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Flooding with brevital in the treatment of agoraphobia: Countereffective?
ooO5-7967
79 0501.0243502
FLOODING WITH BREVITAL IN THE TREATMENT AGORAPHOBIA: COUNTEREFFECTIVE?* DIANNE L. CIMmLEsst,
Eastern
00 0
OF
EDNA B. FOA, GERALD A. GROVES: and ALAN J. GOLDSTEIN
Temple University Medical Pennsylvania Psychiatric
(Received
School, Department of Psychiatry. Institute. Philadelphia. PA 19129. U.S.A.
9 October 1978)
Summary-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.
Treatment of phobias by prolonged imaginal exposure to stimuli which evoke intense anxiety was developed in the 1960s under two labels, implosion (Stamp1 and Levis, 1967) and flooding (Rachman, 1969). These two techniques overlap considerably, but marked differences remain in theory and application despite more than a decade of research. One issue on which proponents of each technique have disagreed is the importance of the experience of anxiety during flooding. Following Solomon, Kamin and Wynne (1953) implosive theorists (Stamp1 and Levis, 1967; Hogan and Kirchner, 1967) assert that not only must the conditioned stimulus be presented without occurrence of the unconditioned stimulus, but the conditioned response, i.e. anxiety, must also be elicited. Consequently, implosive therapists strive to elicit and maintain high levels of anxiety until a spontaneous reduction in anxiety signals that extinction has occurred. As it is presumed that avoidance behavior is maintained by its drive reduction properties (relief of anxiety), it should cease following extinction. Other investigator< have questioned this assumption. Marks, for example, has concluded that, “It is not crucial whether patients are relaxed, neutral, or anxious during . . . exposure” (Marks, 1978). Rachman and Hodgson (1974) concur in general, but add, “The deliberate arousal of anxiety.. . [may be] facilitative in limited cases”. The effect of anxiety during flooding may depend on the nature of the anxiety-producing stimuli for a particular client. Goldstein and Chambless (1978) have suggested that agoraphobia is based on a fear of introceptive stimuli engendered by anxiety itself, hence, a ‘fear of fear’ (Weekes, 1976). Therefore, the experience of anxiety during exposure. is posited to be therapeutic. Since agoraphobics come to fear places where they predict they will panic, exposure to these exogenous stimuli is also important. Thus, for maximal effect flooding should encompass exposure to both the places and feelings which agoraphobics fear. Lending credence to this hypothesis, Watson and Marks (1971) found that flooding to either relevant or irrelevant cues led to improvement for a sample largely composed of agoraphobics. Improvement with irrelevant flooding was positively correlated with the amount of anxiety during flooding. If the interoceptive stimuli of anxiety are important anxiety-eliciting cues for agoraphobics, flooding without anxiety should not be as effective as flooding with anxiety. *This paper was presented
at the International Congress of Behaviour Therapy, Vienna, Austria, 1978. t Present address: Department of Psychology, University of Georgia. : Department of Psychiatry. Boston University Medical School. Requests for reprints should be addressed to D. L. Chambless, Department of Psychology, University of Georgia. Athens, GA 30602. U.S.A. 243
244
DIANNE L. CHAMBLESS.EDNA B. FOA. GERALD A. GROVESand ALAN J. GOLDSTEIN
The present paper represents an attempt to test this hypothesis by controlling the degree of anxiety through intravenous administration of a short acting barbiturate, methohexitone sodium (Brevital). METHOD
Subjects
The Ss were 27 agoraphobic outpatients who sought treatment primarily for their phobias and related complaints at the Behavior Therapy Unit of Temple University Medical School. Most were self-referred after learning through the media of the treatment program; some were referred by other health professionals. Criteria for inclusion in the study were: 1. Presence of fear of few as determined by a 90 min interview conducted by an experienced clinical psychologist. 2. Ability to create visual imagery and the capacity to experience anxiety while imagining phobic events. 3. Absence of serious medical illness, particularly heart disease or chronic respiratory disorders. 4. Age of less than 5Oyr. 5. Agreement to participate in the study and to come twice weekly for 10 weeks. 6. Initial willingness to take medication by injection for treatment purposes. Twenty-nine clients were accepted into the project and initially agreed to participate. Two dropped out in the beginning of treatment. The final sample was composed of 21 women and 6 men. Age ranged from 20 to 43, with a mean of 29.45. Duration of symptoms ranged from 1 yr to 23 yr, the mean being 8.28 yr. Therapists
Therapists were 19 psychologists, psychiatrists and social workers in training at the Behavior Therapy Unit. Previous clinical experience ranged from 2 to 10 yr (?? = 4.31) while experience in behavior therapy varied from 6 months to 9 yr (x = 2.31). The therapists received specific training for the flooding procedures used in this study and continued supervision by two psychologists experienced in flooding. Design Clients were randomly assigned to one of the three treatment groups: (a) non-drugflooding group, (b) drug-flooding group, or (c) attention-control group. A repeated measures design was employed with dependent measures administered before treatment sessions began and again 1 week after the eighth and final treatment session. Therapists and clients were blind as to the hypotheses under study. Because of time constraints the project was terminated after only seven Ss had completed the attention-control group. Ten Ss each completed the experimental groups. Measures
Four kinds of measures were taken at pre-treatment and 1 week post-treatment: client’s ratings, therapist’s ratings, behavioral test and psychophysiological recordings. Client ratings. Four scales-phobic anxiety, phobic avoidance, free-floating anxiety and severity of panic attacks-were adopted from Watsqn and Marks (1971). Scales ranged from 0 to 8 with 8 indicating highest pathology. Therapist ratings. Therapists rated their clients on the Watson and Marks scales described above. These ratings were made without access to the clients’ ratings. behavioral task. An individual behaviorai task was designed for each client by her/his therapist and executed in vivo. The task was selected during the initial interviews with the clients and consisted of having them approach and remain in their most feared situation for 30min if possible, e.g. driving alone for 30min. Clients were encouraged to desist if their anxiety levels became intolerable but were asked to do as much as they could before refusing to continue. Therapists accompanied clients to the point
Brevital
in the treatment
of agoraphobia
245
where they were to begin the task. Each client was asked to record his/her subjective anxiety level on a 0 to 8 rating scale provided at the beginning of the task. Ratings were to be made every 5 min. Furthermore, clients were to note the number of minutes they actually remained in the assigned situation. Psychophysiological measures. Recordings of physiological reactivity to descriptions of phobic stimuli were taken at both assessment periods. Reactivity during descriptions of neutral imagery was used as a baseline measure. Clients were asked to visualize two 100 suds (subjective units of discomfort, Wolpe, 1973) scenes as described by their therapists; each scene lasted 10min. Neutral scenes were also described for 10 min, and the order of presentation was phobic-neutral-neutral-phobic. Measures of reactivity were heart rate-beats per min, and GSR-the number of spontaneous fluctuations (nonspecifics) per min. Fluctuations of 200 ohms or greater were included in the analysis. Procedure
After screening and assignment to therapists, all clients underwent a physical examination by the staff psychiatrist, since drug group clients had to be thoroughly screened medically. Clients were then interviewed by their therapists for two 90-min sessions. During these sessions the therapists were instructed to establish warm. supportive relationships with the clients. After these initial interviews, the first assessment battery was given. After the first assessment battery, clients received eight treatment sessions according to their group assignment. Sessions were held on a twice-weekly basis and were of 2 hr duration each. All sessions were taped in their entirety and checked for adherence to the project protocol. One week after the eighth treatment session, the post-test battery was given. Non-drug -flooding group. Clients in this group were asked to imagine at length the phobic scenes which had been identified during the initial interviews while the therapist recounted these situations in detail. They were told that by using their imaginations to confront the situations they feared, particularly panic attacks, they would learn to be less afraid of these things in reality. Prior to the first flooding session clients were told that every 10min they would be asked to indicate their level of current anxiety (as opposed to how they would have felt in the same situation in reality), on the suds scale. They were instructed not to interrupt the imagined scene when reporting their anxiety; rather they were to indicate the appropriate level and continue immediately with the image. Clients lay on a recliner with their eyes closed during the entire flooding session. They were instructed to imagine the scenes described by the therapist as vividly as possible and to report when clarity of the image diminished at which time the therapist described the scenes more vividly. Periodically, clients were asked to describe ‘where they were’ to ensure that they indeed had been imagining the described scenes. The initial sessions were of moderate intensity, and across sessions more fearful scenes were introduced so that the final two sessions were spent on the client’s worst fears. This procedure is reported in more detail by Foa and Chambless (1978). Thus final sessions commonly included the feared catastrophes, e.g. heart attack, madness, screaming in public. The therapists urged clients to experience the imagined situations as if they were actually occurring, to feel the concomitant anxiety or shame acutely until it diminished. As anxiety fell within a session, the therapist added fresh anxiety-evoking material up to the last 15 min of each 90-min flooding session. If a client’s anxiety had not diminished by 80-85 min, the therapist introduced comforting or coping cues while not reducing the intensity of the phobic stimuli. The remaining 30 min of each 2-hr session was spent in supportive psychotherapy, discussing events that had occurred since the last session and inquiring about contact with phobic situations. Therapists were enjoined from introducing other behavioral techniques and from suggesting clients enter feared situations. Clients who reported entering formerly avoided situations, however, were praised.
246
DIANNE L. CHAMBLES. EDNA B. FOA. GERALD A. GROVES and ALAN J. GOLDSTEIN
Drug-flooding group. Procedures for this group were the same as those for the non-drug group except clients received periodic intravenous injections of a 1% solution of methohexitone sodium (Brevital) during the 90-min ‘flooding sessions. The drug was administered by a psychiatrist who attempted to maintain the client in a calm, relaxed state throughout the flooding session. Nevertheless, four clients experienced various degrees of anxiety during sessions. As a measure of intense anxiety before habituation, reports of subjective anxiety of 70 suds or greater were analyzed for the second and third flooding sessions for both experimental groups. Non-drug group clients reported anxiety higher than 70 suds on an average of 17.28 min per session. The drug group reported comparable anxiety only 6.75 min per session on the average. This difference is highly significant (I,,$~= 10.96; p < 0.001). AS with the non-drug group, clients were told that fear and panics are overcome by systematic confrontation, but it was additionally stated that the drug would accelerate the reconditioning process by speeding the realization that there was nothing to fear from these situations and sensations. Atrention-control group. Clients in this group received eight 2-hr sessions of psychotherapy plus training in progressive relaxation. Each session began with 13 hr of supportive interaction and behavioral analysis followed by -) hr of progressive relaxation including the use of pleasant, relaxing imagery. Clients maintained daily logs of suds levels and descriptions of their interpersonal and physical environment at times of high anxiety. This material constituted the basis for discussion during the 90min of each session allotted to verbal therapy. Such procedures are an important aspect of therapy with agoraphobics but are not expected to result in substantial improvement when used alone (Goldstein and Chambless, in press). Clients were told that if they lowered their chronic anxiety through relaxation and understood the source of their attacks, they would panic less frequently. As with the flooding groups, therapists were explicitly proscribed from suggesting clients enter feared situations and from using any behavioral techniques other than relaxation. Clients were, nevertheless, to be praised for any attempts they made to confront their phobias. RESULTS
To ensure there were no initial differences between the groups, one-way analyses of variance were computed on pretest scores for all dependent measures. No significant differences emerged among the three groups. All analyses for treatment effects were performed on change scores from pretest to post-test. Six of the dependent measures were analyzed with one-way analyses of variance using the least squares solution to the unequal n’s. Unequal variances among the groups on the remaining dependent measures necessitated nonparametric analysis by Kruskal-Wallis analyses of variance. For post hoc tests one-tailed tests of significance were used to compare the non-drugflooding group with both other treatment groups, as the dire&on of the results was hypothesized. Two-tailed tests were used for comparisons between the drug-flooding group and the attention-control group, since no specific pattern of results was hypothesized. RATING
SCALES
Fear of phobic situations. A one-way analysis of variance on clients’ ratings indicated a significant difference among the three groups (F = 4.10; p = 0.03). Post hoc analysis was performed by the Neuman-Keuls procedure in order to detect the source of this difference. The non-drug group was found to have improved more than both the drugflooding group and the attention-control group (see Table 2). Moreover no significant differences were found between the drug group and the attention-control group. On therapists’ ratings significant differences among the groups emerged on the Kruskal-Wallis analysis of variance (see Table 1). Mann-Whitney post hoc tests showed
Brevital in the treatment of agoraphobia FEAR
-1
247
SCORES
CHANGE
1
THERAPISTS
4.0 I 3.5 -
-
3.0 -
THERAPISTS
C
2.5 2.0 1.5 1.0 CLIENTS
.5 -
TtlERAPISl CLIENTS
jjjjj_
o---
NON-
DRUG
Fig. 1. Pretest-post-test
DRUG
ATTENTION
CONTROL
change scores on therapists’ and clients’ ratings of fear.
the non-drug-flooding group as well as the drug-flooding group improved significantly more than the attention control group. The non-drug-flooding group improved more absolutely than the drug-flooding group, although this difference was not statistically significant. Thus, while the pattern of means is the same for therapists’ and clients’ ratings (see Fig. l), therapists differ from clients in perceiving clients in the drug group as significantly improved. Avoidance of phobic situations. Clients’ ratings of avoidance required the MannWhitney procedure for post-hoc tests of the significant Kruskal-Wallis ANOVA. The non-drug-flooding group improved significantly more than the attention-control group. while the drug-flooding group did not. Though the mean change of the non-drug-flooding group was considerably greater than that of the drug-flooding group (see Table 2). this difference was not significant. Therapists perceived both drug-flooding group clients and non-drug-flooding group clients as being significantly more improved than attention-control group clients. The nondrug group changed more than the drug-flooding group but not significantly so (see Table 2). Therapists rated drug-flooding group clients as improved, while the clients did not perceive such changes (see Fig. 2); this is similar to findings for fear ratings. Anxious mood and panic. On clients’ ratings of anxious mood the Kruskal-Wallis ANOVA indicated a difference among the groups, but post hoc Mann-Whitney tests AVOIDANCE
4.0
CHANGE
SCORES
3.5 I 3.0
CLIENTS
THERAPISTS
2.5 2.0
TH
I. 5 CLIENTS
1.0 i 5 i 0
-.5 -1.0
CLIENTS
-
-
THERAPISTS
1I NON-DRUG
Fig. 2. Pretest-post-test
DRUG
ATTENTION
CONTROL
change scores on therapists’ and clients’ ratings of avoidance.
DIANNE L. CHAMBLES. EDNA B. FOA. GERALD A. GROVES and
248
Table
1. Kruskal-Wallis ANOVA on change agoraphobic outpatients Scale
Value of H
Fear Therapist rating Avoidance Therapist rating Client rating Anxious mood Client rating
failed to detect the location of this difference. suggests the attention control group improved therapists’ ratings a one-way analysis yielded On both therapists’ and clients’ ratings on difference among the three groups was found
ALAN J. GOLDSTEIN
scores
of
Probabilit)
30.86
P<
36.43 28.51
P< PC
0.001 0.001
22.55
P<
0.01
Inspection of the mean difference scores less than the two flooding groups. On a non-significant F (F = 1.27; p = 0.30). severity of panic attacks, no significant (F = 0.93; p = 0.41; F = 0.35; p = 0.71).
Behavioral task Nine clients completed all 30min of the behavioral task at pretest and therefore were not included in the analysis of this measure. For the remaining 18 clients, difference scores were computed by subtracting the number of minutes completed in the behavioral task at pretest from those completed at post-test. Both flooding groups increased their performances almost twice as much as the attention control group. These differences, however, were not statistically significant (F = 1.84; p = 0.20).
Table
2. Mean
change
scores
Scale Fear Client ratings Non-drug flooding Drug flooding Attention control Therapist ratings Non-drug flooding Drug flooding Attention control Avoidance Client ratings Non-drug flooding Drug flooding Attention control Therapist ratings Non-drug flooding Drug flooding Attention control Anxious mood Client ratings Non-drug flooding Drug flooding Attention control Therapist ratings Non-drug flooding Drug flooding Attention control * One-tailed test. t Twc+tailed test. $ No significant treatment
on dependent measures flooding. drug flooding
of agoraphobics: three and attention control
treatment
groups:
non-drug
D
S.D.
Posr hoc comparisons
2.60 0.50 -
2.50 1.58 1.91
NDF vs. DF NDF vs. AC DF vs. AC
3.80 2.70 0.43
1.32 2.63
1.33
NDF vs. DF NDF vs. AC DF vs. AC
u = 40.00 u = 1.00 u = 7.00
2.60 0.90 0.43
2.72 I .67 0.79
NDF vs. DF NDF vs. AC DF vs. AC
U = 26.50 u = 13.50 u = 28.00
2.60 1.80 -0.71
I .78 2.10 0.76
NDF vs. DF NDF vs. AC DF vs. AC
U = 38.50 u = 1.50 u = 9.00
p.001’ p < 0.02t
1.30 1.40 0.57
1.49 2.22 0.79
NDF vs. DF NDF vs. AC DF vs. AC
u = 47.50 U = 26.00 u = 31.50
ns ns ns
1.90 1.30 0.57
1.60 1.89
None:
1.52
effect on ANOVA.
Statistic
q(2.24) q(3.24) q(2.24)
= 3.04 = 3.76 = 0.72
Probability
p -=I0.05* p < 0.05’ ns ns
p < 0.001* p < 0.02t ns
p < 0.05. ns ns p <
Brevitai in the treatment of agoraphobia
249
Heart rate and GSR spontaneous fluctuation data were reduced on minutes 2-9 of each of the four IO-mm imagery epochs. Data from the two phobic imagery epochs were averaged as were results from the neutral imagery epochs. At pretest, the average scores on phobic and neutral imagery for all 23 subjects tested were compared using a r test of differences. Subjects did not show significantly more reactivity on phobic imagery at pretest as measured by heart rate (fd = 1.05; p > 0.05)or by the number of GSR spontaneous fluctuations (td = 0.67; p > 0.05). Consequently psychophysiological measures did not receive further consideration in the data analysis of changes with treatment. DfSCUSSION support The results on two main dependent variabies- fear and avoidance-provide for the hypothesis that confrontation with anxiety during flooding will enhance treatment effects for agoraphobics. Though differences between the drug group and the non-drug group were significant only on clients’ ratings of fear, a consistent pattern emerged on most measures. The non-drug group improved most followed by the drug group with the attention-control group improving least. Moreover, only the non-drug group improved significantly more than the attention-control group on both clients’ and therapists’ ratings. Although the differences in mean change of the groups are quite large, the withingroup variances are also large for the two experimental groups. In the attention-control group virtualiy no change occurred whife in the flooding groups some clients were cured and others changed minimally. Furthermore, the effect of experiencing anxiety during flooding might have been obscured in that, despite our efforts to maintain a non-anxiety state in the drug-flooding condition, clients in this group did report occasional anxiety. On the whole therapists’ and clients’ ratings were congruent. The exception is evaluation of the drug group on both fear and avoidance. Therapists perceived the clients in this condition as having improved when compared to the attention-control group while the clients themselves did not. A plausible explanation for this finding is that therapists expected clients in the drug-flooding group to show improvement. Although therapist expectancy was not assessed formally, comments by the therapists in the supervision seminar indicated they thought the drug manipulation would be the most powerful intervention. The third measure pertinent to the hypothesis is the behavioral task on which no difference among groups were detected. This may be due to two procedural inadequacies. Firstly, some of the tasks selected were not difficult enough and thus were completed even at pretest under the perceived high-demand conditions (see Bernstein and Nietzel, 1974, for effects of demand manipulation on behavioral task performance). Secondly, clients appeared to perceive the task as an all-or-none situation. Thus some clients forced themselves to complete the entire 30min despite very high anxiety, and others refused to begin at all even though the early moments of the task should have caused little discomfort. Two additional variables, anxious mood and panic, although they are not directly pertinent to a test of the effects of flooding, were included because of their clinical relevance to the syndrome of agoraphobia. Indeed flooding had minimal impact on these variables. No differences among the groups were found, neither between the two experimental groups nor between the flooding groups and the attention-control group. These findings are consistent with the analysis of agoraphobia proposed by Goldstein and Chambless (1978) who maintain that pervasive anxiety and panic attacks stem from interpersonal conflict. Change on these variables, consequently, should require interventions not applied in this study such as marital-therapy and assertiveness training. The results of this study suggest that the experience of anxiety during flooding improves outcome with agoraphobic clients. This is not necessarily true for clients with
250
DIANNE L. CHAMBLESS.EDNA B. FOA. GERALD A. GROVES and ALAN J. GOLDSTEIN
fears of exogenous stimuli like many specific phobias. If this study were replicated with specific phobics, the results might well be reversed. Indeed with in vice exposure Marks et al. (1972) found specific phobics who hid received a minor tranquillizer improved more than those who had not. However, this drug effect may have stemmed from the tranquillized clients having allowed more rapid exposure. Hussain (1971) used intravenously administered thiopental sodium (Penthothal) during ‘flooding’ with social phobics and agoraphobics. Compared to a group flooded while receiving saline injections, these clients improved dramatically. These findings are strikingly different from our own. It is difficult to interpret Hussain’s findings, however, as the procedure he describes bears little similarity to the usual practice of imagindl flooding. In two other studies the variable of anxiety during flooding with agoraphobics was manipulated with tranquillizers. These studies yielded conflicting results. Hafner and Marks (1976) treated clients with group in viuo exposure combined with diazepam (Valium) or placebo. All groups improved equally. Conflicting results were reported by Johnston and Gath (1973) who combined flooding in fantasy and flooding in uivo with diazepam or a placebo. The diazepam group improved more on the behavioral task but not on ratings of fear. In neither study was it convincingly demonstrated that the drug group was actually less anxious during flooding than the placebo group. Hafner and Marks found the primary drug effect was a reduction in anticipatory anxiety. During exposure both groups reported equal subjective anxiety. Subjective ratings of anxiety during flooding were not reported by Johnston and Gath. GSR was lower for the diazepam group during flooding, but heart rate, the more reliable measure (Mathews, 1971) was not. A second important issue is equality of exposure in drug and placebo groups, as Mathews (1976, cited by Marks, in press) found that, with specific phobias, when the amount of exposure is controlled, clients receiving diazepam improve no more than those getting a placebo. In the Hafner and Marks study, placebo and drug clients were treated in the same groups; hence all clients underwent exposure of equal intensity. No information on this variable was provided by Johnston and Gath leaving open the possibility that in their study as in Marks et al. (1972) drug group clients allowed more rapid and, therefore, more thorough exposure. In short, conclusions on the role of the experience of anxiety during flooding cannot be drawn from these previous studies, since the degree of anxiety experienced ‘and the intensity of the exposure were not simultaneously controlled. When intensity of exposure is controlled and amount of anxiety successfully manipulated as in the present study, the experience of anxiety during flooding does appear to enhance outcome. The results support the notion advanced above that for agoraphobits who fear both fear and and the places in which they expect to experience fear, exposure to both endogenous and exogenous stimuli maximizes the treatment effect of flooding. However, an alternative explanation for our results should be considered. Under some conditions sedatives can lead to impaired learning in humans (Overton, 1977). Thus, the superiority of the non-drug group may be he not to the experience of anxiety but to learning defects in the drug group. Acknowledgemenrs-We wish to express our appreciation to the trainees of the Behavior Therapy Unit for their participation in the study and to Barry M. Shmavonian and Peggy Gaver for their invaluable assistance in collecting psychophysiological data. This study was completed in partial fulfilment of the requirements for the Ph.D. degree of the first author and was supported by a grant from the Boulton Fund. REFERENCES BERNSTEIN D. A. AND NIETZEL M. T. (1974) Behavioral avoidance tests: the effects of demand characteristics and repeated measures on two types of subjects. Behnv. Ther. 5, 183-192. FOA E. B. and CHAMBLE~~ D. L. (1978) Habituation of subjective anxiety during flooding in imagery. Behac. Res. Ther. 16, 391-399. GOLDSTEIN A. J. and CHAMBLESS D. L. (1978) A reanalysis of agoraphobia. Behou. Thu. 9, 47-59. GOLDSTEIN A. J. and CHAMBLESS D. L. Comprehensive treatment of agoraphobia. In Handbook of Behmim[ Inreruentions (Edited by A. J. GOLDSTEIN and E. B. FoA). John Wiley, New York. In press.
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HAFNERJ. and MARKSI. (1976) Exposure in villa of agoraphobics: contributions of diazepam. group exposure. and anxiety evocation. Psychol. Med. 6. 71-78. HOGANR. A. and KIRCHNERJ. H. (1967) Preliminary report of the extinction of learned fears via short-term implosive therapy. J. abnorm. Psychol. 72. 106-109. HUSSAINM. Z. (1971) Desensitization and flooding (implosion) in treatment of phobias. AIII. J. Psychiar. 127, 1509-1514. JOHNSTONE. and GATII D. (1973) Arousal levels and attribution effects in diazepam-assisted flooding. Br. J. Psychiat. 123, 46346. MARKSI. Behavioral psychotherapy of adult neurosis. In Handbook of Psychotherapy and Behavior Modification (Edited by S. GARFIELDand A. E. BERGIN)(2nd Edn). John Wiley. New York. 1978. MARKS I. M., V~SWANATHAN R., LIPSEDGEM. S., and GARDNERR. (1972) Enhanced relief of phobias by flooding during waning diazepam effect. Br. J. Psychiar. 121. 493-505. MATHEWSA. M. (1971) Psychophysiological approaches to the investigation of desensitization and related procedures. Psycho/. Bull. 76, 73-91. OVERTOND. A. (1977) Drug statedependent learning. Psychopharmacology in the Practice of Medicine (Edited by M. E. JARVIK).Appleton-Century-Crofts, New York. RACHMANS. (1969) Treatment by prolonged exposure to high intensity stimulation. Behac. Res. Ther. 7. 295-302. RACHMANS. and HODGSONR. 1. (1974) Synchrony and desychrony in fear and avoidance. Behar. Res. Ther. 12. 311-318. SOLOMON R. L., KAMINL. J. and WYNNEL. C. (1953) Traumatic avoidance learning: The outcomes of several extinction procedures with dogs. J. abnorm. sot. Psycho/. 4. 291-302. STAMPFLT. G. and LEVISD. J. (1967) Essentials of impl?sive therapy: a learning-theory-based psychodynamic behavioral therapy. J. abnorm. Psycho/. 72, 496-503. WATSONJ. P. and MARKS1. M. (1971) Relevant and irrelevant fear in flooding: a crossover study of phobic patients. Behac. Ther. 2, 275-293. WEEKE~C. (1976) Simple. Efictioe Treatment of Agoraphobia. Hawthorn. New York. WOLPEJ. (1973) The Practice of Behavior Therapy. Pergamon Press, New York.
79 0501.0243502
FLOODING WITH BREVITAL IN THE TREATMENT AGORAPHOBIA: COUNTEREFFECTIVE?* DIANNE L. CIMmLEsst,
Eastern
00 0
OF
EDNA B. FOA, GERALD A. GROVES: and ALAN J. GOLDSTEIN
Temple University Medical Pennsylvania Psychiatric
(Received
School, Department of Psychiatry. Institute. Philadelphia. PA 19129. U.S.A.
9 October 1978)
Summary-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.
Treatment of phobias by prolonged imaginal exposure to stimuli which evoke intense anxiety was developed in the 1960s under two labels, implosion (Stamp1 and Levis, 1967) and flooding (Rachman, 1969). These two techniques overlap considerably, but marked differences remain in theory and application despite more than a decade of research. One issue on which proponents of each technique have disagreed is the importance of the experience of anxiety during flooding. Following Solomon, Kamin and Wynne (1953) implosive theorists (Stamp1 and Levis, 1967; Hogan and Kirchner, 1967) assert that not only must the conditioned stimulus be presented without occurrence of the unconditioned stimulus, but the conditioned response, i.e. anxiety, must also be elicited. Consequently, implosive therapists strive to elicit and maintain high levels of anxiety until a spontaneous reduction in anxiety signals that extinction has occurred. As it is presumed that avoidance behavior is maintained by its drive reduction properties (relief of anxiety), it should cease following extinction. Other investigator< have questioned this assumption. Marks, for example, has concluded that, “It is not crucial whether patients are relaxed, neutral, or anxious during . . . exposure” (Marks, 1978). Rachman and Hodgson (1974) concur in general, but add, “The deliberate arousal of anxiety.. . [may be] facilitative in limited cases”. The effect of anxiety during flooding may depend on the nature of the anxiety-producing stimuli for a particular client. Goldstein and Chambless (1978) have suggested that agoraphobia is based on a fear of introceptive stimuli engendered by anxiety itself, hence, a ‘fear of fear’ (Weekes, 1976). Therefore, the experience of anxiety during exposure. is posited to be therapeutic. Since agoraphobics come to fear places where they predict they will panic, exposure to these exogenous stimuli is also important. Thus, for maximal effect flooding should encompass exposure to both the places and feelings which agoraphobics fear. Lending credence to this hypothesis, Watson and Marks (1971) found that flooding to either relevant or irrelevant cues led to improvement for a sample largely composed of agoraphobics. Improvement with irrelevant flooding was positively correlated with the amount of anxiety during flooding. If the interoceptive stimuli of anxiety are important anxiety-eliciting cues for agoraphobics, flooding without anxiety should not be as effective as flooding with anxiety. *This paper was presented
at the International Congress of Behaviour Therapy, Vienna, Austria, 1978. t Present address: Department of Psychology, University of Georgia. : Department of Psychiatry. Boston University Medical School. Requests for reprints should be addressed to D. L. Chambless, Department of Psychology, University of Georgia. Athens, GA 30602. U.S.A. 243
244
DIANNE L. CHAMBLESS.EDNA B. FOA. GERALD A. GROVESand ALAN J. GOLDSTEIN
The present paper represents an attempt to test this hypothesis by controlling the degree of anxiety through intravenous administration of a short acting barbiturate, methohexitone sodium (Brevital). METHOD
Subjects
The Ss were 27 agoraphobic outpatients who sought treatment primarily for their phobias and related complaints at the Behavior Therapy Unit of Temple University Medical School. Most were self-referred after learning through the media of the treatment program; some were referred by other health professionals. Criteria for inclusion in the study were: 1. Presence of fear of few as determined by a 90 min interview conducted by an experienced clinical psychologist. 2. Ability to create visual imagery and the capacity to experience anxiety while imagining phobic events. 3. Absence of serious medical illness, particularly heart disease or chronic respiratory disorders. 4. Age of less than 5Oyr. 5. Agreement to participate in the study and to come twice weekly for 10 weeks. 6. Initial willingness to take medication by injection for treatment purposes. Twenty-nine clients were accepted into the project and initially agreed to participate. Two dropped out in the beginning of treatment. The final sample was composed of 21 women and 6 men. Age ranged from 20 to 43, with a mean of 29.45. Duration of symptoms ranged from 1 yr to 23 yr, the mean being 8.28 yr. Therapists
Therapists were 19 psychologists, psychiatrists and social workers in training at the Behavior Therapy Unit. Previous clinical experience ranged from 2 to 10 yr (?? = 4.31) while experience in behavior therapy varied from 6 months to 9 yr (x = 2.31). The therapists received specific training for the flooding procedures used in this study and continued supervision by two psychologists experienced in flooding. Design Clients were randomly assigned to one of the three treatment groups: (a) non-drugflooding group, (b) drug-flooding group, or (c) attention-control group. A repeated measures design was employed with dependent measures administered before treatment sessions began and again 1 week after the eighth and final treatment session. Therapists and clients were blind as to the hypotheses under study. Because of time constraints the project was terminated after only seven Ss had completed the attention-control group. Ten Ss each completed the experimental groups. Measures
Four kinds of measures were taken at pre-treatment and 1 week post-treatment: client’s ratings, therapist’s ratings, behavioral test and psychophysiological recordings. Client ratings. Four scales-phobic anxiety, phobic avoidance, free-floating anxiety and severity of panic attacks-were adopted from Watsqn and Marks (1971). Scales ranged from 0 to 8 with 8 indicating highest pathology. Therapist ratings. Therapists rated their clients on the Watson and Marks scales described above. These ratings were made without access to the clients’ ratings. behavioral task. An individual behaviorai task was designed for each client by her/his therapist and executed in vivo. The task was selected during the initial interviews with the clients and consisted of having them approach and remain in their most feared situation for 30min if possible, e.g. driving alone for 30min. Clients were encouraged to desist if their anxiety levels became intolerable but were asked to do as much as they could before refusing to continue. Therapists accompanied clients to the point
Brevital
in the treatment
of agoraphobia
245
where they were to begin the task. Each client was asked to record his/her subjective anxiety level on a 0 to 8 rating scale provided at the beginning of the task. Ratings were to be made every 5 min. Furthermore, clients were to note the number of minutes they actually remained in the assigned situation. Psychophysiological measures. Recordings of physiological reactivity to descriptions of phobic stimuli were taken at both assessment periods. Reactivity during descriptions of neutral imagery was used as a baseline measure. Clients were asked to visualize two 100 suds (subjective units of discomfort, Wolpe, 1973) scenes as described by their therapists; each scene lasted 10min. Neutral scenes were also described for 10 min, and the order of presentation was phobic-neutral-neutral-phobic. Measures of reactivity were heart rate-beats per min, and GSR-the number of spontaneous fluctuations (nonspecifics) per min. Fluctuations of 200 ohms or greater were included in the analysis. Procedure
After screening and assignment to therapists, all clients underwent a physical examination by the staff psychiatrist, since drug group clients had to be thoroughly screened medically. Clients were then interviewed by their therapists for two 90-min sessions. During these sessions the therapists were instructed to establish warm. supportive relationships with the clients. After these initial interviews, the first assessment battery was given. After the first assessment battery, clients received eight treatment sessions according to their group assignment. Sessions were held on a twice-weekly basis and were of 2 hr duration each. All sessions were taped in their entirety and checked for adherence to the project protocol. One week after the eighth treatment session, the post-test battery was given. Non-drug -flooding group. Clients in this group were asked to imagine at length the phobic scenes which had been identified during the initial interviews while the therapist recounted these situations in detail. They were told that by using their imaginations to confront the situations they feared, particularly panic attacks, they would learn to be less afraid of these things in reality. Prior to the first flooding session clients were told that every 10min they would be asked to indicate their level of current anxiety (as opposed to how they would have felt in the same situation in reality), on the suds scale. They were instructed not to interrupt the imagined scene when reporting their anxiety; rather they were to indicate the appropriate level and continue immediately with the image. Clients lay on a recliner with their eyes closed during the entire flooding session. They were instructed to imagine the scenes described by the therapist as vividly as possible and to report when clarity of the image diminished at which time the therapist described the scenes more vividly. Periodically, clients were asked to describe ‘where they were’ to ensure that they indeed had been imagining the described scenes. The initial sessions were of moderate intensity, and across sessions more fearful scenes were introduced so that the final two sessions were spent on the client’s worst fears. This procedure is reported in more detail by Foa and Chambless (1978). Thus final sessions commonly included the feared catastrophes, e.g. heart attack, madness, screaming in public. The therapists urged clients to experience the imagined situations as if they were actually occurring, to feel the concomitant anxiety or shame acutely until it diminished. As anxiety fell within a session, the therapist added fresh anxiety-evoking material up to the last 15 min of each 90-min flooding session. If a client’s anxiety had not diminished by 80-85 min, the therapist introduced comforting or coping cues while not reducing the intensity of the phobic stimuli. The remaining 30 min of each 2-hr session was spent in supportive psychotherapy, discussing events that had occurred since the last session and inquiring about contact with phobic situations. Therapists were enjoined from introducing other behavioral techniques and from suggesting clients enter feared situations. Clients who reported entering formerly avoided situations, however, were praised.
246
DIANNE L. CHAMBLES. EDNA B. FOA. GERALD A. GROVES and ALAN J. GOLDSTEIN
Drug-flooding group. Procedures for this group were the same as those for the non-drug group except clients received periodic intravenous injections of a 1% solution of methohexitone sodium (Brevital) during the 90-min ‘flooding sessions. The drug was administered by a psychiatrist who attempted to maintain the client in a calm, relaxed state throughout the flooding session. Nevertheless, four clients experienced various degrees of anxiety during sessions. As a measure of intense anxiety before habituation, reports of subjective anxiety of 70 suds or greater were analyzed for the second and third flooding sessions for both experimental groups. Non-drug group clients reported anxiety higher than 70 suds on an average of 17.28 min per session. The drug group reported comparable anxiety only 6.75 min per session on the average. This difference is highly significant (I,,$~= 10.96; p < 0.001). AS with the non-drug group, clients were told that fear and panics are overcome by systematic confrontation, but it was additionally stated that the drug would accelerate the reconditioning process by speeding the realization that there was nothing to fear from these situations and sensations. Atrention-control group. Clients in this group received eight 2-hr sessions of psychotherapy plus training in progressive relaxation. Each session began with 13 hr of supportive interaction and behavioral analysis followed by -) hr of progressive relaxation including the use of pleasant, relaxing imagery. Clients maintained daily logs of suds levels and descriptions of their interpersonal and physical environment at times of high anxiety. This material constituted the basis for discussion during the 90min of each session allotted to verbal therapy. Such procedures are an important aspect of therapy with agoraphobics but are not expected to result in substantial improvement when used alone (Goldstein and Chambless, in press). Clients were told that if they lowered their chronic anxiety through relaxation and understood the source of their attacks, they would panic less frequently. As with the flooding groups, therapists were explicitly proscribed from suggesting clients enter feared situations and from using any behavioral techniques other than relaxation. Clients were, nevertheless, to be praised for any attempts they made to confront their phobias. RESULTS
To ensure there were no initial differences between the groups, one-way analyses of variance were computed on pretest scores for all dependent measures. No significant differences emerged among the three groups. All analyses for treatment effects were performed on change scores from pretest to post-test. Six of the dependent measures were analyzed with one-way analyses of variance using the least squares solution to the unequal n’s. Unequal variances among the groups on the remaining dependent measures necessitated nonparametric analysis by Kruskal-Wallis analyses of variance. For post hoc tests one-tailed tests of significance were used to compare the non-drugflooding group with both other treatment groups, as the dire&on of the results was hypothesized. Two-tailed tests were used for comparisons between the drug-flooding group and the attention-control group, since no specific pattern of results was hypothesized. RATING
SCALES
Fear of phobic situations. A one-way analysis of variance on clients’ ratings indicated a significant difference among the three groups (F = 4.10; p = 0.03). Post hoc analysis was performed by the Neuman-Keuls procedure in order to detect the source of this difference. The non-drug group was found to have improved more than both the drugflooding group and the attention-control group (see Table 2). Moreover no significant differences were found between the drug group and the attention-control group. On therapists’ ratings significant differences among the groups emerged on the Kruskal-Wallis analysis of variance (see Table 1). Mann-Whitney post hoc tests showed
Brevital in the treatment of agoraphobia FEAR
-1
247
SCORES
CHANGE
1
THERAPISTS
4.0 I 3.5 -
-
3.0 -
THERAPISTS
C
2.5 2.0 1.5 1.0 CLIENTS
.5 -
TtlERAPISl CLIENTS
jjjjj_
o---
NON-
DRUG
Fig. 1. Pretest-post-test
DRUG
ATTENTION
CONTROL
change scores on therapists’ and clients’ ratings of fear.
the non-drug-flooding group as well as the drug-flooding group improved significantly more than the attention control group. The non-drug-flooding group improved more absolutely than the drug-flooding group, although this difference was not statistically significant. Thus, while the pattern of means is the same for therapists’ and clients’ ratings (see Fig. l), therapists differ from clients in perceiving clients in the drug group as significantly improved. Avoidance of phobic situations. Clients’ ratings of avoidance required the MannWhitney procedure for post-hoc tests of the significant Kruskal-Wallis ANOVA. The non-drug-flooding group improved significantly more than the attention-control group. while the drug-flooding group did not. Though the mean change of the non-drug-flooding group was considerably greater than that of the drug-flooding group (see Table 2). this difference was not significant. Therapists perceived both drug-flooding group clients and non-drug-flooding group clients as being significantly more improved than attention-control group clients. The nondrug group changed more than the drug-flooding group but not significantly so (see Table 2). Therapists rated drug-flooding group clients as improved, while the clients did not perceive such changes (see Fig. 2); this is similar to findings for fear ratings. Anxious mood and panic. On clients’ ratings of anxious mood the Kruskal-Wallis ANOVA indicated a difference among the groups, but post hoc Mann-Whitney tests AVOIDANCE
4.0
CHANGE
SCORES
3.5 I 3.0
CLIENTS
THERAPISTS
2.5 2.0
TH
I. 5 CLIENTS
1.0 i 5 i 0
-.5 -1.0
CLIENTS
-
-
THERAPISTS
1I NON-DRUG
Fig. 2. Pretest-post-test
DRUG
ATTENTION
CONTROL
change scores on therapists’ and clients’ ratings of avoidance.
DIANNE L. CHAMBLES. EDNA B. FOA. GERALD A. GROVES and
248
Table
1. Kruskal-Wallis ANOVA on change agoraphobic outpatients Scale
Value of H
Fear Therapist rating Avoidance Therapist rating Client rating Anxious mood Client rating
failed to detect the location of this difference. suggests the attention control group improved therapists’ ratings a one-way analysis yielded On both therapists’ and clients’ ratings on difference among the three groups was found
ALAN J. GOLDSTEIN
scores
of
Probabilit)
30.86
P<
36.43 28.51
P< PC
0.001 0.001
22.55
P<
0.01
Inspection of the mean difference scores less than the two flooding groups. On a non-significant F (F = 1.27; p = 0.30). severity of panic attacks, no significant (F = 0.93; p = 0.41; F = 0.35; p = 0.71).
Behavioral task Nine clients completed all 30min of the behavioral task at pretest and therefore were not included in the analysis of this measure. For the remaining 18 clients, difference scores were computed by subtracting the number of minutes completed in the behavioral task at pretest from those completed at post-test. Both flooding groups increased their performances almost twice as much as the attention control group. These differences, however, were not statistically significant (F = 1.84; p = 0.20).
Table
2. Mean
change
scores
Scale Fear Client ratings Non-drug flooding Drug flooding Attention control Therapist ratings Non-drug flooding Drug flooding Attention control Avoidance Client ratings Non-drug flooding Drug flooding Attention control Therapist ratings Non-drug flooding Drug flooding Attention control Anxious mood Client ratings Non-drug flooding Drug flooding Attention control Therapist ratings Non-drug flooding Drug flooding Attention control * One-tailed test. t Twc+tailed test. $ No significant treatment
on dependent measures flooding. drug flooding
of agoraphobics: three and attention control
treatment
groups:
non-drug
D
S.D.
Posr hoc comparisons
2.60 0.50 -
2.50 1.58 1.91
NDF vs. DF NDF vs. AC DF vs. AC
3.80 2.70 0.43
1.32 2.63
1.33
NDF vs. DF NDF vs. AC DF vs. AC
u = 40.00 u = 1.00 u = 7.00
2.60 0.90 0.43
2.72 I .67 0.79
NDF vs. DF NDF vs. AC DF vs. AC
U = 26.50 u = 13.50 u = 28.00
2.60 1.80 -0.71
I .78 2.10 0.76
NDF vs. DF NDF vs. AC DF vs. AC
U = 38.50 u = 1.50 u = 9.00
p.001’ p < 0.02t
1.30 1.40 0.57
1.49 2.22 0.79
NDF vs. DF NDF vs. AC DF vs. AC
u = 47.50 U = 26.00 u = 31.50
ns ns ns
1.90 1.30 0.57
1.60 1.89
None:
1.52
effect on ANOVA.
Statistic
q(2.24) q(3.24) q(2.24)
= 3.04 = 3.76 = 0.72
Probability
p -=I0.05* p < 0.05’ ns ns
p < 0.001* p < 0.02t ns
p < 0.05. ns ns p <
Brevitai in the treatment of agoraphobia
249
Heart rate and GSR spontaneous fluctuation data were reduced on minutes 2-9 of each of the four IO-mm imagery epochs. Data from the two phobic imagery epochs were averaged as were results from the neutral imagery epochs. At pretest, the average scores on phobic and neutral imagery for all 23 subjects tested were compared using a r test of differences. Subjects did not show significantly more reactivity on phobic imagery at pretest as measured by heart rate (fd = 1.05; p > 0.05)or by the number of GSR spontaneous fluctuations (td = 0.67; p > 0.05). Consequently psychophysiological measures did not receive further consideration in the data analysis of changes with treatment. DfSCUSSION support The results on two main dependent variabies- fear and avoidance-provide for the hypothesis that confrontation with anxiety during flooding will enhance treatment effects for agoraphobics. Though differences between the drug group and the non-drug group were significant only on clients’ ratings of fear, a consistent pattern emerged on most measures. The non-drug group improved most followed by the drug group with the attention-control group improving least. Moreover, only the non-drug group improved significantly more than the attention-control group on both clients’ and therapists’ ratings. Although the differences in mean change of the groups are quite large, the withingroup variances are also large for the two experimental groups. In the attention-control group virtualiy no change occurred whife in the flooding groups some clients were cured and others changed minimally. Furthermore, the effect of experiencing anxiety during flooding might have been obscured in that, despite our efforts to maintain a non-anxiety state in the drug-flooding condition, clients in this group did report occasional anxiety. On the whole therapists’ and clients’ ratings were congruent. The exception is evaluation of the drug group on both fear and avoidance. Therapists perceived the clients in this condition as having improved when compared to the attention-control group while the clients themselves did not. A plausible explanation for this finding is that therapists expected clients in the drug-flooding group to show improvement. Although therapist expectancy was not assessed formally, comments by the therapists in the supervision seminar indicated they thought the drug manipulation would be the most powerful intervention. The third measure pertinent to the hypothesis is the behavioral task on which no difference among groups were detected. This may be due to two procedural inadequacies. Firstly, some of the tasks selected were not difficult enough and thus were completed even at pretest under the perceived high-demand conditions (see Bernstein and Nietzel, 1974, for effects of demand manipulation on behavioral task performance). Secondly, clients appeared to perceive the task as an all-or-none situation. Thus some clients forced themselves to complete the entire 30min despite very high anxiety, and others refused to begin at all even though the early moments of the task should have caused little discomfort. Two additional variables, anxious mood and panic, although they are not directly pertinent to a test of the effects of flooding, were included because of their clinical relevance to the syndrome of agoraphobia. Indeed flooding had minimal impact on these variables. No differences among the groups were found, neither between the two experimental groups nor between the flooding groups and the attention-control group. These findings are consistent with the analysis of agoraphobia proposed by Goldstein and Chambless (1978) who maintain that pervasive anxiety and panic attacks stem from interpersonal conflict. Change on these variables, consequently, should require interventions not applied in this study such as marital-therapy and assertiveness training. The results of this study suggest that the experience of anxiety during flooding improves outcome with agoraphobic clients. This is not necessarily true for clients with
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DIANNE L. CHAMBLESS.EDNA B. FOA. GERALD A. GROVES and ALAN J. GOLDSTEIN
fears of exogenous stimuli like many specific phobias. If this study were replicated with specific phobics, the results might well be reversed. Indeed with in vice exposure Marks et al. (1972) found specific phobics who hid received a minor tranquillizer improved more than those who had not. However, this drug effect may have stemmed from the tranquillized clients having allowed more rapid exposure. Hussain (1971) used intravenously administered thiopental sodium (Penthothal) during ‘flooding’ with social phobics and agoraphobics. Compared to a group flooded while receiving saline injections, these clients improved dramatically. These findings are strikingly different from our own. It is difficult to interpret Hussain’s findings, however, as the procedure he describes bears little similarity to the usual practice of imagindl flooding. In two other studies the variable of anxiety during flooding with agoraphobics was manipulated with tranquillizers. These studies yielded conflicting results. Hafner and Marks (1976) treated clients with group in viuo exposure combined with diazepam (Valium) or placebo. All groups improved equally. Conflicting results were reported by Johnston and Gath (1973) who combined flooding in fantasy and flooding in uivo with diazepam or a placebo. The diazepam group improved more on the behavioral task but not on ratings of fear. In neither study was it convincingly demonstrated that the drug group was actually less anxious during flooding than the placebo group. Hafner and Marks found the primary drug effect was a reduction in anticipatory anxiety. During exposure both groups reported equal subjective anxiety. Subjective ratings of anxiety during flooding were not reported by Johnston and Gath. GSR was lower for the diazepam group during flooding, but heart rate, the more reliable measure (Mathews, 1971) was not. A second important issue is equality of exposure in drug and placebo groups, as Mathews (1976, cited by Marks, in press) found that, with specific phobias, when the amount of exposure is controlled, clients receiving diazepam improve no more than those getting a placebo. In the Hafner and Marks study, placebo and drug clients were treated in the same groups; hence all clients underwent exposure of equal intensity. No information on this variable was provided by Johnston and Gath leaving open the possibility that in their study as in Marks et al. (1972) drug group clients allowed more rapid and, therefore, more thorough exposure. In short, conclusions on the role of the experience of anxiety during flooding cannot be drawn from these previous studies, since the degree of anxiety experienced ‘and the intensity of the exposure were not simultaneously controlled. When intensity of exposure is controlled and amount of anxiety successfully manipulated as in the present study, the experience of anxiety during flooding does appear to enhance outcome. The results support the notion advanced above that for agoraphobits who fear both fear and and the places in which they expect to experience fear, exposure to both endogenous and exogenous stimuli maximizes the treatment effect of flooding. However, an alternative explanation for our results should be considered. Under some conditions sedatives can lead to impaired learning in humans (Overton, 1977). Thus, the superiority of the non-drug group may be he not to the experience of anxiety but to learning defects in the drug group. Acknowledgemenrs-We wish to express our appreciation to the trainees of the Behavior Therapy Unit for their participation in the study and to Barry M. Shmavonian and Peggy Gaver for their invaluable assistance in collecting psychophysiological data. This study was completed in partial fulfilment of the requirements for the Ph.D. degree of the first author and was supported by a grant from the Boulton Fund. REFERENCES BERNSTEIN D. A. AND NIETZEL M. T. (1974) Behavioral avoidance tests: the effects of demand characteristics and repeated measures on two types of subjects. Behnv. Ther. 5, 183-192. FOA E. B. and CHAMBLE~~ D. L. (1978) Habituation of subjective anxiety during flooding in imagery. Behac. Res. Ther. 16, 391-399. GOLDSTEIN A. J. and CHAMBLESS D. L. (1978) A reanalysis of agoraphobia. Behou. Thu. 9, 47-59. GOLDSTEIN A. J. and CHAMBLESS D. L. Comprehensive treatment of agoraphobia. In Handbook of Behmim[ Inreruentions (Edited by A. J. GOLDSTEIN and E. B. FoA). John Wiley, New York. In press.
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HAFNERJ. and MARKSI. (1976) Exposure in villa of agoraphobics: contributions of diazepam. group exposure. and anxiety evocation. Psychol. Med. 6. 71-78. HOGANR. A. and KIRCHNERJ. H. (1967) Preliminary report of the extinction of learned fears via short-term implosive therapy. J. abnorm. Psychol. 72. 106-109. HUSSAINM. Z. (1971) Desensitization and flooding (implosion) in treatment of phobias. AIII. J. Psychiar. 127, 1509-1514. JOHNSTONE. and GATII D. (1973) Arousal levels and attribution effects in diazepam-assisted flooding. Br. J. Psychiat. 123, 46346. MARKSI. Behavioral psychotherapy of adult neurosis. In Handbook of Psychotherapy and Behavior Modification (Edited by S. GARFIELDand A. E. BERGIN)(2nd Edn). John Wiley. New York. 1978. MARKS I. M., V~SWANATHAN R., LIPSEDGEM. S., and GARDNERR. (1972) Enhanced relief of phobias by flooding during waning diazepam effect. Br. J. Psychiar. 121. 493-505. MATHEWSA. M. (1971) Psychophysiological approaches to the investigation of desensitization and related procedures. Psycho/. Bull. 76, 73-91. OVERTOND. A. (1977) Drug statedependent learning. Psychopharmacology in the Practice of Medicine (Edited by M. E. JARVIK).Appleton-Century-Crofts, New York. RACHMANS. (1969) Treatment by prolonged exposure to high intensity stimulation. Behac. Res. Ther. 7. 295-302. RACHMANS. and HODGSONR. 1. (1974) Synchrony and desychrony in fear and avoidance. Behar. Res. Ther. 12. 311-318. SOLOMON R. L., KAMINL. J. and WYNNEL. C. (1953) Traumatic avoidance learning: The outcomes of several extinction procedures with dogs. J. abnorm. sot. Psycho/. 4. 291-302. STAMPFLT. G. and LEVISD. J. (1967) Essentials of impl?sive therapy: a learning-theory-based psychodynamic behavioral therapy. J. abnorm. Psycho/. 72, 496-503. WATSONJ. P. and MARKS1. M. (1971) Relevant and irrelevant fear in flooding: a crossover study of phobic patients. Behac. Ther. 2, 275-293. WEEKE~C. (1976) Simple. Efictioe Treatment of Agoraphobia. Hawthorn. New York. WOLPEJ. (1973) The Practice of Behavior Therapy. Pergamon Press, New York.