LONG TERM FOLLOW-UP OF AGORAPHOBICS TREATED BY BRIEF INTENSIVE GROUP COGNITIVE BEHAVIOURAL THERAPY Larry Evans, Craig Holt and Tian P.S. Oei
This study reports the long term efficacy of a brief intensive (2 days) group cognitive behavioural programme for the treatment of agoraphobia with panic attacks. A total of 97 patients was included in the study. Seventy-four patients were in the treated group and 23 were on the waiting list control group. The Fear Questionnaire (FQ), Fear Survey Schedule (FSS), Maudsley Personality Inventory (MPI), the Hostility and Direction of Hostility Questionnaire (HDHQ) and a clinical assessment based on structured interview to assess current levels of functioning were used as dependent measures. The results show that patients in the treated group show significant improvement on FSS and FQ when compared with the patients in the control group. Clinical rating shows that 85% of the patients were either symptom free or their symptoms had been reduced and these effects of treatment were shown to be maintained at follow-up which was on average 1 year after the treatment. Australian and New Zealand Journal of Psychiatry 1991; 25:343-349 Agoraphobia is an unpleasant and disabling condition which afflicts about 4% of the population [ I ] and is the most common anxiety disorder presenting for treatment [2,3]. Despite the fact that the condition was recognized and described many years ago [4,5J treat-
Department of Psychiatry, University of Queensland and Anxiety Disorder Clinic, New Farm Clinic 22 Sargent Street, New Farm, Qld Larry Evan\ MB. ChB, FRANZCP. FRCPsych. DPM. Associate Profrssor. Direcior Bond University, (;old Coast, Queensland Craig Holt BA (Hons). M Applied Psychology Department of Psychology, University of Queenland, and Anxiety Disorder Clinic Tian P.S. Oci PhD. Associate Professor and Director of Clinical Training Programme Correspond with Prof Evans
ment was not particularly effective until recently 131. One major development in the management of these patients has been the introduction and refinement of various behaviour therapies. Nowadays behavioural techniques are widely and effectively used in the treatment of all anxiety disorders, including agoraphobia l3,61. More recently, cognitive techniques have been combined with other behavioural therapies 171. Emmelkamp, et ul [ 81, have demonstrated positive effects usingcognitive therapy in the treatment of phobias and Mathews et ul 131 have suggested the use of cognitive techniques along with exposure in these disorders. Cognitive techniques that have been used include problem solving treatments 191, positive thinking and distraction techniques [ 101, and cognitive restructuring [XI. Even though group cognitive behaviour therapy has been shown to be reasonably effective, its
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 1, 2015
344
LONG TERM FOLLOW-UP OF AGORAPHOBICS
long term efficacy has not been systematically investigated. While various types of psychotherapy, including group therapy, have been widely used to treat agoraphobia in the past they have not been shown to be particularly effective [ 61. Furthermore, traditional group therapies have tended to be a lengthy form of treatment which are time and resource consuming, as they are usually delivered over several weeks or even months. However in the past few years there have been a number of reports of cognitive therapy based group therapy being used successfully in the treatment of agoraphobia [ I 1- 141. Providing patients with information about their disorder and giving them instructions about the use of various treatment techniques has also proven to be a most effective form of treatment particularly when the spouse has been involved [IS]. Marital and couples treatment often involving the spouse as co-therapist, have also been advocated and shown to be beneficial [ 16-181. Molnar and Evans [ 101 have suggested that from a clinical viewpoint a most effective treatment approach for agoraphobia is to combine the therapeutic approaches outlined above. Combined approaches seem to facilitate maintenance and generalisation of behaviour change I 19,201. Emmelkamp and colleagues [21] found that with agoraphobia, a combination of self-verbalisation training and in-vivo exposure was more successful on a number of outcome measures than either alone. Popler [22] concluded lhat the pervasive nature of agoraphobia dictates that its treatment is most effective when a combination of separate, though interactive, techniques are applied in concert, a conclusion which has been suggested by others [23261. Brief intensive group cognitive behavioural therapy for the treatment of agoraphobia has never been reported before. This report presents the long term follow up results from a brief intensive (2 days) group cognitive behavioural treatment (BIGCBT) programme for agoraphobia [27]. The programme was established in Brisbane in 1981 and includes the various approaches mentioned above [lo]. It is administered in an intensive two day workshop format, using a psycho-educational model that provides information and encourages independence and selfreliance. It is based on a self-help approach, teaching participants to use various treatment techniques themselves to gain mastery over their condition. It has an emphasis on cognitive and behavioural techniques for
anxiety control, including in vivo exposure and flooding. Also taught are the principles of stress management as well as the advantages and disadvantages of various drug treatments. In addition participants are given an understanding of the role of anxiety in the development of behavioural change including avoidance. Other objectives of the programme are to remove feelings of isolation and uniqueness through group interaction and to discourage participants from seeing themselves in a sick and dependent patient role by focussing on the normal aspects of anxiety as a response to stress. Patients are encouraged to set realistic goals for treatment and to take control of themselves and their condition and by doing so improve their self-esteem and self-confidence. This paper reports the results of afollow-up study of 74 agoraphobic patients who attended these treatment programmes between 1981 and 1984.
Method Subjects Ninety-seven patients with the diagnosis of agoraphobia with panic attacks satisfying DSM I11 criteria were included in this study. There were 74 patients in the treatment group and 23 patients in the waiting list control group. The mean ages for the treatment and control groups were 38.6 (S.D. 11.9) and 38.7 (S.D 10.7) respectively. The treatment group consisted of 64 females and the control group had 2 1 females. Subjects in the treatment group were all patients who were referred to the anxiety disorder clinic between 1981 and 1984 and who attended the BIGCBT treatment programme. During the period under study 12 1 patients had attended these programmes. Of these 8 patients could not be contacted and a further IS did not wish to participate in the study. In all 98 patients were followed up and of these 74 had complete data sets and were thus included in the study. Patients in the control group were 23 consecutive referrals to the clinic in 1986.
Procedure Patients were all referred by medical practitioners to the Anxiety Disorder Clinic, Brisbane for assessment and treatment of anxiety disorders. Upon referral, all patients completed the self report questionnaires and were clinically assessed using a structured interview by a psychiatrist or clinical psychologist experienced
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 1, 2015
LARRY EVANS. CRAIG HOLT. TIAN P.S. OEI
in the diagnosis of anxiety disorders. The structured interview took about 60 minutes. A diagnosis according to the DSM I11 criteria was made using information from the interview and self ratings. This diagnosis was later confirmed during a clinical staff meeting attended by all clinic staff where each case was presented and discussed in detail. Although no diagnostic rating scale (eg. SCID) was used in the study great care was exercised to ensure that all diagnoses fulfilled the DSM 111 criteria. Patients and controls were excluded if they had another axis 1 DSM 111 diagnosis as were those with concomitant physical illness. There was no rating made of the number of panic attacks experienced by the subjects and no objective behavioural measurement of their avoidance. No drugs were prescribed to either group at the Clinic although both groups were allowed to continue with medication previously prescribed. All subjects were encouraged to minimise the amount of medication taken. We have previously shown that about 60% of patients referred to the Clinic are taking prescribed psychotropic medication [33], and commented on the types and dosages of these drugs. In the present study we have not analysed the effects of this medication on outcome of the BIGCPT programme however this is an issue which we have since investigated.
Dependent measures Rating was carried out in the treatment group at the time of assessment (Pre), immediately after attending the BlGCBT programme (Post) and at a variable time (F/U) as shown in Table 2. Dependent measures used were the Maudsley Personality Inventory (MPI) [28], the Fear Survey Schedule (FSS) [29,30],the Hostility and Direction of Hostility Questionnaire (HDHQ) [31] and the Fear Questionnaire (FQ) [32]. Patients on the waiting list received the same clinical assessment procedures and dependent measures. They were interviewed twice at the time of initial assessment (Pre 1) and then immediately prior to attending the BIGCBT programme (Pre 2). The average waiting time was 4 months with a minimum of 3 months. After the second assessment interview these patients were given treatment, however, these treatment data were not included in the present data analysis. At follow-up all patients in the treatment group were given a 25 item structured interview constructed by the authors. This structured interview was used to obtain qualitative information about patient’s views of the
345
usefulness of the treatment, their activities since treatment, their current level of functioning, and their current level of medication. Before this interview started, all patients again completed the self report questionnaires which they had previously completed at the time of initial assessment. At the end of the interview, patients were asked to rate themselves on an 8 point rating scale where 8 is symptom free, 5 is symptom reduced and 1 is symptom definitely worse. They were then divided into 3 groups based on this score: Group 1 were those scoring 7 and 8 and were considered symptom free. Group 2 were those scoring 4, 5 and 6 and were considered to be symptom reduced. Group 3 were those scoring 1, 2 and 3 and were considered to be worse or unchanged. The BIGCBT group programme has been described previously in detail [27]. Briefly the programme consisted of the following: lectures, skill acquisition, in vivo exposures and group discussions. Lectures: These consisted of informal talks giving information to patients about the anxiety disorders in general with a focus on agoraphobia with panic disorder, their symptoms and their aetiology. Information about the nature of drugs useful in the treatment of anxiety disorders and their side effects were also discussed as well as the basic principles of learning theory, behaviour therapy and cognitive therapy. The lecture component accounted for about 3 hours of the 18 hours two days treatment programme. Skill acquisition: This section consisted of teaching cognitive and behaviour anxiety control techniques. The techniques taught were relaxation, breathing control, cognitive and behaviour techniques (e.g. the ten commandments of panic control). This component accounted for a further 3 hours of the programme. In vivo exposure: There were 3 x 3 hour sessions of in vivo exposure during which small groups of two to three patients were accompanied by a staff member into situations where they had reported maximum avoidance. In these situations they were given practical on the spot instruction on anxiety control techniques, and their successes in overcoming their avoidance were acclaimed by staff and other patients ensuring immediate positive reinforcement of their behaviour. Group discussion: Planning of the in vivo sessions was carried out in groups. After in vivo exposure, patients were encouraged to share their experiences in the group. Here therapists attended to clarify any ques-
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 1, 2015
LONG TERM FOLLOW-UP OF AGORAPHOBICS
346
Table 1. The means and standard deviations () ofthe self reports outcome measures for the treatment and waiting list control groups
Waiting list Pre 2
Pre 1 FSS FQ-Ag FQ-SOC
114.7 23.0 17.0 36.8 17.9 22.3 6.5
MPI-N MPI-E HDHQ-H HDHQ-D
*
p
This study reports the long term efficacy of a brief intensive (2 days) group cognitive behavioural programme for the treatment of agoraphobia with panic attacks. A total of 97 patients was included in the study. Seventy-four patients were in the treated group and 23 were on the waiting list control group. The Fear Questionnaire (FQ), Fear Survey Schedule (FSS), Maudsley Personality Inventory (MPI), the Hostility and Direction of Hostility Questionnaire (HDHQ) and a clinical assessment based on structured interview to assess current levels of functioning were used as dependent measures. The results show that patients in the treated group show significant improvement on FSS and FQ when compared with the patients in the control group. Clinical rating shows that 85% of the patients were either symptom free or their symptoms had been reduced and these effects of treatment were shown to be maintained at follow-up which was on average 1 year after the treatment. Australian and New Zealand Journal of Psychiatry 1991; 25:343-349 Agoraphobia is an unpleasant and disabling condition which afflicts about 4% of the population [ I ] and is the most common anxiety disorder presenting for treatment [2,3]. Despite the fact that the condition was recognized and described many years ago [4,5J treat-
Department of Psychiatry, University of Queensland and Anxiety Disorder Clinic, New Farm Clinic 22 Sargent Street, New Farm, Qld Larry Evan\ MB. ChB, FRANZCP. FRCPsych. DPM. Associate Profrssor. Direcior Bond University, (;old Coast, Queensland Craig Holt BA (Hons). M Applied Psychology Department of Psychology, University of Queenland, and Anxiety Disorder Clinic Tian P.S. Oci PhD. Associate Professor and Director of Clinical Training Programme Correspond with Prof Evans
ment was not particularly effective until recently 131. One major development in the management of these patients has been the introduction and refinement of various behaviour therapies. Nowadays behavioural techniques are widely and effectively used in the treatment of all anxiety disorders, including agoraphobia l3,61. More recently, cognitive techniques have been combined with other behavioural therapies 171. Emmelkamp, et ul [ 81, have demonstrated positive effects usingcognitive therapy in the treatment of phobias and Mathews et ul 131 have suggested the use of cognitive techniques along with exposure in these disorders. Cognitive techniques that have been used include problem solving treatments 191, positive thinking and distraction techniques [ 101, and cognitive restructuring [XI. Even though group cognitive behaviour therapy has been shown to be reasonably effective, its
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 1, 2015
344
LONG TERM FOLLOW-UP OF AGORAPHOBICS
long term efficacy has not been systematically investigated. While various types of psychotherapy, including group therapy, have been widely used to treat agoraphobia in the past they have not been shown to be particularly effective [ 61. Furthermore, traditional group therapies have tended to be a lengthy form of treatment which are time and resource consuming, as they are usually delivered over several weeks or even months. However in the past few years there have been a number of reports of cognitive therapy based group therapy being used successfully in the treatment of agoraphobia [ I 1- 141. Providing patients with information about their disorder and giving them instructions about the use of various treatment techniques has also proven to be a most effective form of treatment particularly when the spouse has been involved [IS]. Marital and couples treatment often involving the spouse as co-therapist, have also been advocated and shown to be beneficial [ 16-181. Molnar and Evans [ 101 have suggested that from a clinical viewpoint a most effective treatment approach for agoraphobia is to combine the therapeutic approaches outlined above. Combined approaches seem to facilitate maintenance and generalisation of behaviour change I 19,201. Emmelkamp and colleagues [21] found that with agoraphobia, a combination of self-verbalisation training and in-vivo exposure was more successful on a number of outcome measures than either alone. Popler [22] concluded lhat the pervasive nature of agoraphobia dictates that its treatment is most effective when a combination of separate, though interactive, techniques are applied in concert, a conclusion which has been suggested by others [23261. Brief intensive group cognitive behavioural therapy for the treatment of agoraphobia has never been reported before. This report presents the long term follow up results from a brief intensive (2 days) group cognitive behavioural treatment (BIGCBT) programme for agoraphobia [27]. The programme was established in Brisbane in 1981 and includes the various approaches mentioned above [lo]. It is administered in an intensive two day workshop format, using a psycho-educational model that provides information and encourages independence and selfreliance. It is based on a self-help approach, teaching participants to use various treatment techniques themselves to gain mastery over their condition. It has an emphasis on cognitive and behavioural techniques for
anxiety control, including in vivo exposure and flooding. Also taught are the principles of stress management as well as the advantages and disadvantages of various drug treatments. In addition participants are given an understanding of the role of anxiety in the development of behavioural change including avoidance. Other objectives of the programme are to remove feelings of isolation and uniqueness through group interaction and to discourage participants from seeing themselves in a sick and dependent patient role by focussing on the normal aspects of anxiety as a response to stress. Patients are encouraged to set realistic goals for treatment and to take control of themselves and their condition and by doing so improve their self-esteem and self-confidence. This paper reports the results of afollow-up study of 74 agoraphobic patients who attended these treatment programmes between 1981 and 1984.
Method Subjects Ninety-seven patients with the diagnosis of agoraphobia with panic attacks satisfying DSM I11 criteria were included in this study. There were 74 patients in the treatment group and 23 patients in the waiting list control group. The mean ages for the treatment and control groups were 38.6 (S.D. 11.9) and 38.7 (S.D 10.7) respectively. The treatment group consisted of 64 females and the control group had 2 1 females. Subjects in the treatment group were all patients who were referred to the anxiety disorder clinic between 1981 and 1984 and who attended the BIGCBT treatment programme. During the period under study 12 1 patients had attended these programmes. Of these 8 patients could not be contacted and a further IS did not wish to participate in the study. In all 98 patients were followed up and of these 74 had complete data sets and were thus included in the study. Patients in the control group were 23 consecutive referrals to the clinic in 1986.
Procedure Patients were all referred by medical practitioners to the Anxiety Disorder Clinic, Brisbane for assessment and treatment of anxiety disorders. Upon referral, all patients completed the self report questionnaires and were clinically assessed using a structured interview by a psychiatrist or clinical psychologist experienced
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 1, 2015
LARRY EVANS. CRAIG HOLT. TIAN P.S. OEI
in the diagnosis of anxiety disorders. The structured interview took about 60 minutes. A diagnosis according to the DSM I11 criteria was made using information from the interview and self ratings. This diagnosis was later confirmed during a clinical staff meeting attended by all clinic staff where each case was presented and discussed in detail. Although no diagnostic rating scale (eg. SCID) was used in the study great care was exercised to ensure that all diagnoses fulfilled the DSM 111 criteria. Patients and controls were excluded if they had another axis 1 DSM 111 diagnosis as were those with concomitant physical illness. There was no rating made of the number of panic attacks experienced by the subjects and no objective behavioural measurement of their avoidance. No drugs were prescribed to either group at the Clinic although both groups were allowed to continue with medication previously prescribed. All subjects were encouraged to minimise the amount of medication taken. We have previously shown that about 60% of patients referred to the Clinic are taking prescribed psychotropic medication [33], and commented on the types and dosages of these drugs. In the present study we have not analysed the effects of this medication on outcome of the BIGCPT programme however this is an issue which we have since investigated.
Dependent measures Rating was carried out in the treatment group at the time of assessment (Pre), immediately after attending the BlGCBT programme (Post) and at a variable time (F/U) as shown in Table 2. Dependent measures used were the Maudsley Personality Inventory (MPI) [28], the Fear Survey Schedule (FSS) [29,30],the Hostility and Direction of Hostility Questionnaire (HDHQ) [31] and the Fear Questionnaire (FQ) [32]. Patients on the waiting list received the same clinical assessment procedures and dependent measures. They were interviewed twice at the time of initial assessment (Pre 1) and then immediately prior to attending the BIGCBT programme (Pre 2). The average waiting time was 4 months with a minimum of 3 months. After the second assessment interview these patients were given treatment, however, these treatment data were not included in the present data analysis. At follow-up all patients in the treatment group were given a 25 item structured interview constructed by the authors. This structured interview was used to obtain qualitative information about patient’s views of the
345
usefulness of the treatment, their activities since treatment, their current level of functioning, and their current level of medication. Before this interview started, all patients again completed the self report questionnaires which they had previously completed at the time of initial assessment. At the end of the interview, patients were asked to rate themselves on an 8 point rating scale where 8 is symptom free, 5 is symptom reduced and 1 is symptom definitely worse. They were then divided into 3 groups based on this score: Group 1 were those scoring 7 and 8 and were considered symptom free. Group 2 were those scoring 4, 5 and 6 and were considered to be symptom reduced. Group 3 were those scoring 1, 2 and 3 and were considered to be worse or unchanged. The BIGCBT group programme has been described previously in detail [27]. Briefly the programme consisted of the following: lectures, skill acquisition, in vivo exposures and group discussions. Lectures: These consisted of informal talks giving information to patients about the anxiety disorders in general with a focus on agoraphobia with panic disorder, their symptoms and their aetiology. Information about the nature of drugs useful in the treatment of anxiety disorders and their side effects were also discussed as well as the basic principles of learning theory, behaviour therapy and cognitive therapy. The lecture component accounted for about 3 hours of the 18 hours two days treatment programme. Skill acquisition: This section consisted of teaching cognitive and behaviour anxiety control techniques. The techniques taught were relaxation, breathing control, cognitive and behaviour techniques (e.g. the ten commandments of panic control). This component accounted for a further 3 hours of the programme. In vivo exposure: There were 3 x 3 hour sessions of in vivo exposure during which small groups of two to three patients were accompanied by a staff member into situations where they had reported maximum avoidance. In these situations they were given practical on the spot instruction on anxiety control techniques, and their successes in overcoming their avoidance were acclaimed by staff and other patients ensuring immediate positive reinforcement of their behaviour. Group discussion: Planning of the in vivo sessions was carried out in groups. After in vivo exposure, patients were encouraged to share their experiences in the group. Here therapists attended to clarify any ques-
Downloaded from anp.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on July 1, 2015
LONG TERM FOLLOW-UP OF AGORAPHOBICS
346
Table 1. The means and standard deviations () ofthe self reports outcome measures for the treatment and waiting list control groups
Waiting list Pre 2
Pre 1 FSS FQ-Ag FQ-SOC
114.7 23.0 17.0 36.8 17.9 22.3 6.5
MPI-N MPI-E HDHQ-H HDHQ-D
*
p
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