Treatment choice for agoraphobic women: exposure or cognitive-behaviour therapy?

OBJECTIVES: The paper describes a treatment trial where exposure was compared with cognitive-behaviour therapy in the treatment of 39 female participants with a diagnosis of agoraphobia (DSM-111-R). The primary objective of the study was to see if cognitive therapy enhanced the effectiveness of exposure in the treatment of agoraphobia. DESIGN: Participants were randomly assigned to either exposure or cognitive-behaviour therapy. The two treatment groups were balanced for severity and duration of agoraphobia, presence of panic disorder, and age. METHODS: The exposure and the cognitive-behaviour therapy groups received the same amount of therapist-assisted exposure to feared situations but the participants in the cognitive-behaviour therapy group were, additionally, taught to identify and challenge negative automatic thoughts and dysfunctional assumptions. In the cognitive-behaviour therapy condition exposure was presented as an opportunity to identify and challenge negative thoughts. In the exposure condition, participants were given a behavioural rationale for doing exposure. Participants were seen individually for 10 sessions. Assessments were carried out before and after the treatment programme and, also, six months later. Assessments included self-reports of fear and avoidance, a behavioural test and questionnaire measures of relevant cognitions. Thirteen participants dropped out of treatment leaving 14 in the exposure condition and 12 in the cognitive-behaviour condition. Therapy sessions were taped and a sample of tapes was given to a judge who rated the quality of the cognitive-behaviour therapy. RESULTS: Substantial improvement was seen on virtually all measures irrespective of treatment condition both at the end of treatment and six months later. The cognitive-behaviour therapy group and the exposure group did not differ significantly at post-treatment or at six-month follow-up.

Religion, ethnicity and obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is seen in many contrasting cultures but it is not known if the form of the disorder varies between these cultures. There have been anecdotal case reports where religion appeared to play a significant aetiological role in the disorder but the relationship between religion and OCD has not previously been systematically studied. This study was a retrospective, casenote study comparing the country of birth and religious affiliation of three groups of 50 patients. Its aim was to investigate the aetiological role played by religion in the development of OCD. The groups were patients with OCD from a specialist behavioural-cognitive unit, patients assessed in a specialist psycho-dynamic psychotherapy department and patients attending a general adult psychiatry outpatient department. More patients with OCD affiliated themselves with a religion as opposed to either of the other two groups. This difference disappeared when the type of religion was taken into account so that no conclusive relationship between OCD and religion could be identified. The findings do not diminish the importance of religion in the development of OCD in some individuals and suggest that future research in this area should include examination of the rigidity of upbringing and personal perception of the experience of strict rules or imposed religious practices.

The treatment of severe, chronic, resistant obsessive-compulsive disorder. An evaluation of an in-patient programme using behavioural psychotherapy in combination with other treatments.

This study examined 49 in-patients with obsessive-compulsive disorder who were treated over three years. The patients had failed to respond to previous treatment. Treatment consisted of in-patient exposure, occasionally combined with other interventions individually tailored to the patient's specific difficulties. This resulted in significant clinical improvements and an average 40% reduction in rituals in 31 (63.3%) of these chronic patients. These gains were maintained at an average 19-month follow-up. Checking rituals were more likely to be associated with good outcome. Women had a later onset of the disorder and a slight tendency to better prognosis. No other predictors of outcome were found.

Behavioural approaches to anxiety disorders.

Powerful behavioural treatments for many patients with anxiety disorders have been widely available since the 1970s. Despite this, the majority of such patients have continued to be treated with psychotrophic drugs. Recent litigation against the manufacturers of benzodiazepine drugs has made the public increasingly concerned about the prescription of anxiolytic agents. In parallel with the fall in popularity of drug treatment, advances have been made which increase the availability and applicability of behavioural treatments for these patients. This paper examines the impact of the development of self-exposure and cognitive methods on a number of common anxiety syndromes. Clinical examples of self-exposure are given to demonstrate the simplicity of the technique.

Hysterical conversion and dissociation arising as a complication of behavioural psychotherapy treatment of obsessive-compulsive neurosis.

The case history of a patient with obsessive-compulsive disorder who developed hysterical conversion and dissociative symptoms during exposure treatment is described. The theoretical implications of this finding are discussed.

Acne excoriée--a case report of treatment using habit reversal.

Acne excoriée is a self-inflicted skin condition in which the sufferer has an urge to pick real or imagined acnieform lesions and which results in a worsening and spreading of the acne. The condition differs from most artefactual dermatoses as the patient usually spontaneously admits the self-inflicted nature of the condition. Although this condition is considered to be a neurotic manifestation of the patient, traditional psychiatric treatments have proved unsuccessful.

Paradoxical intention and anti-exposure in a non-compliant, obsessive-compulsive ritualiser.

A woman with persistent obsessive-compulsive rituals showed limited improvement with exposure therapy, because of her refusal to comply fully with treatment and a lack of homework practice. She was negativistic towards therapists. Following a relapse, she was asked to try anti-exposure and to increase rituals. Paradoxically, this led to marked self exposure to the feared situation, and self-imposed response prevention, with resultant improvement, whereas anti-exposure instructions are generally anti-therapeutic in obsessive-compulsive disorder.

Delayed emergence of obsessive-compulsive neurosis following head injury. Case report and review of its theoretical implications.

A patient with obsessive-compulsive neurosis arising six months after minor head injury is described. The theoretical implications of this case are discussed. A neuropsychological model to explain the onset of the disorder in this and previously reported cases is suggested.

Obsessive-compulsive disorder occurring as a complication in benzodiazepine withdrawal.

A case history of obsessive-compulsive disorder occurring in a 32-year-old woman after benzodiazepine withdrawal is presented. The possible biochemical and neuropsychological mechanisms involved in the etiology and maintenance of this condition are reviewed.

Creatine phosphokinase levels in the newborn and their use in screening for Duchenne muscular dystrophy.

The PKU sample, if taken after the 3rd day, is suitable for Duchenne muscular dystrophy screening using creatine phosphokinase (CPK) levels. 101 babies (53 girls and 48 boys) had CPK levels measured on filter paper blood specimens taken by heel prick on the 1st and 4th days of life. The method used was that described by Zellweger and Antonik (1975). The CPK levels were markedly raised on the 1st day of life but by the 4th they had reduced to within 3 times the upper limit of the normal range for adults. 10,000 boys were then screened for Duchenne muscular dystrophy using the PKU sample, and 2 cases were found.