Behav. Res. Thu. Vol. 29, No. 6, pp. 539-545, 1991 Printed in Great Britain. All rights reserved
COGNITIVE
0005-7967/91
$3.00 + 0.00
Copyright 0 1991 Pergamon Press plc
BIAS IN SYMPTOMATIC AGORAPHOBICS
AND RECOVERED
LARRYS. STOLER’and RICHARDJ. MCNALLY** ‘Associated
Mental
Health
Services, Chicago, Ill. and %epartment of Psychology, 33 Kirkland Street, Cambridge, MA 02138, U.S.A.
Harvard
University,
(Received 28 February 1991) Summary-Symptomatic agoraphobics, recovered agoraphobics, and normal control subjects completed a series of sentence stems that had either ambiguous or unambiguous meanings, and had either a potentially threatening or a nonthreatening connotation. The written completions made by subjects to these stems were classified as indicating either a biased (i.e. threat-related) or unbiased interpretation of the meaning of the stem, and if a biased interpretation was made, whether the subject indicated efforts at adaptive coping with the perceived threat. Results indicated that symptomatic agoraphobics exhibited strong biases for interpreting information as threatening, relative to normal control subjects. Moreover, recovered agoraphobics resembled symptomatic agoraphobics more than normal control subjects, thus indicating that cognitive biases may persist following cessation of panic attacks and reductions in avoidance behavior. However, recovered agoraphobics also exhibited tendencies to cope adaptively with perceived threats whereas symptomatic agoraphobics did not.
Individuals encounter many situations in daily life whose meaning is not obvious. Tightness in the chest may signify heart disease, or merely muscle soreness. A noise late at night may signify an intruder, or merely a window rattling in the wind. Any tendency to interpret such ambiguous stimuli as threatening ought to increase the likelihood of one’s experiencing anxiety (Eysenck, MacLeod & Mathews, 1987). Although a bias favoring threatening interpretations ought to be associated with anxiety in general, it should be particularly evident in persons suffering from anxiety disorders, such as agoraphobia. To study biases in the interpretation of threat in agoraphobics, McNally and Foa (1987) developed a booklet, based on work by Butler and Mathews (1983), containing ambiguous scenarios involving either internal stimuli (e.g. “You feel discomfort in your chest area. Why?“) or external stimuli (e.g. “You wake with a start in the middle of the night, thinking you heard a noise, but all is quite. What do you think woke you up?“). Symptomatic agoraphobics, recovered agoraphobics, and normal control Ss were asked to write down the first explanation that came to mind for each scenario. After jotting down their response to the open-ended question, Ss turned the page and rank ordered three experimenter-provided explanations in terms of the likelihood of their coming to mind in a similar situation. For each scenario, only one explanation was related to threat. In contrast to recovered agoraphobics and normal control Ss, symptomatic agoraphobics interpreted ambiguous scenarios, external as well as internal, as threatening. In a replication and extension of McNally and Foa’s (1987) study, Clark, Salkovskis, Koehler and Gelder (cited in Clark, 1988) reported that patients with panic disorder without agoraphobia interpreted only internal scenarios as threatening. Taken together, these studies suggest that panic patients with and without agoraphobia exhibit biases for interpreting ambiguous internal stimuli as threatening, but only those with agoraphobia interpret external as well as internal ambiguous stimuli as threatening. These studies parallel other investigations of cognitive bias that underscore the importance of the meanings anxious people ascribe to events, such as certain physiological sensations (for reviews, see McNally, 1990; Mathews, 1990). Indeed, Foa and Kozak (1986) have stated that a satisfactory explanation for fear reduction must extend beyond stimulus-response associations to include the meanings of such associations. *Author
for correspondence. 539
540
LARRY SSTOLER and RICHARDJ.MCNALLY
Most studies on cognitive bias in anxiety have been influenced by the computational model of mind that holds that people encode, store, and retrieve information. For example, Mathews and MacLeod (1985) have suggested that anxiety states are associated with overactive danger schemata that favor the processing of information about threat. However, the cognitive mediational view in general-and the computational view in particular-have been criticized as providing an implausible account of how people disambiguate ambiguous situations (for reviews, see Dreyfus, 1979; Gardner, 1987; Rychlak, 1991). Rychlak’s (1991) predicational conceptualization of mentation provides an alternative understanding of disambiguation. According to Rychlak, people possess an a priori capacity to frame their experiences dialectically such that the meaning of an experience is always cast in terms of ‘this meaning as opposed to that meaning’. Over time, certain meanings that people affirm about themselves become dominant personal premises. Thus, for agoraphobics, certain ideas about personal vulnerability become dominant (White & Epston, 1990). In an effort to elucidate how agoraphobics frame their experience, we devised a sentence completion task to investigate biases in the interpretation of threat in symptomatic agoraphobics, recovered agoraphobics, and normal control Ss. Ss were presented with sentence stems having either an ambiguous or an unambiguous meaning, and having either a potentially threatening or a neutral meaning. They were asked to complete each stem with the first thought that came to mind, and then to jot down two additional sentences. Relative to normal control Ss, symptomatic agoraphobics ought to provide a higher percentage of biased interpretations (i.e. sentence completions denoting a threatening interpretation of the stem’s meaning), especially for those having a potentially threatening or an ambiguous meaning. How might recovered agoraphobics be expected to respond? On the one hand, if the cognitive-behavioral treatment received by these Ss not only abolishes panic attacks and avoidance behavior, but also abolishes cognitive biases, then they ought not to respond differently than normal control Ss. On the other hand, they might recover behaviorally (i.e. no longer meet diagnostic criteria for agoraphobia) while retaining the cognitive biases characteristic of symptomatic agoraphobics. Retention of such biases should be most likely if they are part of a generalized premise of the self as vulnerable. Nevertheless, recovered agoraphobics who provide threatening interpretations of sentence stems might also express adaptive coping efforts for dealing with perceived threats. Indeed, cognitive-behavioral treatments are designed to provide patients with skills for coping with anxiety (Barlow & Craske, 1989). Accordingly, we noted whether Ss expressed efforts to cope adaptively in their responses to sentence stems for which they had provided threat-biased interpretations. METHOD Subjects Symptomatic Agoraphobics (SA). The SA group comprised 10 women and 5 men who met DSM-III-R criteria for panic disorder with agoraphobia (American Psychiatric Association, 1987) as confirmed by the Anxiety Disorders Interview Schedule-Revised (ADIS-R; DiNardo, Barlow, Cerny, Vermilyea, Vermilyea, Himadi & Waddell, 1985). Their mean age was 41.3 yr (range: 24-59 yr), and their mean WAIS-R vocabulary score was 10.9 (Wechsler, 1981). Ss were recruited from the Anxiety Disorders Clinic at the University of Health Sciences/The Chicago Medical School, from private practitioners specializing in anxiety disorders, and from agoraphobia support groups. Recovered Agoraphobics (RC). The RC group comprised 11 women and 4 men who no longer met PDA criteria as confirmed by the ADIS-R. Their mean age was 37.1 yr (range: 3248), and their mean WAIS-R vocabulary score was 11.6. They were recruited from the same sources as were the agoraphobics. They had been successfully treated with cognitive-behavioral therapy (Barlow & Craske, 1989). Normal Controls (NC). The NC group comprised 12 women and 3 men who had never had a panic attack nor met PDA criteria as confirmed by the ADIS-R. Their mean age was 30.9 yr (range:
Cognitive bias
541
2w8), and their mean WAIS-R vocabulary score was 12.5. These Ss were recruited from health clubs. Therefore, they regularly experienced high levels of arousal without interpreting it as threatening as do agoraphobics. Oneway analyses of variance (ANOVAs) and post hoc comparisons indicate that NC Ss were younger than SA Ss [F(l, 42) = 11.35, P < 0.0021 and RA Ss [F(l, 42) = 4.09, P < 0.051. The groups did not differ on the WAIS-R vocabulary test (Wechsler, 1981). Psychopathology questionnaires
The Ss completed psychopathology questionnaires approx. 1 week before participating in the study. Measures of agoraphobic avoidance behavior included the Mobility Inventory for Agoraphobia (MIA; Chambless, Caputo, Jasin, Gracely & Williams, 1985) and the Fear QuestionnaireAgoraphobia Subscale (FQ-Ag; Marks & Mathews, 1979). Measures of the ‘fear of fear’ included the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky & McNally, 1986) the Body Sensations Questionnaire (BSQ; Chambless, Caputo, Bright & Gallagher, 1984), and the Agoraphobic Cognitions Questionnaire (ACQ; Chambless et al., 1984). The Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961) was the measure of depressive symptoms. Finally, Ss completed the State portion of the State-Trait Anxiety Inventory (Spielberger, Gorsuch & Lushene, 1970) immediately before participating in the study. Design
The design was a 3 (Group: SA, RA, NC) x 2 (Sentence structure: Ambiguous, Unambiguous) x 2 (Threat relevance: Threat meaning, Neutral meaning) repeated measures design. The first factor was measured between-Ss, whereas the second and third factors were within-Ss factors. Materials Ss completed 60 sentence stems. Thirty stems had threat meanings, and 30 had neutral meanings. Threat stems described situations or experiences that are often anxiety-provoking for agoraphobics, such as physiological arousal leading to loss of self-control. Neutral stems described situations or experiences that are rarely anxiety-provoking for agoraphobics. Of the 30 threat and 30 neutral stems, 15 of each had an ambiguous sentence structure, and 15 had an unambiguous sentence structure. Ambiguous sentence stems were syntactically ambiguous and had at least two interpretations, whereas unambiguous sentence stems had only one potential meaning. Thus, there were 15 sentence stems of each of the following types: (1) Unambiguous/Threat, (2) Ambiguous/Threat, (3) Ambiguous/Neutral, and (4) Unambiguous/Neutral. Unambiguous/Threat stems unambiguously denoted potential threat (e.g. “When my heart raced and the sweating began, I . . .“). Ambiguous/Threat stems had at least two meanings, only one of which was potentially threatening. For example, “After trying to avoid being in this state, I . . .” could refer to either a personal state (e.g. panic) or a geographical state (e.g. Illinois). Unambiguous/Neutral stems were nonthreatening and unambiguous (e.g. “Realizing that reading can be entertaining, I . . .” ). Ambiguous/Neutral stems had at least two meanings, neither of which was obviously threatening (e.g. “Realizing that visiting professors can be boring, I . . .“). To confirm that threatening sentence stems denoted meanings consistent with characteristic agoraphobic fears, and that neutral sentences did not, we asked two clinical psychology graduate students, experienced in treating agoraphobia, to judge independently whether each stem was either threatening or neutral. Interrater reliabilities were Unambiguous/Threat = 0.93, Ambiguous/Threat = 0.93, Unambiguous/Neutral = 0.87, and Ambiguous/Neutral = 0.80. The 60 sentence stems were typed one to a page. To control for order effects, we generated 15 random sequences with one S in each group receiving a particular sequence. Procedure Ss were tested individually. They signed consent forms, finished any uncompleted questionnaires, underwent the ADIS-R interview (panic disorder and agoraphobia sections), and completed the
542
LARRY S. STOLER and RICHARD J. MCNALLY
State Anxiety to each S:
Scale (Spielberger
et al., 1970). The experimenter
then read the following
instructions
Now, we are ready to move on to the part of the session in which you will be working on a series of incompete sentences, phrases that you will be completing. You have two tasks in writing your completions to these sentences. First, write the first thought that completes the phrase you read in a relevant fashion. Second, on the same sheet, immediately following the sentence you have just completed, write two additional sentences that might follow this sentence, let us say, if all three sentences were part of something longer you were composing, like a diary entry. Finally, work quickly, go on to the next sentence fragment as soon as you have completed a page. Do not go back over sentences that you have already completed. Please print or write legibly. While you are working on these sentences, I will be here doing some work. Just let me know when you are finished with all the sentences. Do you have any questions?
At the completion
of the task, Ss were thanked
for their participation
and debriefed.
Data reduction
Each S’s responses were rated as follows by two clinicians blind to the S’s group. The raters classified a response as biased when the S’s interpretation included expressions of anxiety, panic, danger, or a need to escape. Raters classified a response as unbiased when the S’s interpretation did not include such expressions. The percent agreement was 0.99 across all sentence stem types. For example, the following response to an Ambiguous/Threat stem was classified as biased: “After trying to avoid being in this state, I . . . am angry that I am having a panic attack. My rational thinking sometimes is ineffective. How annoying to be human”. The following response to the same item was classified as unbiased: “. . . looked for a job back home. I didn’t particularly want to move back to Ohio either though. But that is where all my connections are”. The following was classified as a biased response to an Unambiguous/Threat stem: “Feeling discomfort in my chest, I . . . go into a panic attack. I feel that this may be the Big One”. The following was classified as a biased response to an Unambiguous/Neutral stem: “Realizing that laughing a lot can be enjoyable, I . . avoid it a lot. I am afraid of any emotions. I get frightened when I laugh too much”. Finally, the following was classified as a biased response to an Ambiguous/Neutral stem: “Realizing that visiting professors can be boring, I . . . panic. I do not want to be rude. This makes me feel out of control”. For each S, the percentage of biased interpretations was calculated for each sentence stem type. These data were analyzed via a 3 (Group: SA, RA, NC) x 2 (Sentence structure: Ambiguous, Unambiguous) x 2 (Threat relevance: Threat meaning, Neutral meaning) analysis of variance (ANOVA). Also, biased interpretations were subjected to an adaptive coping analysis. That is, for those sentence stems interpreted as threatening, did the S also express an attempt to manage fear through the application of a cognitive or a behavioral technique? Two blind raters judged each biased response as either expressing adaptive coping or not. Percent agreement was 0.98. The adaptive coping score was calculated by dividing the number of coping responses by the number of biased interpretations. The following is an example of a biased response to an Ambiguous/Threat stem that was also judged as expressing adaptive coping: “Fearing this to be the beginning of a terminal attack, I . . . panicked and applied the brakes. I felt the need to escape the situation. By concentrating on relaxing, I was able to stay in the situation”.
RESULTS
The overall percentage of biased interpretations was greater among SA Ss than among NC Ss [F( 1,42) = 21.40, P < O.OOOl], and greater among RA than among NC Ss [F( 1,42) = 12.04, P < O.OOl]. RA Ss, however, did not significantly differ from SA Ss in the percentage of biased interpretations overall. Similarly, the percentage of biased interpretations for Ambiguous/Threat stems was greater among SA Ss than among NC Ss [F(l, 42) = 14.29, P < O.OOOl], and greater among RA Ss than among NC Ss [F( 1,42) = 10.34, P < 0.003]. RA Ss, however, did not significantly differ from SA Ss in the percentage of biased interpretations. Thus, recovered agoraphobics responded like symptomatic agoraphobics when presented with potentially-threatening ambiguous information.
Cognitive
bias
543
The percentage of biased interpretations for Unambiguous/Threat stems was greater among SA Ss than among NC Ss [F(l, 42) = 29.98, P < O.OOl], and greater among RA Ss than among NC Ss [F(l, 42) = 20.50, P < O.OOl]. RA Ss, however, did not significantly differ from SA Ss in the percentage of biased interpretations. Thus, recovered agoraphobics responded like symptomatic agoraphobics when presented with unambiguously threatening information. The percentage of biased interpretations for Unambiguous/Neutral stems was greater among SA Ss than among NC Ss [F( 1,42) = 3.35, P < 0.051, whereas the percentage of biased interpretations among RA Ss did not significantly differ from either SA or NC Ss. Thus, symptomatic neutral information in a threatening agoraphobics interpreted even relatively unambiguous, manner. There were no differences among the groups in the percentage of biased interpretations for Ambiguous/Neutral stems (Ps > 0.05). Group means and standard deviations are shown in Table 1. Analysis
of adaptive coping
A significant oneway ANOVA indicated that the three groups differed in the proportion of adaptive coping responses given to sentence stems that were interpreted as threatening [F(2,42) = 3.38, P < 0.051. SA Ss gave fewer adaptive coping responses than did either RA Ss [F( 1,42) = 5.75, P < 0.021 or NC Ss [F( 1,42) = 4.09, P c 0.051, whereas RA and NC Ss did not differ in the proportion of adaptive coping responses given to stems interpreted as threatening. The proportion of threat-biased sentence stems that received adaptive coping responses were as follows: SA Ss (M = 0.42, SD = 0.21), RA Ss (M = 0.58, SD = 0.17), NC Ss (M = 0.56, SD = 0.18). Thus, although recovered agoraphobics tended to exhibit a residual cognitive bias for interpreting events in a threatening manner, they reported an additional tendency to cope with threat adaptively. Psychopathology
questionnaires
Scores on the psychopathology questionnaires were submitted to oneway analyses of variance (ANOVAs) and posthoc comparisons (Ps < 0.05). SA Ss scored significantly higher than NC Ss on every measure of psychopathology. RA Ss resembled SA Ss in terms of state anxiety and depressive symptoms, but resembled NC Ss in terms of agoraphobic avoidance and catastrophic thinking. In terms of anxiety sensitivity and fears of bodily sensations, RA Ss scored significantly lower than SA Ss, but significantly higher than NC Ss. Group means and standard deviations for the psychopathology questionnaires are shown in Table 2. DISCUSSION The conclusions of this study can be summarized as follows. First, relative to normal control Ss, symptomatic agoraphobics interpret ambiguous information as threatening when it affords a potentially threatening interpretation (i.e. Ambiguous/Threat stems) but not when it does not (i.e. Ambiguous/Neutral stems). Thus, ambiguity alone does not necessarily evoke a fearful interpretation. Only when ambiguity appears in a context relevant to the symptomatic agoraphobic’s central concerns (e.g. about bodily sensations) does the interpretive bias clearly emerge. Moreover, symptomatic agoraphobics, relative to normal control Ss, also interpret neutral information as threatening. Table I. Mean oercentage GFXlp
U/N
SA
0.11 (0.13) 0.06 (0.07) 0.02 (0.04)
RA NC
of biased interuretations
Sentence stem types U/T A/N A/T 0.63 (0.19) 0.57 (0.19) 0.27 (0.16)
0.10 (0.12) 0.07 (0.08) 0.04 (0.07)
0.51 (0.26) 0.46 (0.17) 0.24 (0.14)
Combined 0.34 (0.15) 0.29 (0.10) 0.14 (0.08)
SA: Symptomatic Agoraphobics; RA: Recovered Agoraphobia; NC: Normal Control Ss; U/N: Unambiguous/Neutral; U/T: Unambiguous/Threat; A/N: Ambiguous/Neutral; A/T: Ambiguous/Threat.
LARRY S. STOLER and RICHARD J. MCNALLY
544
Table 2. Mean scores on psychopathology
questionnaires
Group Questionnaire
ACQ AS1
BSQ FQ-Ag MIA State Anxiety BDI
SA
RA
NC
2.51 (0.54) 39.07 (7.84) 3.17 (0.75) 19.47 (11.42) 2.64 (1.12) 42.53a (11.66) 17.33a (11.16)
I .84a
1.56a (0.48) 18.33 (10.25) 1.49 (0.75) 3.13a (3.48) 1.48a (0.49) 3 1.07b (9.07) 5.93 (5.22)
(0.44) 26.33 (12.61) 2.27 (0.64) 8.73a (8.73) 1.88a ( 1.09) 35.40a,b (13.72) 14.20a (11.14)
SA: Symptomatic Agoraphobics; RA: Recovered Agoraphobics; NC: Normal Control Ss. Standard deviations are in parentheses. Means that do not share the same letter differ significantly (P < 0.05). ACQ: Agoraphobic Cognitions Questionnaire; ASI: Anxiety Sensitivity Index; BSQ: Body Sensations Questionnaire; FQ-Ag: Fear QuestionnaireAgoraphobia subscale; MIA: Mobility Inventory for Agoraphobia; BDI: Beck Depression Inventory.
Second, recovered agoraphobics, who no longer meet diagnostic criteria for the disorder, respond like symptomatic agoraphobics to either ambiguously or unambiguously threatening information (e.g. Ambiguous/Threat stems, Unambiguous/Threat stems). The responses recovered agoraphobits gave to neutral sentence stems resembled those of symptomatic agoraphobics. These findings suggest that behaviorally-recovered agoraphobics may retain a cognitive bias for interpreting information in a threatening manner. Although RA Ss were statistically indistinguishable from NC Ss in terms of agoraphobic avoidance (i.e. FQ-Ag), they still scored higher than NC Ss in terms of anxiety sensitivity (i.e. ASI, BSQ). Taken together, these findings suggest that until anxiety sensitivity has been brought within normal limits, otherwise recovered agoraphobics are likely to exhibit cognitive biases for interpreting information as threatening. Third, although recovered agoraphobics exhibited residual cognitive biases, they also exhibited adaptive coping efforts for dealing with threat. This suggests that agoraphobics who have successfully undergone cognitive-behavioral treatment may tend to interpret information in a threatening manner, but then deal with threat adaptively. Investigators advancing cognitive mediational theories of anxiety have recently endeavored to distinguish between automatic and strategic cognitive biases underlying the psychopathology of anxiety disorders (for reviews, see Mathews, 1990; McNally, 1990). Although the task we used in the present study was sensitive to psychopathology, it probably taps an indeterminate mixture of automatic and nonautomatic processes. Although Ss were asked to write down the first thought that came to mind, clearly the effortful nature of the task precludes it being construed as a pure measure of automatic cognitive processing. The present findings are also consistent with a predicational account. According to this view, symptomatic agoraphobics exhibit a cognitive bias that reflects the affirmation of threatening over nonthreatening meanings of dialectically framed alternatives (Rychlak, 1991). Rychlak holds that predication involves affirming patterns of meaning ordered in a broad to narrow fashion. Thus, in contrast to normal control Ss, symptomatic agoraphobics frame a broader range of ambiguous situations as threatening, including ostensibly neutral ones. However, because treatment may narrow the scope of personally affirmed threatening meanings, recovered agoraphobics interpret an intermediate number of situations as threatening, relative to symptomatic agoraphobics and to normal control Ss. According to a predicational view, behavioral exposure treatments disconfirm fear-related beliefs by producing a shift in the grounding assumptions (i.e. premises) that patients affirm in experience. Success at managing previously-threatening situations facilitates recovery as patients integrate these experiences with established self-premises concerning vulnerability. The present study is broadly consistent with other studies that indicate that biases favoring threatening interpretations of events are characteristic of anxiety states (Clark, 1988; Butler &
Cognitive
bias
545
Mathews, 1983; Mathews, Richards & Eysenck, 1989; McNally & Foa, 1987). These studies underscore the importance in elucidating the meanings that patients, as active agents, impose upon their world, and how such predication of threatening meanings can lead to the psychopathology characteristic of pathological anxiety states (Rychlak, 1991). Acknowledgements-This second author. It was J. McNally. We thank their comments on this in Motion (AIM), and at the annual meeting research was conducted
study was part of a doctoral dissertation written by the first author under the supervision of the suooorted in oart bv National Institute of Mental Health Grant MH43809 awarded to Richard D&id E. Schotte, Michael Seidenberg, Joseph W. Hatcher, and, especially, Joseph F. Rychlak for research, and Marleen Lorenz, Christine Louro, Bobbie Offenbeck, Angie Ludwigsen, Agoraphobics Nautilus of Evanston for their assistance in recruiting Ss. A version of this paper was presented of the Association for Advancement of Behavior Therapy, San Francisco, November 1990. This when the authors were at the University of Health Sciences/The Chicago Medical School.
REFERENCES American Psychiatric Association (1987). Diagnostic and statistical manual of menral disorders-revised (3rd edn). Washington, D.C.: American Psychiatric Association. Barlow, D. H. & Craske, M. G. (1989). Mastery of your anxiety and panic. Albany, New York: Graywind. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E. & Erbaugh, J. K. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Butler, G. & Mathews, A. (1983). Cognitive processes in anxiety. Advances in Behaviour Research and Therapy, 5, 5162. Chambless, D. L., Caputo, G. C., Bright, P. & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, 52, 109&1097. Chambless. D. L.. Caouto. G. C.. Jasin. S. E., Gracelv. E. J. & Williams, C. (1985). The Mobility Inventory for Agoraphobia. Behakour Research and Therapy, 23, 3544. Clark, D. M. (1988). A cognitive model of panic attacks. In Rachman, S. & Maser, J. D. (Eds), Panic: Psychological perspectives (pp. 71-89). Hillsdale, N.J.: Erlbaum. DiNardo, P. A., Barlow, D. H., Cerny, J. A., Vermilyea, B. B., Vermilyea, J. A., Himadi, W. G. & Waddell, M. T. (1985). The Anxiety Disorders interview Schedule-Revised (ADIS-R). Albany, New York: State University of New York. Dreyfus, H. (1979). What computers can’t do: The limits of artificial intelligence (rev. edn). New York: Harper & Row. Eysenck, M. W., MacLeod, C. & Mathews, A. (1987). Cognitive functioning and anxiety. Psychological Research, 49, 189-195. Foa, E. B. & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35. Gardner, H. (1987). The mind’s new science (2nd edn). New York: Basic Books. McNally, R. J. (1990). Psychological approaches to panic disorder: A review. Psychological Bulletin, 108, 403419. McNally, R. J. & Foa, E. B. (1987). Cognition and agoraphobia: Bias in the interpretation of threat. Cognilive Therapy and Research, II, 567-581. Marks, I. M. & Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behaviour Research and Therapy, I7, 263-267. Mathews, A. (1990). Why worry? The cognitive function of anxiety. Behaviour Research and Therapy, 28, 4555468. Mathews, A. & MacLeod, C. (1985). Selective processing of threat cues in anxiety states. Behaviour Research and Therapy, 23, 563-569. Mathews, A., Richards, A. & Eysenck, M. (1989). Interpretation of homophones related to threat in anxiety states. Journal of Abnormal Psychology, 98, 31-34. Reiss, S., Peterson, R. A., Gursky, D. M. & McNally, R. J. (1986). Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1-8. Rychlak, J. F. (1991). Artificial inrelligence and human reason. New York: Columbia University Press. Spielberger, C. D., Gorsuch, R. L. & Lushene, R. E. (1970). Manualfor the State-Trait Anxiety Inventory. Palo Alto, Calif.: Consulting Psychologists Press. Wechsler, D. (1981). Manual for the Wechsler Adult Intelligence Scale-Revised. San Antonio, Texas: The Psychological Corporation. White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.
COGNITIVE
0005-7967/91
$3.00 + 0.00
Copyright 0 1991 Pergamon Press plc
BIAS IN SYMPTOMATIC AGORAPHOBICS
AND RECOVERED
LARRYS. STOLER’and RICHARDJ. MCNALLY** ‘Associated
Mental
Health
Services, Chicago, Ill. and %epartment of Psychology, 33 Kirkland Street, Cambridge, MA 02138, U.S.A.
Harvard
University,
(Received 28 February 1991) Summary-Symptomatic agoraphobics, recovered agoraphobics, and normal control subjects completed a series of sentence stems that had either ambiguous or unambiguous meanings, and had either a potentially threatening or a nonthreatening connotation. The written completions made by subjects to these stems were classified as indicating either a biased (i.e. threat-related) or unbiased interpretation of the meaning of the stem, and if a biased interpretation was made, whether the subject indicated efforts at adaptive coping with the perceived threat. Results indicated that symptomatic agoraphobics exhibited strong biases for interpreting information as threatening, relative to normal control subjects. Moreover, recovered agoraphobics resembled symptomatic agoraphobics more than normal control subjects, thus indicating that cognitive biases may persist following cessation of panic attacks and reductions in avoidance behavior. However, recovered agoraphobics also exhibited tendencies to cope adaptively with perceived threats whereas symptomatic agoraphobics did not.
Individuals encounter many situations in daily life whose meaning is not obvious. Tightness in the chest may signify heart disease, or merely muscle soreness. A noise late at night may signify an intruder, or merely a window rattling in the wind. Any tendency to interpret such ambiguous stimuli as threatening ought to increase the likelihood of one’s experiencing anxiety (Eysenck, MacLeod & Mathews, 1987). Although a bias favoring threatening interpretations ought to be associated with anxiety in general, it should be particularly evident in persons suffering from anxiety disorders, such as agoraphobia. To study biases in the interpretation of threat in agoraphobics, McNally and Foa (1987) developed a booklet, based on work by Butler and Mathews (1983), containing ambiguous scenarios involving either internal stimuli (e.g. “You feel discomfort in your chest area. Why?“) or external stimuli (e.g. “You wake with a start in the middle of the night, thinking you heard a noise, but all is quite. What do you think woke you up?“). Symptomatic agoraphobics, recovered agoraphobics, and normal control Ss were asked to write down the first explanation that came to mind for each scenario. After jotting down their response to the open-ended question, Ss turned the page and rank ordered three experimenter-provided explanations in terms of the likelihood of their coming to mind in a similar situation. For each scenario, only one explanation was related to threat. In contrast to recovered agoraphobics and normal control Ss, symptomatic agoraphobics interpreted ambiguous scenarios, external as well as internal, as threatening. In a replication and extension of McNally and Foa’s (1987) study, Clark, Salkovskis, Koehler and Gelder (cited in Clark, 1988) reported that patients with panic disorder without agoraphobia interpreted only internal scenarios as threatening. Taken together, these studies suggest that panic patients with and without agoraphobia exhibit biases for interpreting ambiguous internal stimuli as threatening, but only those with agoraphobia interpret external as well as internal ambiguous stimuli as threatening. These studies parallel other investigations of cognitive bias that underscore the importance of the meanings anxious people ascribe to events, such as certain physiological sensations (for reviews, see McNally, 1990; Mathews, 1990). Indeed, Foa and Kozak (1986) have stated that a satisfactory explanation for fear reduction must extend beyond stimulus-response associations to include the meanings of such associations. *Author
for correspondence. 539
540
LARRY SSTOLER and RICHARDJ.MCNALLY
Most studies on cognitive bias in anxiety have been influenced by the computational model of mind that holds that people encode, store, and retrieve information. For example, Mathews and MacLeod (1985) have suggested that anxiety states are associated with overactive danger schemata that favor the processing of information about threat. However, the cognitive mediational view in general-and the computational view in particular-have been criticized as providing an implausible account of how people disambiguate ambiguous situations (for reviews, see Dreyfus, 1979; Gardner, 1987; Rychlak, 1991). Rychlak’s (1991) predicational conceptualization of mentation provides an alternative understanding of disambiguation. According to Rychlak, people possess an a priori capacity to frame their experiences dialectically such that the meaning of an experience is always cast in terms of ‘this meaning as opposed to that meaning’. Over time, certain meanings that people affirm about themselves become dominant personal premises. Thus, for agoraphobics, certain ideas about personal vulnerability become dominant (White & Epston, 1990). In an effort to elucidate how agoraphobics frame their experience, we devised a sentence completion task to investigate biases in the interpretation of threat in symptomatic agoraphobics, recovered agoraphobics, and normal control Ss. Ss were presented with sentence stems having either an ambiguous or an unambiguous meaning, and having either a potentially threatening or a neutral meaning. They were asked to complete each stem with the first thought that came to mind, and then to jot down two additional sentences. Relative to normal control Ss, symptomatic agoraphobics ought to provide a higher percentage of biased interpretations (i.e. sentence completions denoting a threatening interpretation of the stem’s meaning), especially for those having a potentially threatening or an ambiguous meaning. How might recovered agoraphobics be expected to respond? On the one hand, if the cognitive-behavioral treatment received by these Ss not only abolishes panic attacks and avoidance behavior, but also abolishes cognitive biases, then they ought not to respond differently than normal control Ss. On the other hand, they might recover behaviorally (i.e. no longer meet diagnostic criteria for agoraphobia) while retaining the cognitive biases characteristic of symptomatic agoraphobics. Retention of such biases should be most likely if they are part of a generalized premise of the self as vulnerable. Nevertheless, recovered agoraphobics who provide threatening interpretations of sentence stems might also express adaptive coping efforts for dealing with perceived threats. Indeed, cognitive-behavioral treatments are designed to provide patients with skills for coping with anxiety (Barlow & Craske, 1989). Accordingly, we noted whether Ss expressed efforts to cope adaptively in their responses to sentence stems for which they had provided threat-biased interpretations. METHOD Subjects Symptomatic Agoraphobics (SA). The SA group comprised 10 women and 5 men who met DSM-III-R criteria for panic disorder with agoraphobia (American Psychiatric Association, 1987) as confirmed by the Anxiety Disorders Interview Schedule-Revised (ADIS-R; DiNardo, Barlow, Cerny, Vermilyea, Vermilyea, Himadi & Waddell, 1985). Their mean age was 41.3 yr (range: 24-59 yr), and their mean WAIS-R vocabulary score was 10.9 (Wechsler, 1981). Ss were recruited from the Anxiety Disorders Clinic at the University of Health Sciences/The Chicago Medical School, from private practitioners specializing in anxiety disorders, and from agoraphobia support groups. Recovered Agoraphobics (RC). The RC group comprised 11 women and 4 men who no longer met PDA criteria as confirmed by the ADIS-R. Their mean age was 37.1 yr (range: 3248), and their mean WAIS-R vocabulary score was 11.6. They were recruited from the same sources as were the agoraphobics. They had been successfully treated with cognitive-behavioral therapy (Barlow & Craske, 1989). Normal Controls (NC). The NC group comprised 12 women and 3 men who had never had a panic attack nor met PDA criteria as confirmed by the ADIS-R. Their mean age was 30.9 yr (range:
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2w8), and their mean WAIS-R vocabulary score was 12.5. These Ss were recruited from health clubs. Therefore, they regularly experienced high levels of arousal without interpreting it as threatening as do agoraphobics. Oneway analyses of variance (ANOVAs) and post hoc comparisons indicate that NC Ss were younger than SA Ss [F(l, 42) = 11.35, P < 0.0021 and RA Ss [F(l, 42) = 4.09, P < 0.051. The groups did not differ on the WAIS-R vocabulary test (Wechsler, 1981). Psychopathology questionnaires
The Ss completed psychopathology questionnaires approx. 1 week before participating in the study. Measures of agoraphobic avoidance behavior included the Mobility Inventory for Agoraphobia (MIA; Chambless, Caputo, Jasin, Gracely & Williams, 1985) and the Fear QuestionnaireAgoraphobia Subscale (FQ-Ag; Marks & Mathews, 1979). Measures of the ‘fear of fear’ included the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky & McNally, 1986) the Body Sensations Questionnaire (BSQ; Chambless, Caputo, Bright & Gallagher, 1984), and the Agoraphobic Cognitions Questionnaire (ACQ; Chambless et al., 1984). The Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961) was the measure of depressive symptoms. Finally, Ss completed the State portion of the State-Trait Anxiety Inventory (Spielberger, Gorsuch & Lushene, 1970) immediately before participating in the study. Design
The design was a 3 (Group: SA, RA, NC) x 2 (Sentence structure: Ambiguous, Unambiguous) x 2 (Threat relevance: Threat meaning, Neutral meaning) repeated measures design. The first factor was measured between-Ss, whereas the second and third factors were within-Ss factors. Materials Ss completed 60 sentence stems. Thirty stems had threat meanings, and 30 had neutral meanings. Threat stems described situations or experiences that are often anxiety-provoking for agoraphobics, such as physiological arousal leading to loss of self-control. Neutral stems described situations or experiences that are rarely anxiety-provoking for agoraphobics. Of the 30 threat and 30 neutral stems, 15 of each had an ambiguous sentence structure, and 15 had an unambiguous sentence structure. Ambiguous sentence stems were syntactically ambiguous and had at least two interpretations, whereas unambiguous sentence stems had only one potential meaning. Thus, there were 15 sentence stems of each of the following types: (1) Unambiguous/Threat, (2) Ambiguous/Threat, (3) Ambiguous/Neutral, and (4) Unambiguous/Neutral. Unambiguous/Threat stems unambiguously denoted potential threat (e.g. “When my heart raced and the sweating began, I . . .“). Ambiguous/Threat stems had at least two meanings, only one of which was potentially threatening. For example, “After trying to avoid being in this state, I . . .” could refer to either a personal state (e.g. panic) or a geographical state (e.g. Illinois). Unambiguous/Neutral stems were nonthreatening and unambiguous (e.g. “Realizing that reading can be entertaining, I . . .” ). Ambiguous/Neutral stems had at least two meanings, neither of which was obviously threatening (e.g. “Realizing that visiting professors can be boring, I . . .“). To confirm that threatening sentence stems denoted meanings consistent with characteristic agoraphobic fears, and that neutral sentences did not, we asked two clinical psychology graduate students, experienced in treating agoraphobia, to judge independently whether each stem was either threatening or neutral. Interrater reliabilities were Unambiguous/Threat = 0.93, Ambiguous/Threat = 0.93, Unambiguous/Neutral = 0.87, and Ambiguous/Neutral = 0.80. The 60 sentence stems were typed one to a page. To control for order effects, we generated 15 random sequences with one S in each group receiving a particular sequence. Procedure Ss were tested individually. They signed consent forms, finished any uncompleted questionnaires, underwent the ADIS-R interview (panic disorder and agoraphobia sections), and completed the
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LARRY S. STOLER and RICHARD J. MCNALLY
State Anxiety to each S:
Scale (Spielberger
et al., 1970). The experimenter
then read the following
instructions
Now, we are ready to move on to the part of the session in which you will be working on a series of incompete sentences, phrases that you will be completing. You have two tasks in writing your completions to these sentences. First, write the first thought that completes the phrase you read in a relevant fashion. Second, on the same sheet, immediately following the sentence you have just completed, write two additional sentences that might follow this sentence, let us say, if all three sentences were part of something longer you were composing, like a diary entry. Finally, work quickly, go on to the next sentence fragment as soon as you have completed a page. Do not go back over sentences that you have already completed. Please print or write legibly. While you are working on these sentences, I will be here doing some work. Just let me know when you are finished with all the sentences. Do you have any questions?
At the completion
of the task, Ss were thanked
for their participation
and debriefed.
Data reduction
Each S’s responses were rated as follows by two clinicians blind to the S’s group. The raters classified a response as biased when the S’s interpretation included expressions of anxiety, panic, danger, or a need to escape. Raters classified a response as unbiased when the S’s interpretation did not include such expressions. The percent agreement was 0.99 across all sentence stem types. For example, the following response to an Ambiguous/Threat stem was classified as biased: “After trying to avoid being in this state, I . . . am angry that I am having a panic attack. My rational thinking sometimes is ineffective. How annoying to be human”. The following response to the same item was classified as unbiased: “. . . looked for a job back home. I didn’t particularly want to move back to Ohio either though. But that is where all my connections are”. The following was classified as a biased response to an Unambiguous/Threat stem: “Feeling discomfort in my chest, I . . . go into a panic attack. I feel that this may be the Big One”. The following was classified as a biased response to an Unambiguous/Neutral stem: “Realizing that laughing a lot can be enjoyable, I . . avoid it a lot. I am afraid of any emotions. I get frightened when I laugh too much”. Finally, the following was classified as a biased response to an Ambiguous/Neutral stem: “Realizing that visiting professors can be boring, I . . . panic. I do not want to be rude. This makes me feel out of control”. For each S, the percentage of biased interpretations was calculated for each sentence stem type. These data were analyzed via a 3 (Group: SA, RA, NC) x 2 (Sentence structure: Ambiguous, Unambiguous) x 2 (Threat relevance: Threat meaning, Neutral meaning) analysis of variance (ANOVA). Also, biased interpretations were subjected to an adaptive coping analysis. That is, for those sentence stems interpreted as threatening, did the S also express an attempt to manage fear through the application of a cognitive or a behavioral technique? Two blind raters judged each biased response as either expressing adaptive coping or not. Percent agreement was 0.98. The adaptive coping score was calculated by dividing the number of coping responses by the number of biased interpretations. The following is an example of a biased response to an Ambiguous/Threat stem that was also judged as expressing adaptive coping: “Fearing this to be the beginning of a terminal attack, I . . . panicked and applied the brakes. I felt the need to escape the situation. By concentrating on relaxing, I was able to stay in the situation”.
RESULTS
The overall percentage of biased interpretations was greater among SA Ss than among NC Ss [F( 1,42) = 21.40, P < O.OOOl], and greater among RA than among NC Ss [F( 1,42) = 12.04, P < O.OOl]. RA Ss, however, did not significantly differ from SA Ss in the percentage of biased interpretations overall. Similarly, the percentage of biased interpretations for Ambiguous/Threat stems was greater among SA Ss than among NC Ss [F(l, 42) = 14.29, P < O.OOOl], and greater among RA Ss than among NC Ss [F( 1,42) = 10.34, P < 0.003]. RA Ss, however, did not significantly differ from SA Ss in the percentage of biased interpretations. Thus, recovered agoraphobics responded like symptomatic agoraphobics when presented with potentially-threatening ambiguous information.
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The percentage of biased interpretations for Unambiguous/Threat stems was greater among SA Ss than among NC Ss [F(l, 42) = 29.98, P < O.OOl], and greater among RA Ss than among NC Ss [F(l, 42) = 20.50, P < O.OOl]. RA Ss, however, did not significantly differ from SA Ss in the percentage of biased interpretations. Thus, recovered agoraphobics responded like symptomatic agoraphobics when presented with unambiguously threatening information. The percentage of biased interpretations for Unambiguous/Neutral stems was greater among SA Ss than among NC Ss [F( 1,42) = 3.35, P < 0.051, whereas the percentage of biased interpretations among RA Ss did not significantly differ from either SA or NC Ss. Thus, symptomatic neutral information in a threatening agoraphobics interpreted even relatively unambiguous, manner. There were no differences among the groups in the percentage of biased interpretations for Ambiguous/Neutral stems (Ps > 0.05). Group means and standard deviations are shown in Table 1. Analysis
of adaptive coping
A significant oneway ANOVA indicated that the three groups differed in the proportion of adaptive coping responses given to sentence stems that were interpreted as threatening [F(2,42) = 3.38, P < 0.051. SA Ss gave fewer adaptive coping responses than did either RA Ss [F( 1,42) = 5.75, P < 0.021 or NC Ss [F( 1,42) = 4.09, P c 0.051, whereas RA and NC Ss did not differ in the proportion of adaptive coping responses given to stems interpreted as threatening. The proportion of threat-biased sentence stems that received adaptive coping responses were as follows: SA Ss (M = 0.42, SD = 0.21), RA Ss (M = 0.58, SD = 0.17), NC Ss (M = 0.56, SD = 0.18). Thus, although recovered agoraphobics tended to exhibit a residual cognitive bias for interpreting events in a threatening manner, they reported an additional tendency to cope with threat adaptively. Psychopathology
questionnaires
Scores on the psychopathology questionnaires were submitted to oneway analyses of variance (ANOVAs) and posthoc comparisons (Ps < 0.05). SA Ss scored significantly higher than NC Ss on every measure of psychopathology. RA Ss resembled SA Ss in terms of state anxiety and depressive symptoms, but resembled NC Ss in terms of agoraphobic avoidance and catastrophic thinking. In terms of anxiety sensitivity and fears of bodily sensations, RA Ss scored significantly lower than SA Ss, but significantly higher than NC Ss. Group means and standard deviations for the psychopathology questionnaires are shown in Table 2. DISCUSSION The conclusions of this study can be summarized as follows. First, relative to normal control Ss, symptomatic agoraphobics interpret ambiguous information as threatening when it affords a potentially threatening interpretation (i.e. Ambiguous/Threat stems) but not when it does not (i.e. Ambiguous/Neutral stems). Thus, ambiguity alone does not necessarily evoke a fearful interpretation. Only when ambiguity appears in a context relevant to the symptomatic agoraphobic’s central concerns (e.g. about bodily sensations) does the interpretive bias clearly emerge. Moreover, symptomatic agoraphobics, relative to normal control Ss, also interpret neutral information as threatening. Table I. Mean oercentage GFXlp
U/N
SA
0.11 (0.13) 0.06 (0.07) 0.02 (0.04)
RA NC
of biased interuretations
Sentence stem types U/T A/N A/T 0.63 (0.19) 0.57 (0.19) 0.27 (0.16)
0.10 (0.12) 0.07 (0.08) 0.04 (0.07)
0.51 (0.26) 0.46 (0.17) 0.24 (0.14)
Combined 0.34 (0.15) 0.29 (0.10) 0.14 (0.08)
SA: Symptomatic Agoraphobics; RA: Recovered Agoraphobia; NC: Normal Control Ss; U/N: Unambiguous/Neutral; U/T: Unambiguous/Threat; A/N: Ambiguous/Neutral; A/T: Ambiguous/Threat.
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Table 2. Mean scores on psychopathology
questionnaires
Group Questionnaire
ACQ AS1
BSQ FQ-Ag MIA State Anxiety BDI
SA
RA
NC
2.51 (0.54) 39.07 (7.84) 3.17 (0.75) 19.47 (11.42) 2.64 (1.12) 42.53a (11.66) 17.33a (11.16)
I .84a
1.56a (0.48) 18.33 (10.25) 1.49 (0.75) 3.13a (3.48) 1.48a (0.49) 3 1.07b (9.07) 5.93 (5.22)
(0.44) 26.33 (12.61) 2.27 (0.64) 8.73a (8.73) 1.88a ( 1.09) 35.40a,b (13.72) 14.20a (11.14)
SA: Symptomatic Agoraphobics; RA: Recovered Agoraphobics; NC: Normal Control Ss. Standard deviations are in parentheses. Means that do not share the same letter differ significantly (P < 0.05). ACQ: Agoraphobic Cognitions Questionnaire; ASI: Anxiety Sensitivity Index; BSQ: Body Sensations Questionnaire; FQ-Ag: Fear QuestionnaireAgoraphobia subscale; MIA: Mobility Inventory for Agoraphobia; BDI: Beck Depression Inventory.
Second, recovered agoraphobics, who no longer meet diagnostic criteria for the disorder, respond like symptomatic agoraphobics to either ambiguously or unambiguously threatening information (e.g. Ambiguous/Threat stems, Unambiguous/Threat stems). The responses recovered agoraphobits gave to neutral sentence stems resembled those of symptomatic agoraphobics. These findings suggest that behaviorally-recovered agoraphobics may retain a cognitive bias for interpreting information in a threatening manner. Although RA Ss were statistically indistinguishable from NC Ss in terms of agoraphobic avoidance (i.e. FQ-Ag), they still scored higher than NC Ss in terms of anxiety sensitivity (i.e. ASI, BSQ). Taken together, these findings suggest that until anxiety sensitivity has been brought within normal limits, otherwise recovered agoraphobics are likely to exhibit cognitive biases for interpreting information as threatening. Third, although recovered agoraphobics exhibited residual cognitive biases, they also exhibited adaptive coping efforts for dealing with threat. This suggests that agoraphobics who have successfully undergone cognitive-behavioral treatment may tend to interpret information in a threatening manner, but then deal with threat adaptively. Investigators advancing cognitive mediational theories of anxiety have recently endeavored to distinguish between automatic and strategic cognitive biases underlying the psychopathology of anxiety disorders (for reviews, see Mathews, 1990; McNally, 1990). Although the task we used in the present study was sensitive to psychopathology, it probably taps an indeterminate mixture of automatic and nonautomatic processes. Although Ss were asked to write down the first thought that came to mind, clearly the effortful nature of the task precludes it being construed as a pure measure of automatic cognitive processing. The present findings are also consistent with a predicational account. According to this view, symptomatic agoraphobics exhibit a cognitive bias that reflects the affirmation of threatening over nonthreatening meanings of dialectically framed alternatives (Rychlak, 1991). Rychlak holds that predication involves affirming patterns of meaning ordered in a broad to narrow fashion. Thus, in contrast to normal control Ss, symptomatic agoraphobics frame a broader range of ambiguous situations as threatening, including ostensibly neutral ones. However, because treatment may narrow the scope of personally affirmed threatening meanings, recovered agoraphobics interpret an intermediate number of situations as threatening, relative to symptomatic agoraphobics and to normal control Ss. According to a predicational view, behavioral exposure treatments disconfirm fear-related beliefs by producing a shift in the grounding assumptions (i.e. premises) that patients affirm in experience. Success at managing previously-threatening situations facilitates recovery as patients integrate these experiences with established self-premises concerning vulnerability. The present study is broadly consistent with other studies that indicate that biases favoring threatening interpretations of events are characteristic of anxiety states (Clark, 1988; Butler &
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Mathews, 1983; Mathews, Richards & Eysenck, 1989; McNally & Foa, 1987). These studies underscore the importance in elucidating the meanings that patients, as active agents, impose upon their world, and how such predication of threatening meanings can lead to the psychopathology characteristic of pathological anxiety states (Rychlak, 1991). Acknowledgements-This second author. It was J. McNally. We thank their comments on this in Motion (AIM), and at the annual meeting research was conducted
study was part of a doctoral dissertation written by the first author under the supervision of the suooorted in oart bv National Institute of Mental Health Grant MH43809 awarded to Richard D&id E. Schotte, Michael Seidenberg, Joseph W. Hatcher, and, especially, Joseph F. Rychlak for research, and Marleen Lorenz, Christine Louro, Bobbie Offenbeck, Angie Ludwigsen, Agoraphobics Nautilus of Evanston for their assistance in recruiting Ss. A version of this paper was presented of the Association for Advancement of Behavior Therapy, San Francisco, November 1990. This when the authors were at the University of Health Sciences/The Chicago Medical School.
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