ABSTRACT
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Abstract: This paper is focused in the coping strategies used by patients with an agoraphobic disorder (AD) when they are forced to confront phobic situations. Traditionally, the coping strategies considered were those used by agoraphobia patients to reduce anxiety and psychological distress: the avoidance behavior (to avoid the phobic stimuli) and the escape behavior (when the phobic stimulus is present). Additionally, behaviors used to try to avoid negative physiological responses similar to those occurring in an anxiety crisis (interoceptive avoidance) are also included. A fourth group of behaviors has received less attention: coping strategies that partially allow agoraphobia patients to confront and resist the presence of phobic stimuli. These are stimuli that they need to or are forced to confront. These partial coping strategies (often rituals behaviors) are behaviors to which patients assign a value in decreasing the anxiety to tolerable levels until they are able to confront and resist the phobic scenes (even partially). These behaviors play a non-adaptative role because they difficult the development of adaptative self-control strategies, interfere with daily living conditions, and support the disorder providing an initial and immediate relief of psychological distress. We prefer to name all these strategies non-adaptative coping behaviors. Despite the relevance of these partial coping strategies in the development and consolidation of agoraphobia, their empiric study has been infrequent (especially when compared to the study of both avoidance and escape behaviors). In that sense, with the present study we try to provide data about the following issues: 1) to know how frequently AP' use non-adaptative coping behaviors compared with a group of patients with other disorders. 2) The differential use of behavioral patterns by agoraphobic patients (AP): avoidance behaviors, interoceptive avoidance, escape behaviors, and, especially, the partial coping strategies. 3) The role of partial coping strategies in the evaluation of therapeutic outcome, according to the clinician opinion. The empirical study was designed in two stages: First, the elaboration of a scale to measure coping strategies of phobic stimuli. For that purpose, we took into account literature on the topic, observational data and clinical histories of patients with agoraphobia. The result was a scale (CAD scale) composed by 87 overt behavior items, and 52 covert behavior items. All of these items allowed for the formation of four behavioural patterns, grouping items according to their functions in coping with phobic stimuli: 1) avoidance behavioral pattern; 2) interoceptive avoidance pattern; 3) escape behavioral pattern; and 4) partial coping behavioral pattern. Second stage: The application of the CAD scale to a clinical simple. A group of psychologists and psychiatrists (from a local mental health service unit) were requested to administrate the scale to their patients, with their informed consent. The final sample (n = 235) was as follows: 40 with agoraphobic disorder (30 women and 10 men); 30 with panic disorder (18 women and 12 men); 30 mixed with anxious-depressive disorder (25 women and 5 men); 40 with depressive disorders (32 women and 8 men); 25 with psychotic disorders (10 women and 15 men). A matched group without any clinical disorders was added later (N = 70, 49 women and 21 men). After analysing the results related to the use of non-adaptative coping behaviors, these may be summarized as follows: In gene ral, the group which used less the CAD strategies was the non-clinical group. The patients with agoraphobia were the ones who used the CAD strategies in a more significant level, compared with both the non-clinical group and the groups with other disorders. This includes the use of partial coping behaviors. Results were similar both to CAD overt strategies and covert strategies. Comparing the differential use of CAD strategies by patients with agoraphobia, results show a more significant use of avoidance behaviors (especially in overt behavior form), followed by escape behaviors. Interoceptive avoidance was the third CAD more frequently used. Partial coping behaviors were less used in contrast with other CAD strategies. According to therapist judgments with respect to the relationship between the use of coping strategies and the therapeutic progress evaluation, the AP sample was divided into two groups: positive progress and non-positive progress (negative, unstable or no progress). The positive progress group shows a significant lower use of avoidance behaviors, interoceptive avoidance, and escape behaviors, but only in the overt behavior form. There were no significant effects for partial coping behavior. In other words, a positive evolution in PA was joined by a decrease in avoidance overt behaviors, interoceptive overt avoidance, and escape overt behaviors, but there were no changes in the use of both cognitive coping strategies and partial coping behaviors. Our findings confirm that CAD strategies are more used by AP. Partial coping behaviours are included among these. It was a well-known fact (and previous data supported it), that agoraphobia patients tended to use more both avoidance and escape strategies as procedures which relieved them from anxiety and psychological distress. But, also, there were few data about the role of strategies allowing AP to confront and resist the phobic scenes: the partial coping behaviors. Our data provide information about this kind of coping. Results support that it is more frequently used by agoraphobia patients. This is true when comparing it with patients with other disorders, and, obviously, in contrast with the normal population. But the use of partial coping behaviors is not commonly compared with "more traditional" behaviors such as avoidance or escape behaviors. It may be said that people with agoraphobia choose to avoid or to escape from phobic situations as the best way for them to reduce anxiety. But there is a group of phobic situations an agoraphobic patient must confront on some occasions (attending a medical service, buying something, etc.). These few occasions represent an opportunity to use partial coping strategies. The limited use of these strategies may be due to the fact that other strategies reduce anxiety in a more effective way. In that sense, they may be considered as behaviors having a low frequency of occurrence and a high intensity. We especially appreciate findings about the role of partial coping strategies in the therapeutic progress when a clinician emits judgments about the improvement of agoraphobia patients. These judgments are linked to a decrease of several non- adaptative overt strategies, but there is no change in cognitive coping strategies and neither in partial coping behaviors. These may be interpretated as imprecise therapist judgments, but also as the role played by this kind of strategies in the latent maintenance of agoraphobic responses. Finally, this paper discusses these results according to the counter-therapeutic role of partial coping strategies, and the need to consider them as a target objective in treatment process.
ABSTRACT
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Abstract: The present paper examines the role of a type of coping strategy used by patients with agoraphobic disorders (AD) when they confront phobic stimuli. This strategy consists in a group of overt behaviors and thoughts (ritual behaviors, frequently) which allow agoraphobic patients (AP) to resist the presence of phobic scenes. Those behaviors function like a partial coping in the sense that they allow initially to confront the phobic stimuli, but later they transform themselves in non-adaptative coping behaviors that limit the therapeutic efficiency. The agoraphobic disorder (AD), with or without panic attack (CIE-10, F 40), is considered the more complex phobia and which produces the highest level of disability. Besides, this phobia, contrary to social or specific phobias, has a pervasive tendency (panphobia), reaching each time more situations and stimuli. The essential clinical aspects include anxiety, sensitivity, emotional responses of fear-anxiety-panic and shame, anticipatory responses, catastrophic thoughts, and avoidance and escape behaviors toward phobic scenes. There is an important volume of research about those clinical aspects. But there are only a few studies about the coping strategies used by AP when they need to resist a phobic situation. Traditionally, coping strategies considered were those used by AP to reduce anxiety and psychological distress: the avoidance behavior (to avoid the phobic stimuli) and the escape behavior (when the phobic stimulus is present). Additionally, it also includes behaviors targeted to avoid the negative physiological responses similar to those occurring in an anxiety crisis (interoceptive avoidance). Nevertheless, some experts have reported that AP used some other coping strategies that allowed them to accomplish partial and temporary confrontations toward phobic elements (elements that they needed to confront). In that sense, some authors have proposed other strategies beyond avoidance and escape behaviors, including those partial coping behaviors in the repertories used by agoraphobic patients. So, there are several classifications that take into account these behaviors, but under different terms: Distractions (thoughts or conducts that relieve anxiety in the presence of phobic stimuli). Calming strategies (behaviors that they use when they need to confront a phobic scenario). Searchingfor company (looking for the company of a relative, friend or pet). Safety behaviors or safety signs (behaviors adopted to limit the level of distress as a consequence of feeling "caught" in a phobic situation). Counter-phobic objects (objects or persons to which patients assign the ability to diminish the distress in the case of crisis). Different experts have denominated these strategies "defensive mechanisms", "useless coping strategies", "partial coping strategies" or "non-adaptative coping behaviors". This kind of behaviors and thoughts can be useful in the short-term, but in the long term they favor the continuity of anxiety and the avoidance cycle. These partial coping strategies allow patients with agoraphobia to confront and to resist the presence of the phobic stimuli, but this is done with a high cost, since the confrontations are only partial (they confront the phobic scenarios in certain contexts and with certain characteristics) and temporary, generalizing the use of these strategies to future confrontations. These strategies provide a certain apparent validity: the person is capable to resist the phobic element (that is not possible with both avoidance and escape strategies). Nevertheless, the information provided by these behaviors acts as a reinforcing mechanism and acquires by itself a value of discriminative stimulus about the circumstances in which are possible for confronting the phobic scenes. The role of these behaviors and thoughts in the development of agoraphobia in a chronic disorder is also evident. In this sense, they play a non-adaptative role. These strategies turn to be the unique ways to confront (some part of) phobic stimuli. Then, they generate a high degree of interference with both adaptive behaviors and thoughts that must be dominant in the therapeutic process. Finally, the partial coping strategies pass from being a resource that allows them to resist the phobic stimuli, to a therapeutic aim that clinicians must reduce and eliminate. Taking into account the state of the question, we propose in this paper a new classification of non-adaptative coping strategies used by agoraphobic patients, for including the partial coping strategies. The parameters for constructing a new taxonomy are three: (i) the coping strategies must be grouped according to its function role (i.e., to avoid anxiety and negative physiological responses, to reduce anxiety if it appears, to confront the stimuli with the lower level of distress). So, we prefer the term behavioral patterns, like a group of behaviors and thoughts which rule similar functions. (ii) The classification has to attend to the nature of behaviors, differentiating between overt (manifest) and covert (cognitive) behaviors. This distinction is elemental from an applied point of view. (iii) The third element is to identify the non-adaptative character of the confrontation behaviors, because they incapacitate and interfere in the normal development of the daily life. Additionally, a terminology question: there is several concepts that are being used in an indistinct manner, such as behavioral patterns, strategies or, even, styles. According to what the agoraphobic patients do (in an overt or covert way), we prefer the term behavior, in the sense that this term emphasizes what the people do (and not what they believe o what they would like to do). According to those three parameters, we propose four behavioral patterns. These behavioral patterns have two versions: overt and covert behavior. The components of each pattern share similar functions and they cover all of those strategies that can be used for persons with agoraphobia for coping with the different phobic scenes. The four behavioral patterns are as follow: Avoidance behaviors. This pattern includes all of those behaviors and thoughts that the agoraphobic patients do to avoid the phobic stimuli. Its function consists in to prevent the anxiety and psychological distress by means of avoidance of phobic elements. Interoceptive avoidance. This pattern refers to all behaviors and thoughts that try to avoid the interoceptive signs (negative physiological responses) similar to those that occur during an agoraphobic crisis. Its function consists to prevent physiological negative states by means of avoidance of those behaviors that can generate those states and can be interpreted like the beginning of a crisis. Escape behaviors. This group of behaviors refers to all behaviors and thoughts that are used to remove the patients from a phobic scene. So, its function consists in to reduce and to eliminate the anxiety states by means to run away from the phobic stimuli. Partial coping behaviors. Finally, this fourth behavioral pattern includes all of those strategies that allow AP to resist the presence of phobic elements. This resistance is doing according to some contexts and according to certain characteristics of those elements. The strategies consist on behaviors and thoughts, such as safety signs, distractions, or rituals that reduce the anxiety to tolerable levels. Its function consists to provide several resources that allow to a person with agoraphobia to cope with a phobic situation. Usually, the anxiety does not disappear, but the psychological distress does not reach disability levels. Frequently, the patients carry out these strategies because they are forced or need it. This approach is discussed according to the utility to take into account these four behavioral patterns, and not only the avoidance and escape behaviors. An special consideration have the partial coping strategies in the extent in which these behavior may suppose a false therapeutic progress, at the time that they turn into a resistant element that interferes with the therapeutic resources.
ABSTRACT
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Abstract: Depression is a main Public Health problem due to its high prevalence and to the costs for intervention and treatment. Therefore, it is necessary to identify strategies that allow an adequate assessment that would let us obtain a more precise and useful diagnosis. Nevertheless, animportant obstacle for this task, is a lack of theoretical clarity in regard to diagnostic criteria or, especially, to symptoms which are relevant for depression. This fact is obvious in the scales focused on depression assessment, which have a broad variety of symptoms to assess, and it is possible to overestimate some areas or to underestimate others, related to theoretical criterions which were involved in test construction. So, depression is evaluated in accordance with the questionnaire that is used and, of course, depending of theoretical framework that supports this tool. Therefore, depression is defined in line with the criteria which evaluates it, with regard to assessment s criteria, which could explain the usual difficulty to identify common symptoms when some tools are used, which are then identified as genuine symptoms of depression. As the aim of this paper is to improve some of this limitations, the State/Trait Depression Questionnaire (ST/DEP) is showed as an useful tool for clinical and research work. It offers an assessment of one of the component of depression, the affective one, providing two measures: State and Trait. This allows to differentiate between intensity and frequency. Main-axis factor analysis has been made and the results have shown two main factors in affectivity: Dysthymia (negative affection) and Euthymia (positive affection). The interest on positive affection assessment aims to obtain a more precise tool. So, when scores are inverted in positive items, it is possible to obtain a measurement of low levels on affectation. The relevance of this fact is emphasized because it has been neglected in most of depression scales, that only identify presence or absence, a fact that limits the ability to estimate slight modifications. This issue is very useful at two levels: clinic and research. At a clinical level because it permits to identify slight changes in affectation, which could be important as measurement oftherapeutic efficacyand ofsymptoms remission. In research, because it offers the possibility to dispose of one able tool to differenciate of low levels of affectation, which allow a more accurate estimation of the depression symptoms, specially when working with a nonclinical population. The present study was carried out with a sample of 300 participants (103 males and 197 females), with mean age of 21.82 (2.74 s.d.) for males and 22.26 (3.66 s.d.) for females. It was an instrumental study where the Spanish Experimental Version of Stat-Trait Depression (ST/DEP) was used. All participants received information about research and they answered the questionnaires voluntarily. The findings are shown separately for the two scales (State and Trait) and for the two sub-scales (Dysthymia and Euthymia). Data indicated significant differences between males and females, being the highest scores for females. This is an evidence related to the higher prevalence of depression in women. It is very important to remark that essentially the same strong state and trait factors were found for both males and females, according to the factor structure of the Spanish Experimental Version of the State-Trait Depression Questionnaire (ST/DEP). These factors explained the 54% variance for females and of 53% for males. The Promax Rotation differentiated two factors clearly: Dysthimia and Euthymia. That was similar to what was found in the original English form of the ST-DEP. The factorial structure was then confirmed, because of the bifactorial structure which differentiated the negative and positive affectivity of Depression. Another positive result was the test ability to detect slight changes on affectivity, which will be useful to differentiate between clinical and non clinical population. It is important to point out that the ST/DEP is a measurement of one component of depression: affectivity, which has been identified as a relevant component in this disorder, but this tool is not enough to diagnose depression. This fact is relevant, because some tools for depression assessment are used as a diagnostic criteria, a fact that increases confusion in making a differential diagnostic between anxiety and depression or some other symptoms and clinical problems. All this results provide evidences of the psychometric properties of the Spanish ST-DEP, and make this scale a fruitful and useful assessment instrument.