia indicates that CBT is consistently more effective than waiting-list and placebo control groups. In general, CBT has proved more beneficial than supportive therapy as well. Comparisons with active behavioral treatments provide more variable results. Converging evidence suggests that cognitive change may be a strong predictor of treatment outcome, but that such change may be produced by a number of therapeutic approaches. Pretest-posttest change with CBT is depicted in meta-analytic summary form for each disorder.

Outpatient agoraphobics with panic were studied to determine the nature and extent of their alcohol use/abuse and its relationship to phobic symptoms. From 10 to 20% were alcoholic by DSM-III diagnoses, self-labeling and screening with the Michigan Alcohol Screening Test. Comparisons on self-report measures of demographically similar groups of alcoholic agoraphobics (n = 22) and non-alocholic agoraphobics (n = 21) revealed differences on a variety of etiological and current clinical dimensions. The identified alcoholics were more depressed, more socially phobic, more fearful of somatic symptoms when nervous or afraid and more likely to engage in catastrophic thinking. They also rated recent panic attacks as more intense, and reported smaller reductions in phobic avoidance when accompanied by a trusted companion. Use of alcohol to self-medicate for dysphoria was reported by 91% of the alcoholics and 43% of the nonalcoholics. Substantial proportions of the alcoholics used alcohol to reduce anxiety, to control disturbing cognitions, to accomplish necessary activities, including work or school requirements, to venture into public, and to cope with the anticipation of panic attacks. Implications for research and treatment are discussed.

The aim of this study was to address claims that among bona fide treatments no one is more efficacious than another by comparing the relative efficacy of cognitive therapy (CT) and relaxation therapy (RT) in the treatment of generalized anxiety disorder (GAD) and panic disorder without agoraphobia (PD). Two fixed-effects meta-analyses were conducted, for GAD and PD separately, to review the treatment outcome literature directly comparing CT with RT in the treatment of those disorders. For GAD, CT and RT were equivalent. For PD, CT, which included interoceptive exposure, outperformed RT on all panic-related measures, as well as on indices of clinically significant change. There is ample evidence that both CT and RT qualify as bona fide treatments for GAD and PD, for which they are efficacious and intended to be so. Therefore, the finding that CT and RT do not differ in the treatment of GAD, but do for PD, is evidence for the specificity of treatment to disorder, even for 2 treatments within a CBT class, and 2 disorders within an anxiety class.

This article presents the results of a qualitative analysis of interviews with 25 psychologists in independent practice, investigating everyday treatment decisions and attitudes about treatment outcome research and empirically supported treatments (ESTs). Clinicians noted positive aspects about treatment outcome research, such as being interested in what works. However, they had misgivings about the application of controlled research findings to their practices, were skeptical about using manualized protocols, and expressed concern that nonpsychologists would use EST lists to dictate practice. Clinicians reported practicing in an eclectic framework, and many reported including cognitive-behavioral elements in their practice. To improve their practice, they reported valuing clinical experience, peer networks, practitioner-oriented books, and continuing education when it was not too basic. Time and financial barriers concerned nearly all participants. Clinicians suggested they might be interested in ESTs if they could integrate them into their current frameworks, and if resources for learning ESTs were improved.

The impact of concurrent axis I diagnoses and axis II traits on the efficacy of a 22-session exposure-based treatment program for 43 outpatients with panic disorder and agoraphobia (PDA) and 63 with obsessive-compulsive disorder (OCD) was examined. Trained interviewers used the Structured Clinical Interview for DSM-III-R (SCID) to assess axis I diagnoses and the SCID-II to identify the number of axis II criteria met for anxious, dramatic, and odd clusters. Among axis I diagnoses, secondary major depressive disorder (MDD), dysthymia, social phobia, and generalized anxiety disorder (GAD) were present in sufficient numbers to study their effects on treatment outcome. Outcomes were assessed on self-rated target fears and functioning and on a behavioral avoidance test at post-treatment and at 6 months follow-up. Only GAD comorbidity predicted dropout, whereas MDD and all three personality cluster traits predicted post-treatment outcomes. Follow-up analyses showed significant effects of MDD and GAD, but axis II cluster criteria were not predictive.

For those with social phobia, self-focused attention has been linked with impairment in social performance, increased social anxiety, and a higher frequency of self-critical thoughts during social situations. The purpose of this investigation was to assess correlates of changes in situational self-focus over the course of cognitive-behavioral treatment (CBT). Focus of attention was assessed after in-session role-plays and after in vivo homework assignments during group CBT for social phobia. Analyses revealed a significant decrease in self-focused attention over time; focus on events and stimuli outside of the self remained unchanged. Treatment gains on anxiety during dyadic interactions, on negative self-judgments, and on personalized social fears were related to reduction in self-focused attention. Those with public speaking phobias showed a strong relationship between decreased self-focus and speech anxiety. These findings suggest that changes in self-focused attention during the course of CBT are related to important therapeutic gains. Specific interventions aimed at decreasing self-focus may be a useful treatment strategy.

Forty percent of a sample of 75 inpatient alcoholics received a lifetime diagnosis of one or more anxiety disorders. Phobic disorders were of comparable severity to those treated in phobia clinics. Alcoholics with anxiety disorders were more likely to have had major depressive disorders and to rate lower on the masculinity scale. Although the onset of anxiety disorders preceded that of alcoholism in most cases, the patients did not believe self-medication for anxiety was an important factor in triggering alcohol cbuse. Nevertheless, once both problems existed, the majority of patients with anxiety disorders (59%) indicated that they used alcohol to cope with their anxiety disorder. The data indicate that perhaps 17% of an inpatient alcoholic sample use alcohol, in part, to self medicate for anxiety. Diagnosis and treatment of anxiety disorders among this population may prove critical to relapse prevention.

This review focuses on previous research with families of adults and children with obsessive‐compulsive disorder (OCD). Three primary areas of research are covered: (i) characteristics of family members and the family environment; (ii) the prediction of treatment response based on family variables; and (iii) the inclusion of family members in treatment. Much of the research supports a hypothesized model of family response to symptoms of OCD that ranges on a continuum from overly accommodating to overly antagonistic. Further research indicates that responses at either extreme of this continuum are associated with poorer response to both exposure and response prevention (ERP) and pharmacotherapy. Finally, results of preliminary treatment outcome studies suggest that family‐based interventions aimed at reducing such responses and/or including family members in ERP as coaches or co‐therapists may enhance patients' response to treatment. Based on current theory and research, suggestions for future research and general recommendations for involving family members in treatment are made.

Directors of clinical training (83%) and directors of internships with American Psychological Asso-ciation approval (55%) responded to a survey concerning empirically validated psychological treat-ments in which their students received training. Most programs provided supervised clinical experi-ence in a number of these treatments. However, over 20% of doctoral training programs failed toprovide minimal coverage of empirically validated treatments in didactic courses, and internshipprograms typically did not require that students be competent in any of these treatments beforecompletion of the program. The absence of didactic and clinical training in empirically validatedpsychodynamic therapies and interpersonal therapy was most marked. These findings suggest thatprograms need to be more attentive to teaching data-based treatments.PAUL CRITS-CHRISTOPH received his PhD in clinical psychology fromYale University in 1984. He is currently associate professor of psychol-ogy in psychiatry and director of the Center for Psychotherapy Researchat the University of Pennsylvania. At present he is studying the effects ofbrief dynamic psychotherapy and cognitive therapy for cocaine addic-tion and for generalized anxiety disorder and is examining the processof interpersonal psychotherapy and cognitive therapy for depression.ELLEN FRANK received her PhD from the University of Pittsburgh in1979. She is professor of psychiatry and psychology in the Departmentof Psychiatry at the University of Pittsburgh School of Medicine. Shedirects the Depression and Manic-Depression Prevention Program atWestern Psychiatric Institute and Clinic. Her treatment research hasfocused on the prophylaxis of recurrent mood disorders using interper-sonal psychotherapy, pharmacotherapy, and their combination.DIANNE L. CHAMBLESS received her PhD in clinical psychology fromTemple University in 1979. She is currently professor of psychology atThe American University. She conducts research on the psychopathol-ogy and cognitive-behavioral treatment of anxiety disorders and is par-ticularly interested in psychotherapy integration and the impact of in-terpersonal relationships on anxiety.CINDY BRODY received her BA in psychology from the University ofPennsylvania in 1991 and for 3 years was a research assistant at theCenter for Psychotherapy Research. She is currently a doctoral studentin clinical psychology at The American University. Her major researchinterests are in coping, interpersonal problems, and psychotherapy pro-cess and outcome.JORDAN F. KARP received his BA in psychology from Emory University in1992. He completed 2 years as a research associate in the Depression andManic-Depression Prevention Program at Western Psychiatric Instituteand Clinic. He is currently a medical student at the University ofPittsburgh.WE THANK David Barlow, Barry Wolfe, and Division 12 for assistance

The Social Performance Rating Scale (SPRS) is a modification of the rating system for behavioral assessment of social skills, originally developed by Trower, P., Bryant, B., & Argyle, M. (1978). Social skills and mental health. Pittsburgh: University of Pittsburgh Press) and subsequently adapted by Turner and colleagues (e.g., Turner, S.M., Beidel, D.C., Dancu, C.V., & Keys, D.J. (1986). Psychopathology of social phobia and comparison to avoidant personality disorder. Journal of Abnormal Psychology, 95, 389-394). Designed to yield ratings of social performance appropriate for use in a socially phobic population and based on videotaped role plays, the five SPRS ratings are gaze, vocal quality, speech length, discomfort, and conversation flow. The sum of these ratings provides an internally consistent total score. In an initial study of the psychometric properties of the SPRS, three groups were assessed: individuals with social phobia, another anxiety disorder, or no psychological disorder. Inter-rater reliability for individual items and the total score proved excellent, and positive evidence for convergent, divergent, and criterion-related validity was obtained.

The relationship between adherence to group cognitive-behavioral treatment instructions and outcome was examined for 52 social phobic clients. Less symptomatic clients were no more likely to adhere to treatment instructions than more highly symptomatic clients. Clients were less likely to participate during group treatment sessions if they were higher on avoidant personality traits, and were less likely to complete self-directed exposures if they were more paranoid. Dependent clients tended to complete homework assignments more than less dependant clients. With one exception, adherence to treatment instructions for between session homework was not related to any of the outcome measures at the completion of treatment. However, at the 6-month follow-up, clients who adhered more to homework instructions reported less anxiety during the speech, and also tended to report greater decrements in anxiety and larger changes in their avoidant behavior. These data suggest that homework may be more important in the long-run, when the therapist is no longer present to prompt exposure.

Multiple baseline evaluation of systematic aerobic exercise in the treatment of four clinically depressed women confirmed the value of this mode of treatment compared to an attention placebo. The methodology included control of expectancy, time in treatment, exercise effects, and the use of adjunctive treatments. The results suggest substantial exercise-induced effects on several qualities of depression, including mood and cognitive function. These gains were maintained at a 3-month follow-up evaluation.

Patterns of habituation of subjective anxiety during flooding in fantasy are delineated for eleven obsessive-compulsive and six agoraphobic patients. The majority showed a curvilinear pattern of subjective anxiety response, while three patients showed a linear decelerating pattern. Habituation was found both within and across sessions. The results are compared with habituation patterns in physiological responses during flooding in fantasy and in vivo.

Abstract To identify barriers to the dissemination of empirically supported treatments (ESTs), a random sample of psychologists in independent practice ( N =1291) was asked to complete measures of attitudes towards ESTs and willingness to attend a 3‐hour, 1‐day, or 3‐day workshop in an EST of their choice. The strongest predictor of unwillingness to obtain EST training was the amount of time and cost required for the workshop, followed by objections to the need for EST training. Psychodynamic (compared to cognitive‐behavioral) and more experienced practitioners agreed more strongly with the objections to ESTs overall, as did those whose graduate schools had not emphasized psychotherapy research. Results suggest that both practical and theoretical barriers are significant obstacles to EST dissemination. © 2011 Wiley Periodicals, Inc. J Clin Psychol 67:1–16, 2011.

Background: Despite the considerable efficacy of cognitive-behavioral therapy (CBT) for panic disorder (PD) and agoraphobia, a substantial minority of patients fail to improve for reasons that are poorly understood. Objective: The aim of this study was to identify consistent predictors and moderators of improvement in CBT for PD and agoraphobia. Data sources: A systematic review and meta-analysis of articles was conducted using PsycInfo and PubMed. Search terms included panic, agoraphobi*, cognitive behavio*, CBT, cognitive therapy, behavio* therapy, CT, BT, exposure, and cognitive restructuring. Study selection: Studies were limited to those employing semi-structured diagnostic interviews and examining change on panic- or agoraphobia-specific measures. Data extraction: The first author extracted data on study characteristics, prediction analyses, effect sizes, and indicators of study quality. Interrater reliability was confirmed. Synthesis: 52 papers met inclusion criteria. Agoraphobic avoidance was the most consistent predictor of decreased improvement, followed by low expectancy for change, high levels of functional impairment, and Cluster C personality pathology. Other variables were consistently unrelated to improvement in CBT, understudied, or inconsistently related to improvement. Limitations: Many studies were underpowered and failed to report effect sizes. Tests of moderation were rare. Conclusions: Apart from agoraphobic avoidance, few variables consistently predict improvement in CBT for PD and/or agoraphobia across studies.

Article AbstractObjective: To compare cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), and applied relaxation training (ART) for primary DSM-IV panic disorder with and without agoraphobia in a 2-site randomized controlled trial.Method: 201 patients were stratified for site and DSM-IV agoraphobia and depression and were randomized to CBT, PFPP, or ART (19-24 sessions) over 12 weeks in a 2:2:1 ratio at Weill Cornell Medical College (New York, New York) and University of Pennsylvania ("Penn"; Philadelphia, Pennsylvania). Any medication was held constant.Results: Attrition rates were ART, 41%; CBT, 25%; and PFPP, 22%. The most symptomatic patients were more likely to drop out of ART than CBT or PFPP (P = .013). Outcome analyses revealed site-by-treatment interactions in speed of Panic Disorder Severity Scale (PDSS) change over time (P = .013). At Cornell, no differences emerged on improvement on the primary outcome, estimated speed of change over time on the PDSS; at Penn, ART (P = .025) and CBT (P = .009) showed greater improvement at treatment termination than PFPP. A site-by-treatment interaction (P = .016) for a priori-defined response (40% PDSS reduction) showed significant differences at Cornell: ART 30%, CBT 65%, PFPP 71% (P = .007), but not at Penn: ART 63%, CBT 60%, PFPP 48% (P = .37). Penn patients were more symptomatic, differed demographically from Cornell patients, had a 7.2-fold greater likelihood of taking medication, and had a 28-fold greater likelihood of taking benzodiazepines. However, these differences did not explain site-by-treatment interactions.Conclusions: All treatments substantially improved panic disorder with or without agoraphobia, but patients, particularly the most severely ill, found ART less acceptable. CBT showed the most consistent performance across sites; however, the results for PFPP showed the promise of psychodynamic psychotherapy for this disorder.Trial Registration: ClinicalTrials.gov identifier: NCT00353470

Psychometric properties of the Beck Anxiety Inventory (BAI) (Beck and Steer, 1990) were investigated in a sample of 82 patients suffering from panic disorder with agoraphobia. Before and after brief treatment, patients completed a battery of questionnaires and, for 2-week periods, kept a daily panic diary in which they recorded panic attacks, fear of panic, and average anxiety. The BAI demonstrated excellent internal consistency and good test-retest reliability over a 5-week interval. A partial multitrait, multimethod correlation matrix provided evidence of convergent validity with other measures of anxiety and of divergent validity vis á vis measures of depression. Factor analyses of pretest scores and residual gain scores used to address criticism that the BAI is excessively panic-centric yielded mixed results. In one analysis, the BAI was loaded with multimethod measures of panic and anxiety and, in the other, with questionnaire methods of assessing anxiety and depression. However, the BAI was clearly distinguished from measures of fear of fear, a central construct in panic disorder, and agoraphobic avoidance. Finally, the BAI proved sensitive to change with treatment, yielding effect sizes for improvement comparable to those of other anxiety measures.

Two studies with college students were conducted to further explore the reliability and construct validity of fear of emotion, as assessed by the Affective Control Scale (ACS), a measure of fear of anxiety, depressed mood, anger, and strong positive emotion. The ACS fared well in tests of internal consistency and of convergent and divergent validity. In an analogue study of panic onset with college students with no history of panic, the predictive and incremental validity of the ACS was demonstrated: the ACS predicted students' fear of induced panic-like bodily sensations even once trait and state anxiety were statistically controlled. A second aspect of the investigation was an analogue test of the hypothesis that stress from interpersonal conflict (induced via remembrance of conflictual interactions with an important person) would moderate the ACS's effects on anxiety and fear of induced bodily sensations. This hypothesis was not confirmed.

The effect of comorbid avoidant personality disorder (APD) on response to exposure-based treatment for social phobia was examined in a sample of 48 outpatients with generalized social phobia. Diagnoses were based on the Structured Clinical Interview for DSM-III-R. At pretest, clients with APD were more severely impaired on all self-report measures and had a higher frequency of comorbid diagnoses than those without the disorder. Although clients with APD improved significantly with treatment, they continued to report more severe impairment on all outcome measures at posttest and 3-month follow-up as compared to those without APD. Depression may in part explain the poorer rate of improvement during treatment of those with APD.

Misconceptions apparent in Garfield's comments on the report of the Division 12 Task Force on Promotion and Dissemination of Psychological Procedures are corrected. Issues concerning the use of manuals in psychotherapy training and practice and the value of specific treatments for specific problems are discussed.

In a series of experiments we extended the research on possible memory deficits in subclinical obsessive-compulsive Ss who reported excessive checking. Using a variety of memory tests we compared 20 subclinical checkers to 20 Ss without obsessive-compulsive symptomatology. Contrary to hypothesis, checkers remembered self-generated words better than read words just as much as did normals, but they were more likely than normals to report thinking they had studied words that, in fact, had not been on the study list. Further, they more often confused whether they read or generated the words at study. Checkers did not appear to perseverate on already-recalled words on repeated free recall tests any more than did normals. However, checkers remembered fewer actions overall and more often misremembered whether they had performed, observed, or written these actions. Such memory deficits may contribute to the development of excessive checking.

The relationship between compliance with cognitive-behavioral treatment instructions and outcome was examined for 56 agoraphobic clients treated with in vivo exposure and training in anxiety management strategies. Clients who complied more often with anxiety management instructions during treatment sessions tended to improve more on a behavioral avoidance test than those who were less compliant, but did not differ on three other outcome variables. Compliance with instructions for self-directed exposure between sessions was examined in a subset of 28 of these Ss. Clients who spent more time doing homework reported significantly greater decrements in fear of fear than less compliant clients and also tended to report larger changes on avoidance behavior. However, a quasi-experimental comparison of homework vs no-homework treatment protocols yielded no difference in outcome. Less compliant clients were more symptomatic pretreatment and rated their therapists as less caring and less self-confident.

The relationship between six therapist characteristics and outcome of in vivo exposure treatment for 33 agoraphobic clients was examined in a prospective study. Clients who rated their therapists as more self-confident and those who perceived their therapists to be more caring and involved were significantly more likely to improve on a behavioral avoidance test. Contrary to prior retrospective research, therapists' being perceived as explicit or challening was not a significant predictor of outcome.

Abstract Male and female outpatient agoraphobic clients were compared on a range of measures of personality and psychopathology related to agoraphobia. Few sex differences emerged. Women were slightly more avoidant when alone, and men reported more concern about hurting someone when anxious. Sex-role inventory measures of masculinity were inversely related to severity of avoidance behavior and other measures of psychopathology, and sex differences on avoidance were accounted for by sex differences on masculinity. Both male and female agoraphobics were lower on masculinity than a normative sample. When response to treatment was compared, men and women showed equivalent improvement with the exception of panic frequency on which women showed a poorer outcome.

An intensive group treatment approach for avoidant personality disorder (APD) was devised and evaluated. Seventeen patients with APD participated in a 4-day group treatment program. Treatment included group systematic desensitization, behavioral rehearsal, and self-image work. Outcome was assessed at posttest and 1-year follow-up on self-report measures of social anxiety, social functioning, depression, and self-image. In addition to a MANOVA, results of reliable and clinically significant change are presented. Significant change was observed on the measures as a group. The most notable change was on the Fear of Negative Evaluation scale, where 40% of the sample were recovered at posttest. The results of this program are promising, although the need for a more extended period of treatment is apparent.

The Crandell Cognitions Inventory (CCI) was demonstrated to be a valid and reliable measure of self-reported frequency of depressive thoughts developed on a clinically depressed population. The items individually and the scale as a whole significantly discriminate the cognitions of clinically depressed individuals from the thoughts of a nondepressed, psychiatric control group and a normal control group. The CCI demonstrates high internal consistency and a strong relationship to depth of depression. As predicted the scale has a moderately high correlation with depressive/distorted attitudes but shows little relationship to an extraneous variable: intelligence. As in other studies of depressive cognitions, no sex differences were found on the CCI. The results lend support to Beck's hypothesis that different nosological groups can be discriminated on the basis of specific cognitive content, and the results of a factor analysis support Beck's theory that the thoughts of depressed individuals are characterized by negative views of the self and the future. Partial support is provided for Beck's postulate that depressives hold negative views of the world.

The relationships of avoidance behavior and panic frequency with other measures of psychopathology in a large sample of agoraphobic outpatients are examined and implications for research and treatment discussed.

Twenty-seven agoraphobic outpatients received eight sessions of flooding in fantasy with anxiety, flooding in fantasy with intravenous Brevital, or an attention-control procedure. Results on subjective rating scales provide some support for the hypothesis that agoraphobic clients benefit more from experiencing anxiety during flooding. No significant differences were found on a behavioral task. These results differ from previous findings where diazepam (Valium) was found to have no effect on outcome or to enhance improvement in agoraphobics. The discrepancy may be due to differences in the procedure.

Abstract Isolated sleep paralysis (ISP) has received scant attention in clinical populations, and there has been little empirical consideration of the role of fear in ISP episodes. To facilitate research and clinical work in this area, the authors developed a reliable semistructured interview (the Fearful Isolated Sleep Paralysis Interview) to assess ISP and their proposed fearful ISP (FISP) episode criteria in 133 patients presenting for panic disorder treatment. Of these, 29.3% met lifetime ISP episode criteria, 20.3% met the authors' lifetime FISP episode criteria, and 12.8% met their recurrent FISP criteria. Both ISP and FISP were associated with minority status and comorbidity. However, only FISP was significantly associated with posttraumatic stress disorder, body mass, anxiety sensitivity, and mood and anxiety disorder symptomatology. © 2010 Wiley Periodicals, Inc. J Clin Psychol 66:1–15, 2010.

Objective The contributions of disorder severity, comorbidity and interpersonal variables to therapists' adherence to a cognitive–behavioural treatment (CBT) manual were tested. Method Thirty‐eight patients received panic control therapy (PCT) for panic disorder. Trained observers watching videotapes of the sixth session of a 24‐session protocol rated therapists' adherence to PCT and their use of interventions from outside the CBT model. Different observers rated patients' behavioural resistance to therapy in the same session using the client resistance code. Interview measures obtained before treatment included the Panic Disorder Severity Scale, the anxiety disorders interview schedule for Diagnostic and Statistical Manual of Mental Disorders (DSM)‐IV and the structured clinical interview for DSM‐IV, Axis II. Questionnaire measures were the anxiety sensitivity index at intake, and, at session 2, the therapist and client versions of the working alliance inventory—short form. Results The higher the patients' resistance and the more Axis II traits a patient had, the less adherent the therapist. Moreover, the more resistant the client, the more therapists resorted to interventions from outside the CBT model. Stronger therapist and patient alliance was also generally related to better adherence, but these results were somewhat inconsistent across therapists. Pretreatment disorder severity and comorbidity were not related to adherence. Conclusions Interpersonal variables, particularly behavioural resistance to therapy, are related to therapists' ability to adhere to a treatment manual and to their use of interventions from outside of the CBT model. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner message Patients' behavioural resistance to therapy may make it more difficult for cognitive–behavioural clinicians to adhere to a structured treatment protocol and more likely for them to borrow interventions from outside the CBT model. Patients' Axis II traits may make adherence to treatment CBT protocol more difficult, although whether this is true varies across therapists. Therapists' adherence to a structured protocol and borrowing from outside of the CBT model do not appear to be affected by disorder severity or Axis I comorbidity.

Although poor adherence to hormonal therapies such as aromatase inhibitors (AIs) is widely documented, to the authors' knowledge less is known regarding whether health beliefs predict treatment nonadherence. The objective of the current study was to evaluate the relationship between health beliefs (perceived susceptibility to breast cancer, perceived benefits of AI treatment, and perceived barriers to AI treatment) and adherence to AIs.Postmenopausal women with early-stage, estrogen receptor-positive breast cancer who were currently receiving treatment with an AI completed the 3-factor Health Beliefs and Medication Adherence in Breast Cancer scale and questionnaires concerning their demographics and symptoms. Adherence data (treatment gaps and premature discontinuation) were abstracted from participants' medical charts. Logistic regression analyses were conducted to evaluate the relationship between health beliefs and adherence.Among 437 participants, 93 (21.3%) were nonadherent. Those who perceived greater barriers to their AI treatment were more likely to demonstrate AI nonadherence behaviors by the end of their treatment period compared with those who reported fewer barriers to AI therapy (adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.86 [P = .04]). In contrast, perceived susceptibility to cancer recurrence and perceived benefits of AIs did not appear to predict AI adherence. Minority individuals were found to have lower perceived susceptibility to breast cancer recurrence and higher perceived barriers to AI treatment (P<.05 for both).Greater perceived barriers appeared to predict nonadherence to AIs. Interventions addressing women's negative beliefs regarding the challenges of AI treatment are needed to help optimize adherence in survivors of breast cancer. Cancer 2017;169-176. © 2016 American Cancer Society.

This chapter describes the process by which psychotherapy research is conducted, and the controversies surrounding the proper nature and role of such research. Comparisons of psychotherapy with medication and with the combination of medication and psychotherapy are frequently conducted. Psychotherapy research is a broad field encompassing a number of streams of research. Outcome research focuses on the effects of psychotherapy, both immediate and long-term changes in the problems for which a person seeks or is referred for treatment, as well as improvement on broader variables such as quality of life or interpersonal functioning. The amount of information that must be processed in psychotherapy is enormous and taxes the cognitive capacity of humans as information processors. Cognitive-behavioral researchers have been at the forefront of developing treatment manuals and protocols, and the preponderance of empirically supported treatment research has been in cognitive-behavioral treatments.

Confirmatory factor analysis was used to explore a 3-factor model of expressed emotion (Criticism, Emotional Overinvolvement, and Positivity) in a sample of 104 outpatients with agoraphobia or obsessive-compulsive disorder and 104 relatives of these patients. Multiple methods of measurement included the Camberwell Family Interview, observation of verbal and nonverbal behaviors during patient-relative problem-solving interactions, and ratings of relatives' behavior made by patients and by relatives. The convergent validity of the 3 individual constructs was demonstrated through single-factor models fitted to Criticism, Positivity, and Emotional Overinvolvement measures. A 3-factor model was then estimated and determined to provide adequate fit to the data, thus demonstrating the distinctiveness of the constructs. Criticism and Positivity were strongly and negatively correlated, whereas Emotional Overinvolvement bore little relationship to the other 2 factors.

The relationship of expressed emotion (EE) to behavior therapy outcome for obsessive-compulsive disorder (n = 60) and panic disorder with agoraphobia (n = 41) was investigated. Relatives' emotional overinvolvement and hostility predicted higher rates of treatment dropout. Higher hostility, as assessed by the Camberwell Family Interview (CFI), was related to poorer outcome for target ratings and for the Social Adjustment Scale; higher perceived criticism was also predictive of worse response on target ratings. In contrast, nonhostile criticism on the CFI was associated with better outcome on the behavioral avoidance test. In general, the relationship of EE to outcome was not moderated by type of relative, diagnosis, amount of contact with the relative, or use of psychotropic medication.

The Structured Clinical Interview for DSM-III-R, Axis II and the Millon Clinical Multiaxial Inventory: A Concurrent Validity Study of Personality Disorders Among Anxious OutpatientsBabette Renneberg, Dianne L. Chambless, Deborah J. Dowdall, James A. Fauerbach and Edward J. GracelyBabette Renneberg1 The Agoraphobia and Anxiety Treatment Center, and Temple University Medical School.Search for more papers by this author, Dianne L. Chambless2 The American University.Requests for reprints should be sent to Dianne L. Chambless. PhD, Department of Psychology, The American University, Washington, DC 20016-8062.Search for more papers by this author, Deborah J. Dowdall3 The Agoraphobia and Anxiety Treatment Center.Search for more papers by this author, James A. Fauerbach3 The Agoraphobia and Anxiety Treatment Center.Search for more papers by this author and Edward J. Gracely3 The Agoraphobia and Anxiety Treatment Center.Search for more papers by this authorPublished Online:February 2011https://doi.org/10.1521/pedi.1992.6.2.117PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations About Previous article Next article FiguresReferencesRelatedDetails Cited byCited by1. Comparison of Cognitive Behavioral Therapy and Cognitive Behavioral Group Therapy in the Treatment of Avoidant Personality DisorderOnline publication date: 30 June 2023. Go to citation Crossref Google Scholar2. Pregnancy in Prison, Mental Health and Alternative ApproachesOnline publication date: Go to citation Crossref Google Scholar3. Pregnancy in prison, mental health and admission to prison mother and baby unitsOnline publication date: 15 March 2019. Go to citation Crossref Google Scholar4. 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Antisocial Personality DisorderOnline publication date: Go to citation Crossref Google Scholar Volume 6Issue 2Jun 1992 Information© 1992 The Guilford PressPDF download

Few treatment outcome studies of Obsessive Compulsive Disorder (OCD) have employed Behavioral Avoidance Tests (BATs) to assess changes in symptomatology, probably because of the difficulty of constructing such tests for a disorder which has widely varying symptoms. The few studies that have examined the psychometric properties of BATs for OCD have found mixed evidence for validity but good treatment sensitivity. The present study presents psychometric findings for a multi-step/multi-task BAT that assessed percentage of steps completed, subjective anxiety, global avoidance, and rituals. This measure was used with 50 clients diagnosed with OCD whose symptoms varied widely. The BAT demonstrated good convergent and divergent validity, as well as treatment sensitivity according to effect size calculations. A composite score combining steps, anxiety level, avoidance and rituals also performed well in psychometric tests. Strategies to reduce the complexity of scoring are presented, along with examples of several BAT tasks to enable researchers to employ this behavioral measure.

In a randomized controlled trial, eye movement desensitization and reprocessing (EMDR) for panic disorder with agoraphobia (PDA) was compared with both waiting list and credible attention-placebo control groups. EMDR was significantly better than waiting list for some outcome measures (questionnaire, diary, and interview measures of severity of anxiety, panic disorder, and agoraphobia) but not for others (panic attack frequency and anxious cognitions). However, low power and, for panic frequency, floor effects may account for these negative results. Differences between EMDR and the attention-placebo control condition were not statistically significant on any measure, and, in this case, the effect sizes were generally small (eta2 = .00-.06), suggesting the poor results for EMDR were not due to lack of power. Because there are established effective treatments such as cognitive-behavior therapy for PDA, these data, unless contradicted by future research, indicate EMDR should not be the first-line treatment for this disorder.

The prevalence of personality disorders among 165 agoraphobic outpatients was assessed with the Million Clinical Multiaxial Inventory, Versions I or II. Over 90% of clients met criteria for one or more Axis II diagnoses, the most common of which were avoidant and dependent. Scores on the personality scales were not significantly related to agoraphobic avoidance or panic frequency, but were often related to social phobia and dysphoria. Avoidant, dependent, and histrionic, but not severe personality disorders, were significantly associated with one or more indices of outcome for a sample of 64 clients in a naturalistic psychosocial treatment study, whereas paranoid PD was linked with early termination (< 10 sessions). The most consistent predictor was avoidant personality; clients with this Axis II disorder fared more poorly on agoraphobic and social phobic avoidance and on depression.

The effects of massed versus spaced in vivo exposure sessions were compared in the treatment of 19 agoraphobic and 17 simple phobic outpatients. Subjects received ten 90-min sessions of therapist-assisted exposure and were assessed with self-report measures, a behavioral diary, and a behavioral avoidance test. There were no differences between the two methods of treatment at either posttest or 6-months follow-up with one exception—a frequency of significat findings which would be expected in light of the experimental wise error rate Contrary to assertions in the literature, massed subjects were no more likely to drop out of treatment or to relapse during the follow-up period. Subjects who entered the treatment program rated the two methods of delivery as equally stressful, but unsystematic observation indicated that massed treatment was less acceptable to some potential clients who refused treatment rather than accept random assignment.

Participants with generalized social phobia (GSP) with (n=36) and without (n=19) avoidant personality disorder (AVPD) were compared via contrasts of group means and classification analysis on purported core features of AVPD. GSP-AVPD participants proved to be more severely impaired or distressed on some group contrasts. Cluster analysis identified two groups in the sample, with group membership significantly correlated to AVPD diagnosis. However, almost all significant findings were nullified when severity of social phobia was statistically controlled. Thus, at least where participants with social phobia are concerned, it seems most parsimonious to consider AVPD a severe form of GSP rather than a separate diagnostic category.

The empirical literature on the relationship between moral thought-action fusion (TAF) and obsessive-compulsive disorder (OCD) is characterized by mixed findings. Previous studies have reported religious group differences in moral TAF and the relationship between moral TAF and religiosity. In light of those studies and considering the apparent role of moral TAF in scrupulosity, the purpose of this investigation was to evaluate the possible role of religion as a moderator of the relationship between moral TAF and OCD symptoms. The results revealed that (a) Christians endorsed higher levels of moral TAF than did Jews independent of OCD symptoms; (b) religiosity was correlated with moral TAF in Christians but not in Jews, suggesting that Christian religious adherence is related to beliefs about the moral import of thoughts; and (c) moral TAF was related to OCD symptoms only in Jews. That is, for Christians, moral TAF was related to religiosity but not OCD symptoms, and for Jews, moral TAF was related to OCD symptoms but not religiosity. These results imply that moral TAF is only a marker of pathology when such beliefs are not culturally normative (e.g., as a function of religious teaching or doctrine).

The present study explored the effect of perceived criticism (PC) on levels of anxiety and depression during behavioral treatment among patients diagnosed with obsessive-compulsive disorder (OCD) or panic disorder with agoraphobia (PDA). We posited that patients' perceptions of relatives' criticism and the degree to which they were upset by the criticism (UC) would be related to negative affect and discomfort during exposure. The sample included 75 patients with a primary diagnosis of OCD (n=43) or PDA (n=32) and their participating relatives. Measures of patients' weekly ratings of PC and upset about the criticism, anxious and depressed mood, and subjective discomfort during exposure treatment were analyzed using a mixed model regression approach (SAS Proc Mixed). Patients' anxious and depressed mood predicted greater discomfort during exposure. Patients who were more UC also had higher weekly ratings of anxiety and depression, and more discomfort during exposure sessions. Findings suggest that treatment outcome may be improved by attention to patients' reactions to their interpersonal environment.

Expressed emotion (EE) has been linked to negative outcomes for a variety of psychiatric illnesses. Despite development of effective interventions to reduce EE, relatively little is known about EE's antecedents or maintaining factors. The present study uses a novel methodology (measurement of pronouns used by relatives during the Camberwell Family Interview [CFI] or a problem‐solving interaction with the patient) to explore possible cognitive correlates of EE. Participants were 98 outpatients with obsessive‐compulsive disorder or panic disorder with agoraphobia and their primary relative. Results showed that relatives' pronoun use was stable across situations. Relatives' hostility and criticism, as measured by objective coding of relatives' behavior during the CFI and interactions, respectively, were related to relatives' decreased we ‐focus and increased me ‐focus in the 2 situations. In contrast to expectations, relatives' emotional overinvolvement was related to their decreased we ‐focus during CFIs and interactions. Results support the value of using pronouns as a means to explore important aspects of relationship functioning.

Aims of this study were (a) to summarize the psychometric literature on the Mobility Inventory for Agoraphobia (MIA), (b) to examine the convergent and discriminant validity of the MIA's Avoidance Alone and Avoidance Accompanied rating scales relative to clinical severity ratings of anxiety disorders from the Anxiety Disorders Interview Schedule (ADIS), and (c) to establish a cutoff score indicative of interviewers’ diagnosis of agoraphobia for the Avoidance Alone scale. A meta-analytic synthesis of 10 published studies yielded positive evidence for internal consistency and convergent and discriminant validity of the scales. Participants in the present study were 129 people with a diagnosis of panic disorder. Internal consistency was excellent for this sample, α = .95 for AAC and .96 for AAL. When the MIA scales were correlated with interviewer ratings, evidence for convergent and discriminant validity for AAL was strong (convergent r with agoraphobia severity ratings = .63 vs. discriminant rs of .10–.29 for other anxiety disorders) and more modest but still positive for AAC (.54 vs. .01–.37). Receiver operating curve analysis indicated that the optimal operating point for AAL as an indicator of ADIS agoraphobia diagnosis was 1.61, which yielded sensitivity of .87 and specificity of .73.

Objectives To determine whether social anxiety covaries with satisfaction, social support, and intimacy in romantic relationships. Method Undergraduates and their romantic partners ( N = 163) completed self‐report questionnaires. Results Higher social anxiety in women, but not men, was associated with wanting, receiving, and providing less support, based on self‐ but not partner‐report measures. Women higher in social anxiety also reported being less satisfied in their romantic relationships and self‐disclosing less to romantic partners than women lower in social anxiety. Further, self‐reported received support mediated the relationship between social anxiety and romantic relationship satisfaction in women. In both sexes, higher social anxiety was related to perceiving intimacy as riskier and romantic relationships as less emotionally intimate. Conclusions Together, results suggest that social anxiety is associated with interpersonal difficulty even in established romantic relationships.

Little is known about the quality of socially anxious individuals' romantic relationships. In the present study, we examine associations between social anxiety and social support in such relationships. In Study 1, we collected self-report data on social anxiety symptoms and received, provided, and perceived social support from 343 undergraduates and their romantic partners. One year later couples were contacted to determine whether they were still in this relationship. Results indicated that men's social anxiety at Time 1 predicted higher rates of breakup at Time 2. Men's and women's perceived support, as well as men's provided support, were also significantly predictive of breakup. Social anxiety did not interact with any of the support variables to predict breakup. In Study 2, a subset of undergraduate couples with a partner high (n=27) or low (n=27) in social anxiety completed two 10-minute, lab-based, video-recorded social support tasks. Both partners rated their received or provided social support following the interaction, and trained observers also coded for support behaviors. Results showed that socially anxious individuals received less support from their partners during the interaction according to participant but not observer report. High and lower social anxiety couples did not differ in terms of the target's provision of support. Taken together, results suggest that social anxiety is associated with difficulties even in the context of established romantic relationships. Clinical implications are discussed.

Panic disorder (PD) is associated with significant personal, social, and economic costs. However, little is known about specific interpersonal dysfunctions that characterize the PD population. The current study systematically examined these interpersonal dysfunctions.The present analyses included 194 patients with PD out of a sample of 201 who were randomized to cognitive-behavioral therapy, panic-focused psychodynamic psychotherapy, or applied relaxation training. Interpersonal dysfunction was measured with the Inventory of Interpersonal Problems-Circumplex (Horowitz, Alden, Wiggins, & Pincus, 2000).Individuals with PD reported greater levels of interpersonal distress than that of a normative cohort (especially when PD was accompanied by agoraphobia), but lower than that of a cohort of patients with major depression. There was no single interpersonal profile that characterized PD patients. Symptom-based clusters (with vs. without agoraphobia) could not be discriminated on core or central interpersonal problems. Rather, as revealed by cluster analysis based on the pathoplasticity framework, there were 2 empirically derived interpersonal clusters among PD patients that were not accounted for by symptom severity and were opposite in nature: domineering-intrusive and nonassertive. The empirically derived interpersonal clusters appear to be of clinical utility in predicting alliance development throughout treatment: Although the domineering-intrusive cluster did not show any changes in the alliance throughout treatment, the nonassertive cluster showed a process of significant strengthening of the alliance.Empirically derived interpersonal clusters in PD provide clinically useful and nonredundant information about individuals with PD.

In Salkovskis' [Salkovskis, P. (1985). Obsessional-compulsive problems: a cognitive-behavioural analysis. Behaviour Research and Therapy, 28, 571-588; Salkovskis P. (1989) Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677-682] cognitive model for obsessive-compulsive disorder (OCD), inflated perception of responsibility is highlighted as the critical feature that maintains the disorder. In the current study, the relationship between responsibility and obsessive-compulsive (OC) symptoms was examined. Specifically, three measures of responsibility were evaluated for their psychometric properties. These measures were then used to test Salkovskis's model by examining the relationships among pervasive responsibility, automatic thoughts related to causing harm, and OC symptom severity. Findings provide partial support for the validity and reliability of the measures and for the model as a whole. Based on regression analyses, data support that pervasive responsibility significantly contributes to the prediction of OC symptoms. Furthermore, this relationship appears to be mediated by automatic thoughts related to causing harm in OCD contexts.

In prospective research, psychiatric patients' perceived criticism (PC) from family members has been linked to higher rates of relapse and worse treatment outcome. Researchers have disagreed about whether PC contributes to poor treatment outcomes or whether it merely reflects the severity of a patient's disturbance. In this study, structural equation modeling was used to conduct a cross-lagged panel analysis of the relationship between PC and anxiety symptom severity assessed before and after treatment in anxiety-disordered patients. PC was found to be unrelated to concurrent symptom severity. Furthermore, pretreatment PC significantly predicted posttreatment symptom severity over and above the effect of pretreatment symptom severity, whereas pretreatment symptom severity failed to significantly predict posttreatment PC. Thus, these results are consistent with (although not proof of) the hypothesis that PC detracts from patients' ability to respond to treatment, and inconsistent with the hypothesis that PC is a reflection of a patient's symptom severity.

Luborsky et al.'s conclusion that there are no meaningful differences in the efficacy of various psychothera-pies should be reconsidered for the following reasons: (a) errors in data analysis, (b) exclusion of research on many types of clients (e.g., children and adolescents), (c) faulty generalization to comparisons between therapies that have never been made, and (d) erroneous assumption that the average difference between all sorts of treatments for all sorts of problems can be assumed to represent the difference between any two types of treatment for a given problem. Concern for clients' welfare demands that psychologists be very wary of accepting the Dodo bird verdict.

The effects of social phobia subtypes and of comorbid avoidant personality disorder (APD) on the symptoms of 45 outpatients with a primary diagnosis of social phobia were examined. Generalized social phobic subjects with (GSP-APD, n = 16) and without APD (GSP-NAPD, n = 13) reported greater social anxiety and fear of negative evaluation than specific social phobic subjects without APD (SSP-NAPD, n = 16). Compared to SSP-NAPD clients, GSP-APD clients tended to exhibit poorer social skills during behavioral testing and were more likely to be unmarried and to use medication. GSP-APD subjects were more depressed than both SSP-NAPD and GSP-NAPD subjects, while non-APD groups did not differ. The results showed that both social phobia subtype and APD comorbidity contributed to the differences found among the three subgroups of social phobic clients.

It has been repeatedly demonstrated that clinicians rely more on clinical judgment than on research findings. We hypothesized that psychologists in practice might be more open to adopting empirically supported treatments (ESTs) if outcome results were presented with a case study. Psychologists in private practice (N=742) were randomly assigned to receive a research review of data from randomized controlled trials of cognitive-behavioral treatment (CBT) and medication for bulimia, a case study of CBT for a fictional patient with bulimia, or both. Results indicated that the inclusion of case examples renders ESTs more compelling and interests clinicians in gaining training. Despite these participants' training in statistics, the inclusion of the statistical information had no influence on attitudes or training willingness beyond that of the anecdotal case information.

Twenty-one agoraphobics participated in a 6-month study designed to (a) compare imaginal flooding under high- (no sedation) and low- (sedation used) anxiety conditions: (b) examine the long-term effects of imaginal flooding in the absence of further exposure treatment; and (c) explore the impact of communications training on chronic anxiety and panic attacks. A reevaluation of the effects of sedation is presented in this report. Imaginal flooding without sedation was, on the whole, superior to the attention control placebo and imaginal flooding with sedation on therapists' and clients' ratings of fear and avoidance. However, the superiority of the non-drug flooding group cannot be attributed (as was concluded in an earlier report) to higher levels of anxiety across flooding sessions. Rather the drug (methohexitone sodium) appears to have impeded across-session habituation, perhaps by interfering with long-term memorial processes. The effects of imaginal flooding without sedation were stable over 4 months without further exposure treatment. These clients did receive training in solving important interpersonal problems through self monitoring and increased expressiveness. Contrary to hypotheses, not only was no further improvement obtained on fear and avoidance with this treatment, but also anxious mood and panic attacks remained unaffected. It is surprising to note that in-vivo treatment was no more effective than imaginal flooding on fear and avoidance. These and other findings suggest imaginal flooding well warrants further study.

Abstract Background The hippocampus plays an important role in psychopathology and treatment outcome. While posterior hippocampus (PH) may be crucial for the learning process that exposure-based treatments require, affect-focused treatments might preferentially engage anterior hippocampus (AH). Previous studies have distinguished the different functions of these hippocampal sub-regions in memory, learning, and emotional processes, but not in treatment outcome. Examining two independent clinical trials, we hypothesized that anterior hippocampal volume would predict outcome of affect-focused treatment outcome [Interpersonal Psychotherapy (IPT); Panic-Focused Psychodynamic Psychotherapy (PFPP)], whereas posterior hippocampal volume would predict exposure-based treatment outcome [Prolonged Exposure (PE); Cognitive Behavioral Therapy (CBT); Applied Relaxation Training (ART)]. Methods Thirty-five patients with posttraumatic stress disorder (PTSD) and 24 with panic disorder (PD) underwent structural magnetic resonance imaging (MRI) before randomization to affect-focused (IPT for PTSD; PFPP for PD) or exposure-based treatments (PE for PTSD; CBT or ART for PD). AH and PH volume were regressed with clinical outcome changes. Results Baseline whole hippocampal volume did not predict post-treatment clinical severity scores in any treatment. For affect-focused treatments, but not exposure-based treatments, anterior hippocampal volume predicted clinical improvement. Smaller AH correlated with greater affect-focused treatment improvement. Posterior hippocampal volume did not predict treatment outcome. Conclusions This is the first study to explore associations between hippocampal volume sub-regions and treatment outcome in PTSD and PD. Convergent results suggest that affect-focused treatment may influence the clinical outcome through the ‘limbic’ AH, whereas exposure-based treatments do not. These preliminary, theory-congruent, therapeutic findings require replication in a larger clinical trial.

The relationship between fear of physical anxiety symptoms and cognitive misinterpretation of those symptoms, as measured by responses to the Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire, respectively, was examined for two samples of outpatients with panic disorder. Factor analytic and correlational analyses demonstrated that the patients' self-rated fear of specific physical and psychological symptoms was related to the frequency of specific logically related catastrophic thoughts (e.g., fears of heart palpitations or chest pressure with thoughts of a heart attack). This specific relationship between the somatic sensations and the catastrophic thoughts experienced by agoraphobic individuals provides further support for the cognitive theory of panic disorder. When the responses to the two questionnaires were factor-analyzed together, four factors were identified: symptoms and thoughts relevant to cardiovascular, neurological, gastrointestinal, and behavioral control systems, respectively. These findings suggest that the nature of panic-related fears varies across patients, and that the use of specific treatment interventions designed to modify the specific variations in their expression may be advisable. Depression and Anxiety 11:1–9, 2000. © 2000 Wiley-Liss, Inc.

Gender differences in the construct validity of Jack's (1991) Silencing the Self Scale (STSS) were assessed using 187 female and 169 male undergraduates. Results of exploratory and confirmatory factor analyses revealed gender differences in the scale's latent structure and at best provided only limited support for the validity of the scale's four subscales for women. Among men, the studies exposed a weakness in the scale's construct validity and provided insights into possible alternative interpretations made by men when responding to the scale's items. Convergent and discriminant validity of the scale were assessed by correlating it with measures of neuroticism and attachment. Whereas the construct validity of the STSS for use with women was supported, evidence was weaker for men. For men, data suggest that the STSS, in part, taps a motive to avoid intimacy and relationship situations that limit one's sense of independence and autonomy, a construct incongruous with Jack's notion of self-silencing.

The construct validity of the Perceived Criticism Measure (PCM) was examined in 2 studies. In Study 1, 50 community couples participated in problem-solving interactions after which they rated interaction-specific perceived criticism and their criticism of their spouses. In addition, they provided ratings of perceived criticism for their relationship overall and completed measures of psychopathology and marital satisfaction. For both husbands and wives, convergent validity was demonstrated by moderate-to-large correlations between the PCM and spouses' own ratings of their criticism for both general and interaction-specific perceived criticism. In Study 2, 37 patients with obsessive-compulsive disorder and their spouses participated in problem-solving interactions and provided ratings of marital satisfaction and general perceived criticism. Five untrained coders rated the interactions according to their own definitions of the relatives' destructive criticism of the patient. Their aggregated ratings proved strongly related to patients' PCM scores. Higher PCM scores were related to lower marital satisfaction in both Studies 1 and 2. The results of these studies are supportive of the convergent validity of the Perceived Criticism Measure. Evidence of discriminant validity was mixed.

Developing a better understanding of modifiable psychological factors that account for gender differences in anxiety may provide insight into interventions that can be used to target these risk processes. The authors developed a mediational model to examine the degree to which gender differences in anxiety are explained by instrumentality and mastery while controlling for the influence of environmental stress and social desirability. Undergraduates (159 men and 239 women) completed an online questionnaire including measures of mastery, instrumentality, daily hassles, social desirability, and anxiety. Women reported significantly lower levels of instrumentality and mastery and higher levels of anxiety than men. Path analyses indicated that instrumentality and mastery were both significant mediators of the relationship between gender and anxiety after controlling for social desirability and hassles. The addition of a direct path from gender to anxiety was not significant and did not improve the fit of the model. These findings suggest that differences in gender socialization and mastery learning experiences for men and women help account for the female preponderance of anxiety. Interventions aimed at building instrumentality and mastery, particularly among girls, may help buffer against anxiety.

Purpose Aromatase inhibitors (AIs) are a potentially life-saving treatment for breast cancer survivors, yet poor adherence to treatment is a prevalent problem. A common adverse effect of AI treatment is arthralgia, which is identified by survivors as a major reason for treatment discontinuation. Women who experience arthralgia on AIs often report feeling they have aged rapidly while on the treatment. In the present study, we examined whether arthralgia-associated ageing perceptions predicted non-adherence. Patients and methods We conducted a prospective cohort study among women with stage I–III breast cancer, who were on an AI and completed the Penn Arthralgia Aging Scale within 2 years of AI initiation. Adherence data were abstracted from medical charts by trained raters. Cox proportional hazard analysis was used to determine the relationship between ageing perceptions and time to non-adherence. All analyses included adjustments for joint pain severity. Results Among 509 participants, 144 (28.3%) were non-adherent. As hypothesised, women with high levels of ageing perceptions were at greater risk of non-adherence than women with low levels of ageing perceptions (adjusted hazard ratio [HR], 1.71; 95% confidence interval [CI], 1.10–2.67; p = .02). High levels of depressive symptoms were also uniquely associated with increased risk of non-adherence (adjusted HR, 1.63; 95% CI, 1.03–2.59; p = .04). Conclusion Perceptions of ageing related to arthralgia and depressive symptoms predicted non-adherence to AIs. These findings suggest that interventions that address negative beliefs about ageing due to AI-related arthralgia and depressive mood can potentially improve rates of adherence to AIs.

The National Institute of Mental Health (NIMH) plays an enormous role in establishing the agenda for mental health research across the country (its 2016 appropriation was nearly $1.5 billion; NIMH, 2016a). As the primary funder of research that will lead to development of new assessments and interventions to identify and combat mental illness, the priorities set by NIMH have a major impact on the mental health of our nation and training of the next generation of clinical scientists. Joshua Gordon has recently begun his term as the new Director of NIMH and has been meeting with different organizations to understand how they can contribute to the grand challenge of reducing the burden of mental illness. As a group of clinical psychological scientists (most representing the Coalition for the Advancement and Application of Psychological Science), he asked what we saw as key gaps in our understanding of the burden of mental illnesses and psychological disorders that psychosocial research could help fill. In response, we first present data illustrating how funding trends have shifted toward biomedical research over the past 18 years and then consider the objectives NIMH has defined in its recent strategic plan (U.S. Department of Health and Human Services, National Institutes of Health, & National Institute of Mental Health, 2015). We then note ways that advances in psychosocial research can help achieve these objectives. Critically, this involves integrating psychosocial and biomedical approaches to efficiently relieve the suffering of millions of Americans who struggle with mental illnesses and psychological disorders. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Married couples with a female agoraphobic spouse (n = 22) were compared with demographically similar community control couples (n = 21) on self-report and observational measures of marital interaction. Consistent with hypotheses, husbands of agoraphobic women were more critical of their wives than were control husbands, and clinical couples were less likely to engage in positive problem solution than control couples. Contrary to hypothesis, clinical husbands were not less supportive than control husbands. Where general measures of marital distress were concerned, clinical couples, relative to control couples, evinced more distress by self-report, by their higher rate of negative nonverbal behavior, and by their longer sequences of negative exchanges.

The reliability and validity of the SCL-90-R Obsessive Compulsive Scale were examined using a multi-trait multi-method approach in a sample of 54 outpatients with obsessive-compulsive disorder (OCD). The OC scale proved to be internally consistent. Evidence for convergent validity was mixed, and the results suggest poor divergent and criterion-related validities. The scale demonstrated sensitivity to changes with behavioral treatment. Overall, the SCL-90-R proved to be a poor measure of OCD symptoms.

Relationships between outcome of in vivo exposure and the quality and quantity of homework assignments were examined for 82 outpatients with anxiety disorders (35 with panic disorder with agoraphobia; 47 with obsessive-compulsive disorder). Consistent with prior research, treatment outcome was largely unrelated to both quality and quantity of homework. The one exception was a significant correlation between worse outcome and larger subjective-units-of-distress scores during exposure. This effect was small and in the direction opposite to that predicted. A secondary goal was to explore client characteristics related to homework compliance. Although trends emerged for homework quantity to relate to race, diagnostic group and pre-treatment functioning, these relationships were no longer significant following f -correction for the number of tests. Methodological weaknesses in the area of homework compliance and outcome are discussed. Keywords: CognitiveBehavioralTreatmentAnxietyHomeworkTherapyClientCharacteristicsHomePractice

Abstract This study was designed to (a) provide initial validity data on the Expanded Sexual Arousability Inventory developed by E. F. Hoon (1978) and (b) to investigate the relationship of self‐reported sexual arousability to anxiety. Subjects were 252 female undergraduates and 90 female volunteers from the community who completed inventories concerning their sexual responsiveness. The arousal and anxiety scales were found to be uncorrelated, whereas a third scale, satisfaction, was so highly correlated with arousal as to be redundant. All scales showed high split‐half reliability, and the construct validity of arousal and anxiety was generally supported. No relationship was found, with either sample, between self‐reported sexual anxiety and arousal. These findings indicate the relationship between these two variables is not simple. However, it should be noted that the current subjects were not severely sexually anxious, and it cannot be concluded from these data that very high anxiety might not inhibit arousability.

Many college students use alcohol, and most of these students experience problems related to their use. Emerging research indicates that socially anxious students face heightened risk of experiencing alcohol-related problems, although the extant research on alcohol use and social anxiety in this population has yielded inconsistent findings. This meta-analysis was conducted to examine the relationship between social anxiety and alcohol variables in college students. A literature search was used to identify studies on college students that included measures of social anxiety and at least one of the alcohol variables of interest. All analyses were conducted using random effects models. We found that social anxiety was negatively correlated with alcohol use variables (e.g., typical quantity and typical frequency), but significantly positively correlated with alcohol-related problems, coping, conformity, and social motives for alcohol use, and positive and negative alcohol outcome expectancies. Several moderators of effect sizes were found to be significant, including methodological factors such as sample ascertainment approach. Given that social anxiety was negatively related to alcohol use but positively related to alcohol-related problems, research is needed to address why individuals high in social anxiety experience more problems as a result of their alcohol use. Avoidance of social situations among socially anxious students should also be taken into account when measuring alcohol use. The primary limitation of this study is the small number of studies available for inclusion in some of the analyses.

To identify variables predicting psychotherapy outcome for panic disorder or indicating which of 2 very different forms of psychotherapy-panic-focused psychodynamic psychotherapy (PFPP) or cognitive-behavioral therapy (CBT)-would be more effective for particular patients.Data were from 161 adults participating in a randomized controlled trial (RCT) including these psychotherapies. Patients included 104 women; 118 patients were White, 33 were Black, and 10 were of other races; 24 were Latino(a). Predictors/moderators measured at baseline or by Session 2 of treatment were used to predict change on the Panic Disorder Severity Scale (PDSS).Higher expectancy for treatment gains (Credibility/Expectancy Questionnaire d = -1.05, CI95% [-1.50, -0.60]), and later age of onset (d = -0.65, CI95% [-0.98, -0.32]) were predictive of greater change. Both variables were also significant moderators: patients with low expectancy of improvement improved significantly less in PFPP than their counterparts in CBT, whereas this was not the case for patients with average or high levels of expectancy. When patients had an onset of panic disorder later in life (≥27.5 years old), they fared as well in PFPP as CBT. In contrast, at low and mean levels of onset age, CBT was the more effective treatment.Predictive variables suggest possibly fruitful foci for improvement of treatment outcome. In terms of moderation, CBT was the more consistently effective treatment, but moderators identified some patients who would do as well in PFPP as in CBT, thereby widening empirically supported options for treatment of this disorder. (PsycINFO Database Record

Background No studies of psychotherapies for panic disorder (PD) have examined effects on comorbid personality disorders (PersD), yet half such patients have a PersD. Methods In a randomized trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), PersD was assessed pre-to-post treatment with the Structured Clinical Interview for the Diagnosis of Axis-II Disorders (SCID-II). For patients completing therapy (n = 118, 54 with PersD), covariance between panic and SCID-II criteria improvements was analyzed. SCID-II diagnostic remission and recovery were evaluated. Comparative efficacy of PFPP versus CBT for improving PersD was analyzed both for the average patient, and as a function of PersD severity. Results 37 and 17% of PersD patients experienced diagnostic PersD remission and recovery, respectively. Larger reductions in PersD were related to more panic improvement, with a modest effect size (r = 0.28). Although there was no difference between treatments in their ability to improve PersD for the average patient (d = 0.01), patients meeting more PersD criteria did better in PFPP compared to CBT (P = .007), with PFPP being significantly superior at 11 criteria and above (d = 0.66; 3 more criteria lost). Conclusions PersD presenting in the context of primary PD rarely resolves during psychotherapies focused on PD, and change in PersD only moderately tracks panic improvements, indicating non-overlap of the constructs. Patients receiving panic-focused psychotherapies may require additional treatment for their PersD. PFPP may be superior at improving severe PersD, but replication of this finding is required.

Purpose Poor adherence to oral adjuvant hormonal therapy for breast cancer is a common problem, but little is known about the relationship between self-report adherence measures and hormonal suppression. We evaluated the relationship of three self-report measures of medication adherence and oestrogen among patients on aromatase inhibitors (AIs). Materials and methods We recruited 235 women with breast cancer who were prescribed AI therapy. Participants self-reported AI adherence by completing the following: (1) a single item asking whether they took an AI in the last month, (2) a modified Morisky Medication Adherence Scale-8 (MMAS-8) and (3) the Visual Analog Scale (VAS). Serum estrone and estradiol were analysed using organic solvent extraction and Celite column partition chromatography, followed by radioimmunoassay. Results Ten percent of participants reported they had not taken an AI in the last month and among this group, median estrone (33.2 pg/ml [interquartile range (IQR) = 22.3]) and estradiol levels (7.2 pg/mL [IQR = 3.3]) were significantly higher than those in participants who reported AI use (median estrone = 11.5 pg/mL [IQR = 4.9]; median estradiol = 3.4 pg/mL [IQR = 2.1]; p < 0.001). This relationship held when controlling for race and AI drug type. Conclusions A single-item monthly-recall adherence measure for AIs was associated with oestrogen serum levels. This suggests that patient-reported monthly adherence may be a useful measure to identify early non-adherence behaviour and guide interventions to improve patient adherence to hormonal treatment.

Abstract Although widely used, the Hamilton Rating Scale for Depression (HRSD) and Hamilton Anxiety Rating Scale (HARS) discriminate poorly between depression and anxiety. To address this problem, Riskind, Beck, Brown, and Steer ( J Nerv Ment Dis . 175:474–479, 1987) created the Reconstructed Hamilton Scales by reconfiguring HRSD and HARS items into modified scales. To further analyze the reconstructed scales, we examined their factor structure and criterion-related validity in a sample of patients with major depressive disorder and no comorbid anxiety disorders ( n = 215) or with panic disorder and no comorbid mood disorders ( n = 149). Factor analysis results were largely consistent with those of Riskind et al. The correlation between the new reconstructed scales was small. Compared with the original scales, the new reconstructed scales correlated more strongly with diagnosis in the expected direction. The findings recommend the use of the reconstructed HRSD over the original HRSD but highlight problems with the criterion-related validity of the original and reconstructed HARS.

This article presents the results of a qualitative analysis of interviews with 25 psychologists in independent practice, with a focus on decision making with a selected patient. We endeavored to examine how clinical decision making intersected with the principles of evidence based practice (EBP) as laid out by Spring (2007). Clinicians reported that diagnostic impressions were generally formulated through unstructured assessment rather than validated instruments, and that treatment selection was based on therapists' perceptions of a treatment's match with client characteristics. Therapists viewed CBTs as appropriate for addressing symptoms but believed they needed to depart from CBT strategies to address underlying issues. Nonetheless, they often defined successes and failures in treatment in terms of symptoms. Overall, clinicians rarely mentioned utilization of research evidence for assessment or treatment selection and practice. Results are discussed within the framework of EBP.

Eighteen African American and 57 White agoraphobic outpatients were compared on symptom severity. The groups did not differ on severity of depression or fear of fear, or on frequency of panic attacks. However, Black clients were more severely phobic than White clients on self-report, assessor, and behavioral measures. Forty-three White and 15 Black clients provided posttest data after treatment with in vivo exposure. Both Black and White clients improved, but Black clients remained more severe at treatment's end on measures of phobia and changed somewhat less with treatment on these variables. Differences were generally less evident at follow-up, but African Americans did show less change on frequency of panic attacks and on one measure of avoidance.

Abstract In an attempt to evaluate how widows of various ages adapt sexually to loss of a marital partner, 100 relatively healthy, community-dwelling widows between the ages of 40 and 89 completed a reliable 101-item questionnaire which evaluated three major areas: 1) barriers to sexual expression posed by age-related changes in body image, mood state and environmental context; 2) degree of unhappiness associated with loss of various marriage-oriented activities; and 3) perceived utility of various activities which indirectly might satisfy sexual and affectional needs. Controlling for income, education, heterosocial involvement, and family contact, and using level of morale and depression as corroborative measures, results showed specific age differences across variables assessed. In particular, younger widows, when compared with their older counterparts, viewed changes in body image, the dearth of unattached men, and limited financial resources for social activities as representing significant sexual barriers. Increasing age of the widow was associated with lower unhappiness ratings with loss of marriage-related activities. For the sample as a whole, greater unhappiness was expressed with the loss of nonsexual, heterosocial activity (e.g., conversation with a man, going places with a man). Results also indicated that, regardless of the widow's age, activities pertaining to her children and grandchildren, wearing attractive clothing, and expressing her spirituality are all effective in meeting affectional and sexual needs. Results are discussed within the context of older female sexuality, affectional adaptation to widowhood, and therapeutic implications directed at this neglected group.

In a test of Hooley’s (1987) attributional model of expressed emotion (EE), attributions for negative behaviors and events in patients’ lives were examined in relatives of 74 outpatients with panic disorder with agoraphobia or obsessive-compulsive disorder. Attributions were extracted from 10-minute problem-solving interactions between relatives and patients, whereas EE was assessed during a separate interview with the relative. Consistent with prior findings in relatives of individuals with other disorders, relatives who made greater proportions of attributions of patient responsibility demonstrated significantly higher levels of EE-hostility. In addition, nonspousal relatives (mostly parents) who attributed any negative behaviors or events to a patient’s disorder were significantly higher in emotional overinvolvement (EOI); no such relationship was found for spouses. Finally, patients with relatives who made attributions to the patient’s disorder received less benefit from behavior therapy than did those whose relatives made no such attributions, even when EE variables were controlled.