Marital relationship and the treatment of panic disorder with agoraphobia: a critical review

Clinical Psychology Review 23 (2003) 247 – 276

Marital relationship and the treatment of panic disorder with agoraphobia: a critical review Roger Marcaurellea, Claude Be´langera,b,*, Andre´ Marchanda,c a

University of Quebec in Montreal, Montreal, Canada McGill University and Douglas Hospital Research Center, Montreal, Canada c L.-H. Lafontaine Hospital, Fernand-Seguin Research Center, Montreal, Canada b

Received 5 April 2002; received in revised form 5 June 2002; accepted 22 August 2002

Abstract The purpose of this paper is (1) to specify, among studies on the links between marital relationship and cognitive-behavioral treatment of panic disorder with agoraphobia (PDA), the conceptual and methodological limitations that may have produced inconsistent results in this field so far; and (2) to propose avenues of research that will help in remedying current weaknesses and answering important questions in this area. Following definition of PDA and a survey of its socioeconomic consequences, the authors examine results of the various ways research has tried to specify the links between marital relationship and the development, maintenance, and treatment of this disorder: the study of major life events before and after the onset of PDA, interpersonal problems and quality of marital relationship in the presence of PDA, the links between marital relationship and PDA treatment outcome, variability of experimental outcomes according to types of measure used to study these links, the effect of the spouse as co-therapist in PDA treatment, and the impact of a PDA treatment based on marital communication and problem-solving. Research hypotheses and methodological procedures are proposed to improve understanding of PDA and its treatment outcome. D 2003 Elsevier Science Ltd. All rights reserved. Keywords: Panic disorder with agoraphobia; Marital relation; Cognitive behavior therapy

*

Corresponding author. Department of Psychology, University of Quebec in Montreal, CP 8888, Succ. Centre-Ville, Montreal, QC, Canada H3C 3P8. Tel.: +1-514-987-3000x1452; fax: +1-514-987-7953. E-mail address: [email protected] (C. Be´langer). 0272-7358/03/$ – see front matter D 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 2 - 7 3 5 8 ( 0 2 ) 0 0 2 0 7 - 6

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1. Introduction Panic disorder with agoraphobia (PDA) is a very costly psychosocial problem for individuals, families, and society (Katon, 1996). Inability to work, financial dependency, and overuse of health services by people who suffer from this anxiety disorder are markedly higher than they are, on average, for other mental disorders (Katon, 1996). It is also known that cognitive-behavioral therapy (CBT) is, as of now, the most documented and efficient intervention for PDA (Clum, Clum, & Surls, 1993; Gould, Otto, & Pollack, 1995). Based on ‘‘in vivo’’ exposure, its efficacy varies between 66% (Roth & Fonagy, 1996) and 80% (Barlow & Lehman, 1996). However, if one takes into account a 6% attrition rate (Craske & Rodriguez, 1994), between 26 and 40% among participants do not feel a significant symptom reduction. In addition, only 50% of people who do not suffer from panic attacks anymore following treatment ultimately reach a level that is nearly free of all symptoms (Barlow & Brown, 1996). Moreover, in a long-term follow-up study (2–9 years), residual agoraphobic avoidance as well as personality disturbances after treatment and recovery were found to be of prognostic value in PDA relapse, whereas levels of panic, agoraphobia, and depressed mood before treatment were not (Fava, Zielezny, Savron, & Grandi, 1995). Residual symptoms therefore appear common and significant in PDA, even after treatment and remission (Barlow & Lehman, 1996; Fava, 1996; Fava et al., 2001; Noyes, Holt, & Woodman, 1996). In seeking to improve treatment of PDA, many researchers have sought to understand the role of interpersonal difficulties, more specifically, the role of marital problems in the development and maintenance of PDA. Up until now, however, studies about the role of marital relationship in the etiology and treatment of PDA are mixed and not very conclusive (Bouchard, Bolduc, Boisvert, & Gauthier, 1995; Carter, Turovsky, & Barlow, 1994; Marchand, Comeau, & Trudel, 1994). As a result, some authors proposed a new direction by investigating social support factors in general, rather than the marital relationship (Carter et al., 1994; Fokias & Tyler, 1995). Nonetheless, a consensus is emerging, suggesting that methodological and conceptual limitations have hindered reaching a satisfactory clarification of the links between marital functioning, etiology, and treatment of PDA. A recent review paper by Daiuto, Baucom, Epstein, and Dutton (1998) affords a landmark analysis of these issues. However this article has some limitations. First, in its analysis of the links between PDA etiology and marital relationship, it does not provide an overview of current theoretical models; second, it does not present a broad psychosocial context that includes studies on significant live events before onset of PDA as well as on interpersonal relationships of PDA subjects; third, it does not show an exhaustive and well-classified picture of the various concepts (marital satisfaction and adjustment) and means of assessment (self-report questionnaires, interviews, behavior coding, PDA-specific, and non-PDA-specific measures) used to study marital relationship with respect to PDA; fourth, it does not bring to light the full consequences of the data available. Further clarifying these issues could help in developing more satisfactory conclusions concerning the behavior of couples and the treatment of PDA. Therefore, the purposes of this article are to: (1) summarize results of empirical research concerning the links between marital relationship and cognitive and behavioral treatment of

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PDA; (2) identify the methodological and conceptual limitations that have hindered the clarification of these links; and (3) introduce methodological and heuristic avenues likely to further the understanding of these links and to improve the treatment of PDA.1

2. Panic disorder with agoraphobia Before considering these issues as such, it may be useful to define what PDA is in terms of its main symptoms, prevalence, and socioeconomical impact. While panic disorder without agoraphobia (PD) is characterized by recurrent panic attacks, PDA includes besides these attacks avoidance of their triggering situations (American Psychiatric Association, 1994). PDA may start with the panic attacks themselves. Sudden and all-encompassing, these attacks are marked by symptoms such as heart palpitation, chest pain, a feeling of choking, dizziness, and the fear of dying, losing control, or ‘‘going crazy,’’ etc. (American Psychiatric Association, 1994). The individual may then be tempted to flee places where the attack occurred, for example, crowds, standing in line, bridges, trains, the subway, etc. In some cases, avoidance of specific stressful situations for a period of time is also reported to precede the onset of panic attacks and may be characteristic of the prodromal phase of PDA; in this context, the first panic attack would appear as a culmination of a chain of stress reactions, when more stressful life events occur and/or when life circumstances no longer allow avoidance (Fava & Mangelli, 1999). Avoidance is accompanied by various fears, such as finding oneself in places or situations from which it may be difficult or embarrassing to escape, or having no help available. It constitutes the essence of agoraphobic behavior. As a result, the agoraphobic tends to delegate responsibilities to others. He or she reduces traveling and often requires being accompanied when leaving home. The more the number of avoided places, the more the individual’s functioning is impaired. Some patients even become unable to leave their home (American Psychiatric Association, 1994). 2.1. Prevalence and socioeconomical consequences of PDA Various epidemiological studies estimate at 5% the lifetime prevalence rate of PDA (Wittchen & Essau, 1993). The ratio of women suffering from PDA is three times higher than that of men (American Psychiatric Association, 1994). PDA is often accompanied by other psychiatric disorders, such as depression (30%), other anxiety disorders (20%), alcohol and drug abuse (15%), or even suicide attempts (between 6% and 20%) (Hirschfeld, 1996; Massion, Warshaw, & Keller, 1993). PDA is likely to be transmitted through the family. Morbidity rates for this disorder in firstdegree relatives varies between 17% and 33%, this number being four to seven times more

1

Bibliographical research for this study was done mainly with the use of the following data banks: PsycINFO (years 1967 – 2001) and Medline (years 1966 – 2001). The following keywords were variously combined in order to identify the relevant literature: panic, agoraphobia, marital, relation, interpersonal, couple, and dyadic.

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frequent than in individuals whose parents do not suffer from mental disorders (Crowe, Noyes, Pauls, & Slymen, 1983; Harris, Noyes, Crowe, & Chaudhy, 1983). As compared to those whose parents are without mental disorder, children of parents suffering from PDA are more vulnerable to risk factors, and up to 68% of them go through anxiety disorders or depression (Biederman, Rosenbaum, Bolduc, Faraone, & Hirshfeld, 1991; Capps, Sigman, Sena, Henker, & Whalen, 1996). Even though there may be a genetic aspect to this transmission, the interpersonal components of the family may also contribute. In fact, observation by children of panic symptoms in their parents seems related to the development of PDA in children (Elhers, 1993). PDA has a very noxious impact on individual functioning, as well as on social welfare and health care costs. In comparison with the overall average of people affected by other psychiatric disorders, people suffering from PDA feel less healthy (Katon, 1996). They also use emergency room services more frequently, are hospitalized more often for emotional problems, consult twice as often in general medicine and four times more often in psychiatry, consume more psychotropic drugs, and neglect more their search for employment due to emotional problems (Klerman, Weissman, Ouellette, Johnson, & Greenwald, 1991; Rees, Richards, & Smith, 1998). For those among them who require medical treatment, in the United States, annual cost of their medical care corresponds to US$2444 per individual vs. US$403 for the general population (Siegel, Jones, & Wilson, 1990). Similarly, according to American data, these individuals rely more on social support government programs, in a ratio one and a half times that of the average of individuals suffering from other psychiatric problems (Klerman et al., 1991). In agoraphobics who can keep their job, work efficiency is reduced by 83% (Edlund & Swann, 1987). Thus, personal, familial, professional, economical, and social costs of PDA are considerable. While exploring the factors likely to influence the efficacy of treatment for this disorder, in the last two decades, researchers have put most of their efforts into investigating interpersonal relationships and particularly marital relationship. The issue will first be examined from the general standpoint of interpersonal relationships.

3. PDA and interpersonal problems While trying to identify possible etiological factors of PDA, many studies have examined major life events in the months preceding emergence of PDA symptoms—in most cases, before the first panic attack. However, the majority of empirical results for this question come from studies without a control group and/or based solely on clinical judgment (Franklin & Andrews, 1989; Pollard, Pollard, & Corn, 1989). While expressing reservations with regard to the reliability and validity of these studies, Franklin and Andrews (1989) summarize 13 of them as follows: 86% of participants suffering from PDA report at least one major life event or significant stressor at the time of their first panic attack; 69% attribute it to health related events; 39% to interpersonal conflicts; and 32% to separation or loss. These results suggest that interpersonal conflicts could play a significant role in the onset of PDA. Six studies with better control design help in furthering the understanding of this link. They all include a

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control group as well as valid questionnaires to identify major life events in association with emergence of PDA. These studies are summarized in Table 1. The first two studies suggest that, in comparison with normal participants, more PDA patients report at least one major life event before the emergence of symptoms. Similarly, in most studies (four out of six), people suffering from PDA report significantly more major life events during this period. In both studies where this was not the case, either marked distress or a greater number of negative life events can be noted. In addition, the study by Pollard et al. (1989) compares PDA patients to themselves and to other PDA patients in terms of: (1) the time immediately preceding TPA symptoms and (2) periods other than the one preceding the onset of these symptoms. Results indicate that a greater number of PDA patients experience at least one major life event and report a greater number of them, for the period immediately preceding emergence of symptoms. Together, these six studies also indicate that the number of interpersonal and marital conflicts is not usually greater than that of other major life event categories, a greater number of the former being reported in only two out of the six studies. Other types of events, such as health problems and separation experiences due to death of a significant person, which are not related to interpersonal conflicts, may be relatively more frequent. Therefore, even though they are clearly present in a significant number of participants, marital problems do not stand out as compared to other interpersonal problems, with regard to stress factors linked to onset of PDA. Rather, they are part of an array of potential stressors that must also be considered. Still, it is important to note that the measures used in these six studies are different from each other. Therefore, differences observed may be due, at least in part, to the various ways of categorizing life events. In addition, these studies are based on retrospective data as they ask participants to recall major life events that may have occurred many years before or that may be recent and still quite vivid. These trials also assume that PDA starts with panic attacks and leave out cases where the first panic may have been preceded by a significant period of agoraphobic behavior. These experimental conditions may very well distort or bias recall (Fava & Mangelli, 1999). Validity of these life events studies is therefore limited and their results should be interpreted with caution. Other studies suggest that interpersonal stress is related to development of PDA after the initial emergence of symptoms. In fact, within the factors associated with agoraphobic avoidance after onset of PDA, we find stress related to interpersonal relationships (De Ruiter & Garssen, 1989) and to social fears (De Jong & Bouman, 1995; Fleming & Faulk, 1989). According to Wade, Monroe, and Michelson (1993), weak improvement at the end of PDA treatment is linked to chronic stressors (average to severe) as reported by 43% of participants. Among the chronic stressors mentioned, 63% were interpersonal, while 28% were of a marital nature. Interpersonal and marital relationships therefore seem tied, at various degrees, to onset and maintenance of PDA. However, the nature and direction of this link remains to be defined. The higher prevalence of relational problems in people suffering from PDA, compared to other groups, seems to confirm the significant link between this disorder and interpersonal factors. In fact, when comparing normal individuals to people suffering from PDA, the latter have more interpersonal difficulties (Buchheim, 1992; Lange & van Dyck, 1992; McCarthy & Shean, 1996) and more familial problems (McCaghren, 1985; Oppenheimer & Frey, 1993).

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Study

n

Groups

Measure

Period covered by the events

More subjects reporting at least one event

Higher event/ subject ratio

More eventrelated distress

Greater number of events in some event categories

Rapee, Litwin, and Barlow (1990)

131

Life Experiences Survey (Sarason, Johnson, & Seigel, 1978)

6 months before the onset of the disorder

Yes (PDA vs. other anxiety disorders)

No

Yes (PDA and other anxiety disorders vs. normal)

No

Pollard et al. (1989)

100

(1) PDA (n = 64) (2) Other anxiety disorders (n = 33) (3) Normal (n = 34) (1) PDA (‘‘index group’’; n = 50) (2) PDA (‘‘comparison group’’; n = 50)

Social Readjustment Rating Scale (Holmes & Rahe, 1967)

Yes

Yes

–

–

Franklin and Andrews (1989)

102

18 months (12 months before and 6 months after the onset of the disorder for gr. 1) 12 months before the onset of the disorder

–

Yes

No

Yes (interpersonal conflicts (mostly maritalb), health problems, separation, financial crisis)

(1) PDA (n = 51) (2) Normal (n = 51)

Life Event Scale (Tennant & Andrews, 1976)

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Table 1 Number and negative impact of major life events before the onset of PD or PDA symptomsa

46

(1) PD (n = 23) (2) Normal (n = 23)

Scale of Life Events (Paykel, Prusoff, & Uhlenhut, 1971)

Roy-Byrne, Geraci, and Uhde (1986)

88

(1) PD (n = 44) (2) Normal (n = 44)

Horesh, Amir, Kedem, Goldberger, and Kotler (1997)

88

(1) PD with or without agoraphobia (44) (2) Normal (44)

PERI-M Life Events Inventory (Dohrenwend, Krasnoff, Askenasy, & Dohrenwend, 1978) Israeli PERI Life Event Scale (Levav, Krasnoff, & Dorenwend, 1981)

12 months before the onset of the disorder 12 months before the onset of the disorder

12 months before the onset of the disorder

–

Yes

–

–

No

Yes

–

No

–

Yes (events with severe intensity; death or major illness of a parent) Yes (events sustained by subjects themselves; moving)

Yes (negative events; love and family)

a The ‘‘yes’’ and ‘‘no’’ of the last four columns indicate significant and nonsignificant results, respectively. The long dash means that the study does not offer any data relative to the concerned dimension. b According to Franklin and Andrews (1989), the three most important chronic stressors (sustained for more than a year) identified by people suffering from PDA are: problematic relations in the family (70.6%), health problems (59.6%), and difficulties with the spouse (51%).

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Favarelli (1985)

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They report as much or more interpersonal difficulties as compared to depressed individuals (Oppenheimer & Frey, 1993; Weissman, 1991) and to people suffering from other psychiatric problems (Arrindell & Emmelkamp, 1986). The idea of a significant link between PDA and interpersonal factors is also supported by data suggesting dysfunction in the mode of interaction of people suffering from PDA. In contrast with normal people, PDA patients show less autonomy (Hafner & Minge, 1989; McCarthy & Shean, 1996), self-confidence and affirmation (McCarthy & Shean, 1996). They also manifest more neurotic traits, and are more prone to direct aggression toward themselves (Clair, Oei, & Evans, 1992; Hafner & Minge, 1989). They use negative coping skills, such as avoidance more often (Brodbeck & Michelson, 1987; Katerndahl, 1999), as well as magical thought and blaming themselves or others (Katerndahl, 1999). They have a stronger tendency to interpret information as threatening (Stoler & McNally, 1991), and are more irritable and hostile (Clair et al., 1992; Fava et al., 1993). They more often have the impression of being criticized, which leads them to reply more often negatively to a negative interpersonal message (Fauerbach, 1992). Compared to depressed individuals, they are more prone to use magical thought rather than a problem-solving approach (Hoffart & Martinsen, 1993). Even after a 6-month or longer remission from PDA symptoms, a significant proportion of people tends to keep certain dysfunctional traits, such as a lack of self-affirmation, high indecisiveness, self-criticism, emotionality, and frustration, as well as the feeling of being rejected when criticized (Mavissakalian & Hamann, 1992). As shown by Fava et al. (1995), these residual interpersonal difficulties prove to be significant predictors of relapse. Altogether, interpersonal and marital problems seem therefore tied to the different stages of PDA. However, the strength and the direction of these links must be further specified. The cross-sectional approach of the research examined so far does not allow to know whether the interpersonal difficulties and dysfunctions are essentially the cause or the effect of PDA. Nevertheless, if agoraphobics have more interpersonal problems than normal subjects, it is likely that they also have more marital problems and that the latter contributes, in some way, to the symptoms of PDA. A certain number of models have tried to explain these links between PDA and marital relationship.

4. Marital models of PDA At least four marital models of PDA have been proposed. Some authors suggest that, on the one hand, the spouse of the individual suffering from PDA is himself subject to psychological disorders and that he gets a psychological reward from his role of care provider toward the PDA patient who is in a situation of dependence upon him (or her). The non-agoraphobic spouse may then feel threatened by the increased improvement and autonomy of the agoraphobic partner (Fry, 1982; Hafner, 1977b; Mittelman, 1958; Webster, 1953). Indeed, maintenance of PDA may protect the non-agoraphobic spouse from the threat of a potentially autonomous partner. However, the hypothesis of a spouse characterized by a personality problem and maintaining a dysfunctional relation has not yet been confirmed by controlled research (Marchand et al., 1994; Vandereycken, 1983).

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According to another model, based on the hypothesis of a ‘‘complementary union’’ (Hafner, 1977a), both spouses may gain profit from the agoraphobic dynamics: rather dependent, the agoraphobic woman may seek parental protection from a domineering spouse, who feels valued by taking her in charge. There also, the spouse will feel threatened by any decrease in agoraphobia and any increase in autonomy observed in the agoraphobic spouse (Goodstein & Swift, 1977; Hafner, 1977a; Hand & Lamontagne, 1976). As indicated by Marchand et al. (1994), empirical research on this model remains mixed. Agoraphobia could also be thought to serve in reducing marital conflicts in the short-term (Goldstein & Chambless, 1978; Marchand et al., 1994). Agoraphobia may be a way, for dissatisfied women who are also dependent and afraid of being alone, to manage the dilemma between the dissolution or maintenance of their marriage (Symonds, 1971). Panic would therefore be a way to express the feeling of being trapped in the marital relationship and agoraphobia would serve in providing secondary gains, such as receiving attention. This process of marital conflict reduction through PDA is also interpreted according to traditional sexual roles (Fodor, 1974; Craske & Zoellner, 1995; Kleiner & Marshall, 1985; Hafner, 1984; Shean, 1990). For the woman, the conflict would be between the desire for greater autonomy than she is conventionally allowed, and the fear of the consequences resulting from her assertiveness—including feeling alone in the case of separation from her spouse. In agoraphobic males, symptoms of the disorder would arise when their spouse, being usually introverted and afraid of any aggressive behavior, tries to get out of the submissive mold. Liotti and Guidano (1976) come to such a conclusion in their behavioral analysis of 15 agoraphobic men. In a review of the literature on the links between gender and agoraphobia, Bekker (1996) concludes that the theme of dependency has received good empirical support for agoraphobic women; however, it is also common in other disorders, and therefore it does not account specifically for agoraphobia. According to the author, research must be expanded to include other aspects of the development of sexual identity, such as the management of physical sensations and cognitions, and the sexual content of parent–child interactions during childhood of agoraphobics. A fourth model, the ‘‘state model of interpersonal problems,’’ suggests that relationship problems of the PDA patient are due to his or her agoraphobic situation or ‘‘state’’ (Hoffart, 1997). Interpersonal problems, including marital difficulties, result from the pathological state of PDA, rather than contributing to it. The agoraphobic patient being more dependent on people close to him because of his or her disorder, a tension develops in his or her intimate interpersonal relationships. This tension may be further exacerbated by the depressive or anxious affects that are often secondary to this disorder. According to this model, more general symptoms, such as interpersonal and marital difficulties, should decrease when PDA symptoms diminish. Interpersonal difficulties may possibly influence treatment outcome, but not in a major way. Hoffart (1997) does present an empirical study that supports this model. However, as will be shown in this paper, many studies observe that a reduction of PDA symptoms may lead to an increase in marital difficulties. Such a finding cannot be explained by Hoffart’s model. In the light of these models, it is now appropriate to evaluate the empirical research for the links between PDA and marital relationship.

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5. Presence of marital problems in PDA patients Up until now, evaluation of marital relationship in people suffering from PDA has given only mixed results. A major epidemiological study, done in the US (Epidemiological Catchment Area study or ECA), reveals that 12% of people suffering from PD or PDA do not get along well with their spouse; this number is six times more than for people without this disorder (Markowitz, Weissman, Ouellette, Lish, & Klerman, 1989; Weissman, 1991). This proportion is almost as much as the one regarding major depressive disorder. A metaanalysis of four studies done by Emmelkamp and Gerlsma (1994) concludes that, even though the marital relationship of agoraphobics seems characterized by greater distress, as compared to normal individuals, the difference ranges between small and medium. However, some authors clearly conclude that, compared to normal individuals, people suffering from PDA are less adjusted or satisfied in their marriage (Fauerbach, 1992; Kleiner, Marshall, & Spevak, 1987; McCarthy & Shean, 1996). But others have found no significant difference in the marital adjustment and communication of people suffering from PDA as compared to individuals not suffering from a mental disorder (Arrindell & Emmelkamp, 1986; Fisher & Wilson, 1985; Powers, 1984). When evaluated through behavioral coding, marital relationship seems in one instance similar to that of partners both free from mental disorders (Buglass, Clarke, Henderson, & Kreitman, 1977) and, in the other instance, it appears more problematic (Fauerbach, 1992). In sum, with the exception of ECA study, which is epidemiological, four controlled studies support the hypothesis of more marital problems in agoraphobics and four do not confirm it. Unfortunately, this inconsistency has not yet received proper explanation.

6. Marital relationship and PDA treatment outcome Another way to evaluate the role of interpersonal and marital relationships in PDA is to examine how treatment outcome varies as a function of these variables, and thus how they predict it. In most studies reported here, marital relationship is defined in terms of one or many of the following variables: marital satisfaction, dyadic adjustment, and communication style or conflict resolution style. Marital satisfaction is simply the degree of content regarding certain aspects of marital relationship as well as the whole relationship. Dyadic adjustment indicates, in addition to satisfaction, various aspects of couple functioning, such as communication, control, dependency, intimacy, and flexibility. Sometimes, the concept of adjustment is used more broadly, in family, occupational, and social contexts. Communication style and conflict resolution styles are essentially aspects of communication between spouses, such as avoidance, initiative, aggressivity, and congruence. Most studies with respect to these used self-report questionnaires. The new definitions of marital satisfaction and marital adjustment proposed by Daiuto et al. (1998) will not be retained here, as they are somewhat confusing. According to these authors, satisfaction would refer to a subjective and global evaluation of the relationship, whereas adjustment would correspond to a more objective, descriptive and specific account of the couple’s interaction. This leads the authors

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to classify, for instance, the Dyadic Adjustment Scale by Spanier as an assessment of satisfaction, but the latter includes some evaluation of the couples’ interaction. Thus, it seems more appropriate to carry on with the definitions proposed in this paper, while adding other assessment specifications such as self-report questionnaires, interviews, behavioral coding, and, as will be done below, PDA-specific or non-PDA-specific measures. According to Arrindell, Emmelkamp, and Sanderman (1986), overall social adjustment at pretest is a good predictor of PDA treatment outcome. Similarly, social and occupational adjustments before treatment predict PDA treatment outcome after 2 years (Monteiro, Marks, & Ramm, 1985) and 5 years (Lelliott, Marks, Monteiro, Tsakiris, & Norshirvani, 1987). Familial adjustment at baseline is also a good predictor of treatment outcome, at least for the 1-year period following therapy (Hudson, 1974). Although studies on these adjustment types as predictive factors are sparse, they all support the idea that social and familial adjustments are tied to PDA treatment outcome. The direction of this link, however, remains to be clarified. A larger number of studies are concerned with the association between the quality of marital relationship before PDA treatment and treatment outcome. While the prognostic value of other forms of interpersonal adjustment on treatment outcome appears consistent through all studies so far, up until now, the predictive value of marital variables is again subject to contradictory results. First, conclusions of major descriptive reviews, as well as of metaanalyses are mixed. The descriptive review by Carter et al. (1994) concludes that treatment based on in vivo exposure seems to lead to a reduction of PDA symptoms, whatever the quality of marital relationship before treatment. However, better marital adjustment or greater marital satisfaction at pretest predicts a greater reduction of agoraphobic symptoms at posttest. On the other hand, reviews by Coˆte´ and Gauthier (1988) and Kleiner and Marshall (1985) conclude that the degree of marital difficulty at baseline predicts efficacy of therapy through in vivo exposure at follow-up only. According to these authors, the exact nature of the marital difficulties involved remains to be clarified. Three other reviews (Jansson, Ost, & Jerremalm, 1987; Marchand et al., 1994; Steketee & Shapiro, 1995) find that pretreatment marital relationship does not predict PDA treatment outcome consistently, neither at posttest nor at follow-up. Similarly, Emmelkamp and Gerlsma (1994), in a quantitative review without a global effect size estimate, assert that the effect sizes are too variable and that the methodological difficulties are too numerous to come to any firm conclusions concerning prediction of PDA treatment outcome through quality of marital relationship. Classical meta-analyses also generate mixed results. Gathering results of six studies, Dewey and Hunsley (1990) conclude that the higher the marital adjustment at pretest, the greater the reduction of agoraphobic symptoms, at least up to 1 year after treatment. However, adding two other studies to the above mentioned six, Daiuto et al. (1998) conclude in their meta-analysis that the predictive link between marital adjustment and PDA treatment outcome is not significant. It should be noted, however, that, because of methodological reasons mostly related to the homogeneity of the data, this meta-analysis could only included less than half of the studies conducted on the topic (8 out of 21). Given the conflicting conclusions among both descriptive reviews and meta-analyses, further enquiry is needed on marital variables as predictors of PDA treatment outcome. Some

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clues may be found in studies, which allow to compare the prognostic value of different types of measure of marital relationship (Daiuto et al., 1998). In some studies (which will be detailed below), on the one hand, traditional questionnaires on marital satisfaction and adjustment, such as the Dyadic Adjustment Scale or the Maudsley Marital Questionnaire, fail to confirm the predictive power of these variables on treatment outcome; on the other hand, in the same studies, questionnaires specific to agoraphobic issues in the couple or behavioral coding of the couple come out to be good predictors of treatment outcome. Among means of measuring marital relationship, it is therefore important to draw a distinction between traditional marital questionnaires, on the one hand, and questionnaires specific to agoraphobic issues in the couple and behavioral coding of the couple, on the other hand. As part of re-examining the prognostic value of marital relationship on PDA treatment outcome, Tables 2 and 3 contain all the studies on the relationship between pretreatment marital variables and treatment outcome, based on self-report questionnaires, which are not focused on the issue of PDA in the couple. These tables list 21 articles or doctoral theses, describing 19 different experimental conditions.2 These studies examine whether marital communication, satisfaction, or adjustment, as measured before treatment, predicts the outcome of a PDA treatment based primarily on in vivo exposure. Table 2 contains studies supporting the hypothesis that marital communication, satisfaction, or adjustment are significant predictors of PDA treatment efficacy. For example, good communication would be significantly related with a better treatment outcome and, therefore, with a greater reduction of symptoms than for participants whose communication is poorer. Table 3 contains studies that could not confirm this type of hypothesis. Studies in Table 2 are based on two questionnaires on marital satisfaction and two on marital adjustment. Studies in Table 3 are based on 4 questionnaires on couple communication, 4 on marital satisfaction and 11 on marital adjustment. According to Table 2, only 3 studies show that marital communication, satisfaction, or adjustment is significant predictor of treatment outcome at posttest, while Table 3 contains 16 studies that could not demonstrate this link. As for follow-up, 2 out of 3 studies in Table 2 and 1 study out of 11 in Table 3 show a significant link between baseline marital variables and treatment outcome. In all, only 3 studies out of a potential of 14 establish such a link at follow-up. However, these results should be interpreted according to the fact that follow-ups are of variable lengths, ranging from 1 to 60 months. Worth noting is a study by Milton and Hafner (1979) in Table 3, which found no significant link between pretest marital adjustment and treatment outcome at posttest, but did at follow-up, after 3 and 6 months. Interestingly, according to Telfer (1992), marital adjustment at follow-up, varying between 1 and 10 years, shows to be the best predictor of PDA treatment outcome. Perhaps, these results refer to long-term marital processes that have escaped the boundaries of most measuring instruments used until now. This issue deserves a more thorough investigation since longitudinal data are still limited.

2

The paper by Chambless and Gracely (1988) appears in both Tables 2 and 3 because different results were obtained by two different experiments.

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Table 2 Marital communication, satisfaction, or adjustment as predictors of PDA treatment outcome at posttest (measures of marital relationship other than PDA-specific or behavioral coding) Study

n

Measurea

Length of treatment

Correlation with treatment outcomeb

Methodological comments

Posttest Follow upc Chambless and Gracely (1988)

2 intensive Yes weeks

No (6 and 12 months)

2 intensive Yes A: Marital weeks Pre-Counseling Inventory (Stuart & Stuart, 1973); S: Semantic Differential Scales (measures gap between ideal spouse and spouse) Marks et al. (1983), 27 A: Maudsley 28 weeks Yes Monteiro et al. agoraphobics Marital (1985), and Questionnaire Lelliott et al. (Crowe, 1978; (1987) Arrindell, Boelens, & Lambert, 1983)

Yes (1 and 3 months)

Bland and Hallman (1981)

134 S: Marital agoraphobics Satisfaction Questionnaire

12 couples

No random assignment, no control group, variable additional treatment No random assignment, no control group, unvalidated questionnaires

Yes (24 and No random 60 months) assignment, no control group

a

Letters preceding questionnaire names have the following meanings: A = marital adjustment questionnaire, B = behavioral coding, C = communication or problem-solving questionnaire, S = marital satisfaction questionnaire, SSI = semistructured interview. b Yes and no indicate, respectively, a significant and nonsignificant negative correlation between the marital variable and the PDA symptom scores. A significant negative correlation suggests that the better the marital relationship at pretest, the more PDA symptoms are reduced at posttest and/or follow-up. c Numbers in parentheses correspond to the follow-up period in terms of the number of months after the posttest.

Methodologically speaking, none of the studies mentioned in Table 2 used random assignment or a control group, whereas Table 3 contains seven that did; two of the latter measured marital communication, and the five others, marital adjustment. Among the three studies of Table 2, one used nonvalidated questionnaires, while in Table 3, three studies did. In all, 15 studies out of 21 do not support the hypothesis of a link between PDA treatment outcome at posttest or at follow-up, and marital variables nonspecific to PDA as measured at pretest by self-report questionnaires. In addition, studies that support a significant link are based on less rigorous methodology. The differences noted in these studies may be explained by diverse experimental conditions, notably the absence of a control group in many of these

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Study

Chambless and Gracely (1988) Arnow et al. (1985) Arrindell et al. (1986)

n

30 agoraphobics 25 couples 25 couples

Cobb et al. (1984)

19 couples

Cohen (1987)

7 couples 24 agoraphobics

De Beurs, Lange, van Dick, and Koele (1995) Emmelkamp et al. (1992)

Emmelkamp (1980)

72 couples

20 agoraphobics

Measure

Length of treatment

Correlation with treatment response Posttest

Follow-up

Methodological comments

S: Marital Satisfaction Questionnaire

10 sessions

No

–

No random assignment, no control group Random assignment, control group (relaxation) No random assignment, no control group, additional treatment for some subjects after 3 months Random assignment, control group (without spouse as co-therapist) No random assignment, no control group No random assignment, no control group

A: Dyadic Adjustment Scale (Spanier, 1976) A: Maudsley Marital Questionnaire (Crowe, 1978; Arrindell et al., 1983)

6 sessions in 1 month 1 month (intensive)

No

No (8 months)

No

No (3, 6, 9, and 12 months)

A: Maudsley Marital Questionnaire (Crowe, 1978; Arrindell et al., 1983), modified version A: Dyadic Adjustment Scale (Spanier, 1976) C: Interactional Problem Solving Inventory (Lange, Markus, Hageman, & Hanewald, 1991) A: Maudsley Marital Questionnaire (Crowe, 1978; Arrindell et al., 1983); C: Communication Questionnaire (Buunk & Nijkens, 1980) A: Marital Deprivation Scale (Dutch adaptation of the Marital Attitudes Evaluation Scale by Shutz)

5 h in individual sessions 15 sessions

No

No (6 months)

No

–

13 sessions

No

–

6 sessions in one month

No

No (1 month)

Random assignment, control group (without spouse as co-therapist)

10 sessions

No

No (1 month)

No random assignment, no control group

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Table 3 Marital communication, satisfaction, or adjustment as nonpredictors of PDA treatment outcome at posttest (measures of marital relationship other than PDAspecific or behavioral coding)

42 couples

Keijers, Hoogduin, and Schapp (1994)

60 agoraphobics 22 couples

Craske et al. (1989)

Jansson et al. (1987)

12 weekly sessions

No

No (12 and 24 months)

12 sessions

No

No (2 months)

S: MHS (Azrin et al., 1973)

12 sessions

No

–

12 sessions

No

5 individual sessions

No

No (7 and 15 months) No (12 to 24 months)

1 month

No

7 individual sessions

No

Yes (3 and 6 months) No (3 months)

10 sessions

No

–

A: Marital Adjustment Test (Locke & Wallace, 1959); S: Marital Happiness Scale (MHS; Azrin, Naster, & Jones, 1973) C: Interactional Problem Solving Inventory (Lange et al., 1991)

Peter and Hand (1988)

40 agoraphobics 25 agoraphobics

Milton and Hafner (1979) Marchand et al. (2001)

18 couples 25 agoraphobics

A: Maudsley Marital Questionnaire (Crowe, 1978; Arrindell et al., 1983) A: Dyadic Adjustment Scale (Spanier, 1976); S: MHS (Azrin et al., 1973) A: Marital Questionnaire (Crowe, 1976) A: Dyadic Adjustment Scale (Spanier, 1976)

Thomas-Peter et al. (1983)

25 agoraphobics

C: The Marital Patterns Test (Ryle, 1966)

Random assignment, control group (without spouse as co-therapist), MHS unvalidated No random assignment, no control group No random assignment, no control group, MHS unvalidated No random assignment, control group (relaxation) No random assignment, no control group, MHS unvalidated No random assignment, no control group Random assignment, control groups (conventional CBT, self-managed CBT, self-managed CBT with help of a close relative) Random assignment, control groups (waiting list, placebo)

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Himadi et al. (1986) and Cerny et al. (1987)

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studies, the use of nonvalidated questionnaires, the variability of the marital dimensions measured by different questionnaires, the evaluation of marital relationship in some cases through the agoraphobic person only, and in others through the couple. The limited number of participants in many studies, the differences in the treatments themselves and in their length, the frequent absence of follow-up, or its use on a much too short-term basis might also explain the differences in the results. As a whole, empirical research to this day does not support the hypothesis that marital communication, satisfaction, or adjustment, as measured at pretest by self-administered questionnaires without specific focus on PDA, is valuable indicator of treatment prognosis. This does not indicate however that no aspect of marital relationship can be found to be a good predictor of PDA treatment outcome. The classical marital questionnaires may not be able to grasp some crucial aspects of marital relationship that do influence PDA treatment outcome. Results obtained through measures other than the traditional marital relationship questionnaires hint is this direction.

7. PDA-specific measures and behavioral coding measures of marital relationship Four studies allow the comparison, in terms of predictive power on PDA treatment outcome, between marital self-report questionnaires without reference to PDA issues in the couple, on the one hand, and PDA-specific measures or behavioral coding measures of marital relationship, on the other. Table 4 outlines these studies. One of these studies, by Craske, Burton, and Barlow (1989), found that marital satisfaction at pretest was not correlated with PDA treatment outcome (see Table 3 for this result), while two of the five subscales of a PDA-specific self-report marital measure, the Couple Interaction Checklist Questionnaire (or CICQ, developed by the authors), did predict the outcome. These subscales were (1) the evaluation by the agoraphobic subject of a better communication on the part of the partner concerning agoraphobic fears and (2) the evaluation by the spouse of his or her own encouragement and support toward the agoraphobic partner. Similarly, a study by Cohen (1987) did not find any predictive power in marital adjustment (see Table 3 for this result) but noted that three of the subscales of the CICQ, i.e., understanding of agoraphobia by the partner, agreement between the partners on how to manage the fears of the agoraphobic partner, and the degree of communication regarding agoraphobia, were correlated with PDA treatment outcome. However, the questionnaire used by Craske et al. (1989) and Cohen (1987) does not seem to have been validated, thereby limiting the scope of results obtained with this instrument. Similarly, Thomas-Peter, Jones, Sinnott, and Scott Fordham (1983) obtained opposite results as a function of different marital relationship measures used in their research. On the one hand, a communication questionnaire, which was non-PDA-specific, with given affection, received affection, the difference between both, and dominance as subvariables, did not allow for prediction of treatment outcome (see Table 3 for this result). However, the Management Effectiveness of a Significant Other Rating (devised by the authors), a PDAspecific semistructured interview, did show a significant correlation with treatment outcome.

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Table 4 PDA-specific and behavioral coding measures of marital relationship as predictors of PDA treatment outcome at posttest Study

n

Measure

Length of treatment

Correlation with treatment response

Methodological comments

Post-test Follow-up Cohen (1987) 7 couples

C: Couples Interaction Checklist

15 sessions

Yes

Craske et al. (1989)

22 couples

C: Couples Interaction Checklist

12 sessions

Yes

ThomasPeter et al. (1983)

10 sessions Yes 13 nonSSI: Rating through agoraphobic the semistructured spouses interview Management Effectiveness of a Significant Other Rating 5 individual No 25 couples B: Behavioral coding sessions of a semistructured individual interview through the Camberwell Family Interview

Peter and Hand (1988)

–

No random assignment, no control group, unvalidated questionnaire – No random assignment, no control group, unvalidated questionnaire – Random assignment, control groups (waiting list, placebo) Yes (12 to No random 24 months) assignment, no control group

This interview measures the perception, by the non-agoraphobic spouse, of his or her efficiency as a manager of the agoraphobic behavior of his or her partner. Results indicated that the tendency of the spouse to encourage independence of his or her agoraphobic partner predicts a reduction of agoraphobic symptoms. Although the interview used here does not seem to be validated, each participant was evaluated by two judges and concordance between raters was high. It then appears that PDA-specific marital questionnaires (Cohen, 1987; Craske et al., 1989; Thomas-Peter, Jones, Sinnott, and Scott Fordham, 1983) may reveal links between marital relationship and PDA treatment outcome, while classical evaluation of marital satisfaction and adjustment cannot. As suggested by Daiuto et al. (1998), these divergent results may be explained by the idea that the couple may seem well-adjusted in general, while having a dysfunctional interaction with regard to PDA. For example, the great care given by the spouse to reduce the stress experienced by his or her partner in agoraphobic situations can be evaluated by the couple as a sign of good marital adjustment in the Dyadic Adjustment Scale (Spanier, 1976). However, this pattern actually constitutes poor adjustment with regard to this disorder, given that it encourages avoidance. The objective evaluation of the aspects of marital relationship specifically concerning PDA therefore appears important because it could possibly bring to light marital factors related to the maintenance of PDA symptoms.

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A study by Peter and Hand (1988) reveals another aspect of change in prognostic value of marital variables as a function of change in types of measure. First, the authors did not note any correlation at pretest, posttest, or at follow-up, between satisfaction and marital adjustment in both partners, on the one hand, and reduction of agoraphobia, on the other (see Table 3 for this). However, results were more conclusive with behavioral coding from the Camberwell Family Interview (Brown & Rutter, 1966), a semistructured interview with good psychometric properties. This interview was separately administered to each of the spouses. It concerned the behavior of each partner as judged by the other. Recorded on an audiotape, the interview was then coded with regard to five subvariables: the number of critical comments, hostility, excessive emotional involvement, number of positive remarks, and warmth. From a calculation of the degree of criticism for the couple as a whole, it was found that a low degree of criticism at pretest predicted reduction of symptoms at follow-up, 1 or 2 years after treatment, but not at posttest. A research by Arnow, Barr Taylor, Stewart Agras, and Telch (1985) reminds one of the comparison allowed by the Peter and Hand’s (1988) study. Arnow et al. observed that following a successful communication-based marital therapy, marital adjustment in agoraphobics, as measured by the Dyadic Adjustment Scale, had not changed between pretest and posttest. However, standardized behavioral coding in a dyadic situation through the Marital Interaction Coding System (Hops, Wills, Patterson, & Weiss, 1972) showed a reduction of negative behavior and an increase of positive behavior in agoraphobics. It could be that results from self-report questionnaires are distorted by the very dysfunctional aspects of marital relationship that these instruments are meant to identify, particularly by denial or avoidance of problems or conflicts. Indeed, studies noted that couples in which one spouse is suffering from PDA have a tendency to deny marital problems (Mead, 1982) or to avoid them (Tillotson, 1992). Winter and Gournay (1987) identified, in both partners of these couples, constructs that tend either to exclude or not to recognize interpersonal problems. Hafner and Minge (1989) found that, contrary to husbands of nonagoraphobic wives, husbands of agoraphobics evaluated their wife as more autonomous and masculine than she would evaluate herself. The authors also noted that these husbands rated their wives’ autonomy higher than the control group (husbands whose wives were not agoraphobic). On the other hand, the self-evaluation of agoraphobic wives of their own autonomy and masculinity was inversely related to their agoraphobia. The less they felt autonomous and masculine, the more severe was their avoidance. Therefore, denial or underestimation, by the partner, of autonomy and assertiveness problems of their agoraphobic wives could play a significant role in treatment response, all the while escaping the scope of marital satisfaction or adjustment questionnaires. A study conducted by Friedman (1990) concluded, in a similar vein, that people suffering from PDA reported less marital conflicts than individuals without mental health problems. Himadi, Cerny, Barlow, Cohen, and O’Brien (1986) observed that, at pretest, partners in satisfied couples perceived their spouse suffering from PDA as more avoidant and more anxious, and felt more dysphoric than husband of unsatisfied couples. Thus, paradoxically, partners from less satisfied couples saw their agoraphobic spouse as less distressed than did more satisfied partners. The hypothesis of a certain denial process in the agoraphobic’s couple thus reappears. As suggested by Winter

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and Gournay (1987), it may be that couples where one partner is afflicted with PDA often have similar construct systems, which confers mutual validation of their dysfunctional thinking. In that sense, the more similar the construct systems of spouses are, the less the agoraphobic symptoms would diminish. Thus, mixed results from studies about the links between marital relationship, development of agoraphobia, and treatment outcome could perhaps be reduced by PDA-specific marital measures and by behavioral coding which would be likely to counteract hiding of problems by the couple. This research avenue seems quite promising.

8. The effect of treatment on marital relationship One way to specify the link between the quality of marital relationship and the intensity of PDA symptoms consists in measuring the scope of the changes in marital relationship after treatment. If PDA symptoms do not offer secondary gains for any one of the partners, and therefore do not have an etiological link with marital relationship, one may expect that a conventional PDA treatment will reduce PDA symptoms, as well as the marital tensions that are due to the management of this disorder by both partners. However, if the PDA symptoms bring secondary rewards, it is probable that their reduction, during or following treatment, will disturb the pathological balance that has been maintained in the couple until then. Thus, treatment could disturb the marital relationship. If the change is desirable for the nonagoraphobic partner, he or she will respond in a favorable way. If not, the partner will hardly adjust to the new situation, will react unfavorably, will offer resistance to reduced PDA symptoms, and will damage the marital relationship. Empirical results on this topic suggest a complex picture. On the one hand, in vivo exposure treatment seems capable of improving marital adjustment (Monteiro et al., 1985), marital communication (Arnow et al., 1985), and interpersonal relations (Hoffart, 1997; Lange & van Dyck, 1992), in addition to diminishing PDA symptoms. It was also noted that CBT of PDA decreases hostility and irritable mood and increases friendliness (Fava et al., 1993). Moreover, it increases internal locus of control (Bakker, Spinhoven, van der Does, van Balkom, & van Dyck, 2002a; Bakker, Spinhoven, van der Does, van Balkom, & van Dyck, 2002b). Marital adjustment has been shown to be linked to internal locus of control (Camp & Ganong, 1997). Thus, improvement of the marital relationship could be seen as a positive side-effect of PDA treatment. It is also known that catastrophic misinterpretations of bodily sensations during panic attacks are a significant factor in PDA severity (Bakker et al., 2002a, 2002b). Moreover, maritally unajusted individuals have more irrational cognitions than adjusted ones (Mo¨ller, Rabe, & Nortje, 2001). Thus, reduction of PDA-connected irrational cognitions through PDA treatment could perhaps reduce dysfunctional cognitions as a whole in PDA patient and improve marital adjustment. The hypothesis would be that difficulties occasioned by PDA decrease the quality of marital relationship, and that, in turn, reduction of PDA maintenance factors (e.g., external locus of control and catastrophical cognitions) and of PDA symptoms through treatment improves the couple’s functioning. However, other studies suggest that the situation is more complex and seems rather to be a matter of bidirectional causality.

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Many authors report that the marital relationship may sometimes deteriorate following PDA treatment. In studies on the matter, one can identify two major types of patterns with regard to the effect of treatment on marital relationship. These patterns are twofold, in the sense that they point to either improvement or deterioration of marital relationship after the same PDA treatment. In the first twofold pattern, which will be called simultaneous, during the same period after treatment, either improvement or deterioration of marital relationship is experienced by different couples. In the second twofold pattern, which will be called successive, improvement and deterioration alternate in time within the same couple. The simultaneous twofold pattern suggests that reduction of PDA symptoms (especially when fast) through treatment is accompanied, in some couples, by improvement, and in others, by deterioration of their marital relationship (Barlow, Mavissakalian, & Hay, 1981; Kitch, 1983; Milton & Hafner, 1979; Perlmutter, 1990). Hafner (1984) identifies on his part a twofold pattern of marital change that takes opposite directions through time. In this successive twofold pattern, during the first 6 months after the beginning of therapy, some couples go through more conflicts, but find a way to resolve them in the following 6 months and PDA symptoms then remain low. Contrary to this, other couples cut themselves off behind dysfunctional complementary interactions, such as dominance and submission, as well as behind stereotyped conceptions of the role of each in the couple. No apparent relational difficulties are then manifested during the first 6 months. However, conflicts appear in the following 6 months; they remain without a solution and predict recurrence of PDA symptoms. Hafner (1977b) even reports that, in such couples, the neurotic symptoms of the masculine, non-agoraphobic, partner (measured by the Middlesex Hospital Questionnaire) diminished as the PDA symptoms increased again in his wife. Thus, both PDA treatment outcome and quality of marital relationship after treatment seem tied to the capacity of the couple to resolve conflicts (Hafner, 1984) or to adapt to the changes brought about by therapy, such as greater autonomy of the agoraphobic. A study by Emmelkamp and Van der Hout (1983) reveals that the more agoraphobics complain about their partner or their marital relationship during PDA therapy, the less their treatment is successful, suggesting the link between inability to find solutions to marital conflicts and agoraphobic symptomatology. In some couples, treatment outcome is related to spouses’ incapacity to acknowledge their problems in the first place. According to Chernen and Friedman (1993), contrary to members of a couple who report marital problems at pretest, the ones who believe they have none, experience no reduction of PDA symptoms or a very weak one. Similarly, when at posttest the spouse nourishes an idealized conception of the agoraphobic partner, one can expect a weak change in PDA symptoms at a 6-month follow-up, and even less at a 12-month follow-up, the spouse seemingly maintaining a stereotyped image of the partner in spite of the changes brought about by therapy (Hafner & Ross, 1983). It is thus quite clear that PDA treatment may affect marital relationship and that, in turn, marital relationship may influence treatment outcome. The couple’s ability to identify problems and to find solutions to them appears crucial in this dynamics and seems to deserve special attention as part of aspects of PDA treatment concerning the couple.

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9. The spouse as co-therapist Taking into account the link between PDA treatment efficacy and problem-solving ability in couples, other studies tried to see whether a therapeutic contribution from the partner was likely to improve treatment outcome. Some studies on the involvement of the partner during in vivo exposure conclude that exposure with the presence of the partner reduces PDA symptoms more than exposure without (Barlow et al., 1981; Barlow, O’Brien, & Last, 1984; Cerny, Barlow, Craske, & Himaldi, 1987; Cobb, 1982) or than exposure with the company of a friend (Oatley & Hodgson, 1987). But the majority of studies conclude to the contrary, that presence of the spouse during exposure does not significantly improve treatment results (see notably Cobb, Matthews, Childs-Clarke, & Blowers, 1984; Emmelkamp et al., 1992; Himadi et al., 1986; Marchand, Boisvert, Beaudry, Be´rard, & Gaudette, 1985; Marchand, Cloutier, Gareau, & Boivin, 2001; Marchand & Comeau 1992). Meta-analyses by Daiuto et al. (1998), Dewey and Hunsley (1990), and Emmelkamp and Gerlsma (1994) come to the same conclusion. According to Craske et al. (1989), it is the quality of marital communication and not simply the presence of the spouse as co-therapist that is linked to treatment efficiency. These authors found that the better marital communication is perceived by the agoraphobic, the less he or she feels anxiety during exposure. In addition, the degree of anxiety during in vivo exposure explains the majority of the variance of PDA treatment outcome (Michelson, Mavissakalian, Marchione, Dancu, & Greenwald, 1986). Therefore, good marital communication in the context of in vivo exposure would seem to have a significant impact on treatment outcome. In addition, a weaker marital adjustment at pretest predicts greater anxiety during in vivo exposure for a 3-month period (Murphy, Michelson, Marchione, Marchione, & Testa, 1998). Marital adjustment and communication in the couple thus seems to favor success in therapy by diminishing anxiety. In relation to this, subjects who abandon therapy have a poorer communication regarding anxiety symptoms than people who complete treatment (Carter, Turovsky, Sbrocco, Meadows, & Barlow, 1995). The idea that the quality of marital communication may prevail on simple accompaniment by the partner, with regard to treatment efficiency, is also supported by the fact that the introduction of the spouse as cotherapist is more beneficial with treatments that include cognitive restructuring, than with those relying almost exclusively on simple accompaniment during exposure (Barlow et al., 1984; Carter et al., 1994; Cerny et al., 1987; Woods, 1989). In this context, when communication in the couple is difficult before beginning PDA treatment, therapy with the spouse as co-therapist might not give the expected results. One could then conceive a combined psychosocial treatment, starting with the acquisition of communication and problem-solving skills within the couple, so as to integrate these skills in the next phase of the PDA treatment, with the spouse as co-therapist.

10. Effect of marital communication and problem-solving therapy on PDA Even with the large number of studies on marital relationship of people suffering from PDA, only five measured the impact of adding a treatment based on marital commun-

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ication and problem-solving skills to in vivo exposure. Here again, results are mixed. According to Kleiner (1987) and Crowe (1989), combining these two treatments diminishes more PDA symptoms than in vivo exposure only. Similarly, Arnow et al. (1985) showed that adding a treatment focused on marital interaction provides more help in reducing PDA symptoms, than adding relaxation. Two studies, however, did not find a significant differential effect between exposure alone, and exposure combined with a treatment focused on marital interaction (Chambless, Foa, Grobes, & Goldstein, 1982; Cohen, 1987). Thus, at this point, it is difficult to draw conclusions over impact of marital communication and problem-solving therapy on PDA symptoms. However, a good proportion of these couples might have no significant communication problem. Therefore, addition of a communication and problem-solving therapy to PDA treatment might have a greater impact on nonadjusted couples than on adjusted couples. This hypothesis would require empirical validation.

11. Conclusions and recommendations To this day, results of empirical research have remained mixed with regard to knowing: (1) whether individuals suffering from PDA have more interpersonal and marital problems than normal population; (2) whether marital communication, satisfaction, or adjustment at pretest predicts the outcome of CBT of this disorder; and (3) whether the combination of CBT with a therapy on marital communication and problem-solving reduces PDA symptoms significantly more than CBT alone. On the basis of the present literature review, as a whole, in comparison with normal participants, individuals suffering from PDA experience more major life events during the months preceding the onset of the disorder, sometimes including marital and interpersonal problems. These individuals are also affected by other types of stressors, particularly health problems, or different loss or separation experiences. In fact, whether before or after onset of PDA, agoraphobics seem to experience more interpersonal difficulties than individuals without psychological disorders. However, studies comparing the quality of marital relationship in normal individuals and people suffering from PDA are contradictory. This question remains unsolved. As suggested by Bouchard et al. (1995), efforts are needed to better understand why agoraphobics seem to have more interpersonal difficulties than normal subjects, while their marital relationship is not clearly more dysfunctional. As a whole, marital communication, satisfaction, and adjustment are not good predictors of treatment outcome. However, these results come mostly from self-report questionnaires that evaluate marital variables in a general way. As discussed, a few studies showed that other marital variables—more specific to PDA or based on behavioral coding of tasks related to marital relationship—are better predictors of PDA treatment outcome than classical marital measures. Many questions remain with regard to the links between marital relationship and PDA. These require experimental designs capable of resolving the methodological and conceptual

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problems that have limited the scope of possible discoveries and inferences until now. The following are some considerations that might help in answering these questions. (1) Methodological rigor should be improved by incorporating control groups and by using validated measures. (2) Because other stressors than marital difficulties play a significant role in the onset and exacerbation of PDA, the evaluation of marital relationship will be ideally performed in the larger context of all possible stressors. (3) Because research has not been able to distinguish marital difficulties as cause or consequence of PDA, it seems important to ask spouses to evaluate the degree in which dissatisfaction in the couple is due to PDA symptoms, and establish a temporal relationship between agoraphobic symptoms and marital distress. (4) Longitudinal studies must be conducted in order to measure, in the long-term, the links between marital relationship and the development of PDA. (5) In order to better predict potential problems tied to treatment, as well as to better specify the intervention targets and the order in which they should preferably be aimed at, it would be beneficial to include different types of evaluations of marital relationship. This could include behavioral coding of marital interactions. (6) The couple may be well adjusted in general but may have acquired dysfunctional patterns specifically with regard to PDA. An evaluation of marital functioning specific to PDA is therefore essential. (7) Inclusion of the non-agoraphobic partner must take into account the characteristics of the couple’s interaction. When there are marital difficulties at the onset, it may be wise to work on marital communication before asking the partner to participate as co-therapist. The above methodological orientation, also brought forth by Daiuto et al. (1998), must be specified in the following terms. (1) One must first consider the probability that marital difficulties do not contribute significantly to PDA in a certain number of couples. (2) Since in many cases the couple of the PDA patient may not be dysfunctional, the experimental design would benefit in distinguishing between functional and dysfunctional couples. If the addition of a therapy focused on marital communication and solving-problem is to make a significant difference, it may be for dysfunctional couples only. (3) Given that almost all studies on the marital relationship of individuals with PDA only rely on self-report questionnaires, behavior coding may bring to light crucial interaction processes that escaped these questionnaires so far. (4) It is also possible that dysfunctional aspects of marital relationship that are supposed to be evaluated by questionnaires contribute in fact in sidestepping the results of the latter. Again, this problem might be overcome through behavior coding, which can more easily identify conflict denial or avoidance, for instance. Notwithstanding the many contradictory results obtained until now, the question of the links between marital relationship and PDA treatment remains relevant, and is likely to be clarified by a methodology that can better specify important factors in the development, maintenance, and treatment of this disorder.

Acknowledgements This publication was supported by a grant from the Conseil Que´be´cois de la Recherche Sociale (CQRS) to the second and third authors.

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