Pergamon S0005-7967(96)00009-5

Behav. Res. Ther. Vol. 34, No. 5/6, pp. 413~,21, 1996 Copyright/i2; 1996 Elsevier Science Ltd

Printed in Great Britain. All rights reserved 0005-7967/96 $15.00 + 0.00

C H A N G E I N D A N G E R C O G N I T I O N S IN A G O R A P H O B I A

A N D S O C I A L P H O B I A D U R I N G T R E A T M E N T

RICHIE G. POULTON and GAVIN ANDREWS* Clinical Research Unit for Anxiety Disorders, Department of Psychiatry, University of New South Wales

at St Vincent's Hospital, Sydney, Australia

(Received 4 December 1995)

Summary--Cognitive theories of anxiety emphasise the differences in anxious concerns and symptomatol- ogy across the anxiety disorders. The nature and extent of danger appraisal in social phobics and agoraphobics was examined and compared with that of a non-phobic group of adult stutterers. All groups were measured before, during and after treatment. Results showed that the form of danger appraisal was related to the fears exhibited, reductions in the particular appraisals of danger were associated with reductions in specific fears, and specific patterns of danger appraisal emerged. Agoraphobics' concerns with physical and loss of control danger normalized during treatment. Despite considerable and significant improvement, social phobics continued to have social evaluation danger scores significantly higher than the control group at the end of treatment. While cognitive behavioural therapy does change relevant fear cognitions, it appears that the intransigence of social phobic concerns about negative evaluations may require extra time and/or therapy. Copyright © 1996 Elsevier Science Ltd.

INTRODUCTION

Cognitive theorists have suggested that phobic disorders can result from incorrect and excessive appraisal of danger in objectively non-threatening situations (Beck, 1976; Beck & Emery, 1985; Clark, 1986). Studies have demonstrated that anxious patients systematically overestimate the probability and/or cost of negative events in a variety of situations (Butler & Matthews, 1983; McNally & Foa, 1987; Lucock & Salkovskis, 1988; Menzies & Clarke, 1995; Andrews, Freed & Teesson, 1994; Poulton & Andrews, 1994). Overestimates of catastrophic/negative outcomes could be responsible for the maintenance of phobic disorders in so much as the perception of a high degree of danger even when away from a situation will result in continued avoidance of that situation. Thus prevented from entering their feared situation and testing their worst expectations, phobic persons do not overcome their phobic avoidance (Seligman & Johnston, 1973; Rachman, 1983; Rachman, 1990; Clark, 1988; Clark & Beck, 1988; Telch, Brouillard, Telch, Agras & Taylor, 1989).

Catastrophic thinking about panic can predict treatment outcome as measured on indices of panic and avoidance behaviour (e.g. Chambless & Gracely, 1989). Cognitive measures are often good predictors of treatment outcome and maintenance of treatment gains may also be related to cognitive variables (Franklin, 1990). Similar findings have been observed in the treatment of social phobia (Butler, Cullington, Munby, Amies & Gelder, 1984; Heimberg, Becker, Goldfinger & Vermilyea, 1985; Heimberg, Dodge, Hope, Kennedy, Zollo & Becker, 1990; Heimberg & Barlow, 1991; Mattick & Peters, 1988; Mattick, Peters & Clarke, 1989). For example, Mattick and Peters (1988) and Mattick et al. (1989) demonstrated that a reduction in the degree of concern over the opinion of others (Fear of Negative Evaluation (FNE); Watson & Friend, 1969), was the most important mediating cognitive variable effecting improvement.

Cognitive behaviour therapy should lead to improvement and maintenance of treatment gains via the alteration of maladaptive cognitions. However, relatively few studies have addressed this issue directly and have used cognitive measures to assess outcome [e.g. Irrational Beliefs Test (Jones, 1969), FNE] that may not discriminate adequately between anxiety and cognitions (Chambless & Gillis, 1993; Heimberg, 1994). Heimberg (1994) in his review of cognitive assessment

*Author for correspondence.

413

414 Richie G. Poulton and Gavin Andrews

strategies in social phobia treatment outcome research, suggested that alternative strategies such as measurement of probability estimates of negative outcomes (cf. Lucock & Salkovskis, 1988) be used. Changing phobic patients' appraisal of danger by altering their probability and cost estimates of negative outcomes should therefore be important in the successful treatment of phobic disorders. Exactly what type of danger appraisal should be targeted in treatment of each phobic disorder remains unclear. Currently there is evidence of cognitive specificity among the anxiety disorders in the form of selective encoding biases of threat relevant information (e.g. MacLeod, Matthews & Tata, 1986; MacLeod, 1991; Watts, McKenna, Sharrock & Trezise, 1986). A recent study suggests that selective attention to emotional material in general may be characteristic of normal states of heightened emotion but that anxiety disorders may be characterized, and maintained, by a more specific kind of selective attention to threat, namely attention to stimuli that are perceived as threatening because they reflect idiosyncratic beliefs (Martin, Williams & Clark, 1991).

Agoraphobics and social phobics differentially endorse self-report instruments (e.g. Agoraphobic Cognitions Questionnaire) measuring different types of negative outcomes (Andrews, 1991), and in one of the few studies to examine specific appraisals in a congruent diagnostic group, Lucock and Salkovskis (1988) found that, compared with matched controls, 12 social phobics overesti- mated the probability that unpleasant social events would occur and that social skills training produced specific changes in this appraisal. This study measured probability estimates only. There are no published studies that have measured both probability and cost estimates (see Carr, 1974; Paterson & Neufeld, 1987), to produce a composite measure of appraisal of danger to assess these irrational cognitions before and during cognitive behavioral treatment. Additionally, there are no reports investigating the process of change in danger appraisals as treatment progresses. Assuming the validity of the cognitive model of anxiety, it is important to demonstrate if and how cognitive behavioural treatment effectively alters these types of cognitions that are hypothesized to be responsible for the maintenance of phobias.

The present study will therefore attempt to: (a) ascertain the nature and extent of danger appraisal in agoraphobic and social phobic patients, (b) identify the specific types of danger appraisal associated with each disorder and their relationship with avoidance behaviour and state anxiety, (c) examine the relative contribution of probability and cost estimates to the appraisal of danger, and (d) investigate the temporal process of change in danger appraisals made by agoraphobics and social phobics and a control group of stutterers as each group participated in a structured, intensive 3 week cognitive-behavioral treatment program (Andrews, Crino, Hunt, Lampe & Page, 1994; Neilson & Andrews, 1992).

METHOD

Patients meeting DSM-III-R criteria for either panic disorder with agoraphobia (n = 45, mean age = 39 years) or social phobia (n = 64, mean age = 31 years) took part in the study. All patients received a clinical diagnosis from a consultant psychiatrist that was confirmed by the computerized self-report version of the Composite International Diagnostic Interview. 67% of the agoraphobics and 54% of the social phobics were female. These sex differences were not significant. A control group of stutterers (n = 32) undergoing treatment over the same duration was included. Stuttering is not an anxiety disorder and research has shown that stutterers are no different from normal Ss in personality factors related to trait anxiety (Andrews, Craig, Feyer, Hoddinott, Howie & Neilson, 1983) or in how they appraise social evaluation danger in a public speaking situation (Pouiton & Andrews, 1994).

All Ss were participating in a 3 week intensive cognitive behavioral treatment program. These treatments have been described in detail elsewhere (Andrews et al., 1994). Briefly, treatment occurs in a group format, patients attend the clinic full time for week one, conduct self directed exposure away from the clinic in week two and return full-time to the clinic in week three. The treatment incorporates instruction in techniques for relaxation and control of anxiety and panic and patients are taught to identify and challenge faulty cognitions. They complete a graded hierarchy of exposure tasks during treatment that culminate in a final treatment goal. For agoraphobics this goal entails traveling alone by train and underground train to a suburb some 20 km from the clinic and returning. For social phobic patients it involves giving a 5 min talk in front of an unknown

Danger appraisal and treatment 415

audience. Both programs are characterized by a high level of specification--agoraphobics focus on thinking and behavior related to panic outcome and social phobics focus on thinking and behavior related to their irrational fear of negative social evaluation. The control group of stutterers undergo an intensive 3 week cognitive behavioural treatment aimed at improving fluency. This program has been described in detail elsewhere (Neilson & Andrews, 1992). As part of that treatment stutterers have to give a talk on their penultimate day of treatment in the same setting as do the social phobics. This allowed for a direct comparison of changes in appraisal of danger with treatment between phobic and non-phobic Ss.

Subjects in this study were asked to complete a number of questionnaires designed to measure appraisal of danger related to the final treatment goal (see below). The first administration occurred on the second afternoon of the program after patients were informed of the graduated set of exposure tasks they were required to complete during treatment. Patients then completed the same questionnaires at the end of week one (day 5), at the beginning of week three (day 15) and on the final day of treatment (day 19) after they had completed the task presuming they "had to do the previous days task (i.e. travelling at some time in the future)".

The Danger Appraisal Questionnaire was made up of three scales:

(1) The Physical Illness Danger scale comprised four of the five items originally used in the Panic Appraisal Inventory (PAl) "physical concerns" subscale (Telch et al., 1989). The scale was modified slightly for the purposes of this study so that the wording referred to future events. Items were: (1) you will have a heart attack, (2) you will have a stroke, (3) you will faint, (4) you will suffocate. The original subscale item 'I may die' was omitted because in pilot testing it had very low endorsement rates.

(2) The Social Evaluation Danger scale was comprised of five items selected from the Social Cognitions Questionnaire developed and piloted at our unit (Morris-Yates, 1993). It has been found to effectively discriminate between social phobics and other anxiety disorders on the basis of cognitions related to social situations. The Social Evaluation Danger scale has satisfactory test-retest reliability (r = 0.72) and high internal consistency (~ = 0.91). Items were: (1) people will find fault with you, (2) people will see you as incompetent or foolish, (3) people will see you are anxious and not like you, (4) people will laugh at you, (5) you will make a scene in front of others.

(3) The loss of Control Danger scale was the five item PAl "loss of control concerns" subscale (Telch et al., 1989). Items were: (1) you will go insane, (2) you will become completely hysterical, (3) you will scream, (4) you will lose control of your senses, (5) you will do something uncontrollable.

The physical danger and loss of control scales are reported to have high test-retest reliability (r = 0.86) and high internal consistency (r = 0.91) (Telch et al., 1989). As these two scales were originally developed for use in an agoraphobic population it was necessary to demonstrate their psychometric properties in a social phobic group. In an independent sample of social phobics (n = 21), test-retest reliability was found to be satisfactory (physical illness danger--r = 0.76; loss of control danger--r -- 0.75) and internal consistency was moderate to high (physical illness danger, • = 0.69; loss of control danger, ~ = 0.89).

Subjects were asked to rate (0-8, "very unlikely" to "extremely likely") the probability of each of the 14 events occurring to them when attempting the final treatment task. They were then asked to rate the cost of the events (0-8, "not at all bad" to "extremely bad"), presuming they actually occurred when completing the final treatment task. Composite measures of danger appraisal were obtained by multiplying the mean probability estimates by the mean cost estimates (after Carr, 1974; see also McNally & Foa, 1987; Beck & Emery, 1985; Poulton & Andrews, 1994).

The Fear Questionnaire (FQ) (Marks & Matthews, 1979) was used to assess Ss' level of phobic avoidance. The FQ consists of 15 items representing three separate phobia types (agoraphobia, blood injury phobia and social phobia). For each item, the S rates the degree of avoidance to the specific object or situation. The five item agoraphobia subscale and the five

416 Richie G. Poul ton and Gav in Andrews

item social phobia subscales were used. This widely used instrument possesses adequate psycho- metric properties.

R E S U L T S

As expected, agoraphobics had higher scores on the agoraphobic avoidance subscale of the Fear Questionnaire than social phobics (F(1, 107)= 69.47, P <0.001), there was a main effect for treatment (F(I, 107)= 167.72, P < 0.001), and the agoraphobics avoidance decreased more over treatment than did social phobics (F(I, 107) = 56.19, P < 0.001) (Fig. 1). In contrast the social phobics scored more highly on the social phobic avoidance subscale of the Fear Questionnaire (F(I, 107) = 71.38, P < 0.001), there was a main effect for treatment (F(1, 107) = 98.10, P < 0.001) but the interaction effect was not significant (F(I, 107)= 2.17, n.s.). Thus there is evidence for the specificity of the avoidance in the two phobic groups and for the specificity of treatment.

Standardized scores were computed for pr~post measures on the three types of danger appraisal for agoraphobics and social phobics.

Agoraphobics appraised more physical illness danger than social phobics (F(I, 107)= 14.37, P < 0.001), there was a significant main effect (F(I, 107) = 39.89, P < 0.001) but the interaction was not significant (F(I, 107)= 2.78, n.s.), (Fig. 2). Social phobics scored more highly than agoraphobics for appraisal of social evaluation danger (F(I, 107)= 69.23, P < 0.001), there was a main effect for treatment (F(I, 107) = 129.05, P < 0.001) and social phobics appraisal of social evaluation danger decreased more than agoraphobics over treatment (F(I, 107)= 15.06, P < 0.001), (Fig. 2). Finally, there was no difference between agoraphobics and social phobics in their appraisal of danger due to loss of control (F(1,107) = 3.37, n.s.), both groups decreased over treatment (F(I, 107)= 94.96, P < 0.001), and agoraphobics decreased more than social phobics (F(I, 107)= 6.86, P < 0.01), (Fig. 2).

As shown in Table 1 (above the diagonal) agoraphobics' state anxiety and agoraphobic avoidance at the end of treatment was correlated with all three types of danger appraisal, and social phobic avoidance was correlated with appraisal of social evaluation and loss of control danger. The three types of danger appraisal were moderately correlated in agoraphobics.

For social phobics at the end of treatment (below the diagonal), state anxiety was correlated with appraisal of physical illness and social evaluation danger and social phobic avoidance was correlated with appraisal of social evaluation and loss of control danger.The three types of danger appraisal were moderately correlated in social phobics.

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Fig. 1. Change in agoraphob ic and social phobic avoidance dur ing t reatment .

Danger appraisal and treatment 417

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Fig. 2. Change in dange r cogni t ions dur ing t rea tment in agoraphob ics and social phobics.

A more detailed analysis of changes during treatment in the three types of danger appraisal was conducted.

The mean physical illness danger appraisal scores (probability × cost), at four times during treatment were analyzed using two-factor analysis of variance (ANOVA) with the variables "group" (social phobics, agoraphobics, stutterers) and "time" (day 2, 5, 15, 19 repeated measure). There was no overall difference between agoraphobics and social phobics (F(I, 138)= 0.16, n.s.). In contrast there was a significant group effect between social phobics and stutterers [F(I, 138) = 17.13, P < 0.0901]. There was a significant time effect [F(3, 414) = 15.71, P < 0.001] and a

Table I. Correlation of danger appraisal, phobic avoidance and state anxiety in agoraphobics (above diagonal, n = 45) and social phobic (below diagonal, n = 64) at post-treatment

Physical Illness Social Evaluation Loss of Control Agoraphobic Social State Danger Danger Danger Avoidance Avoidance Anxiety

Physical Illness Danger Social Evaluation Danger 0.16 Loss of Control Danger 0.32* Agoraphobic Avoidance - 0.06 Social Avoidance 0.00 State Anxiety 0.34*

0.59** 0.77** 0,42* 0.22 0.44** - - 0.82** 0,56** 0.55** 0.64**

0.62** - - 0.57** 0.39* 0.72** 0.17 0.23 - - 0.43* 0.59** 0.50** 0.47** 0.15 - - 0.54** 0.44** 0.26 - 0.04 0.2 - -

*P < 0.05. **P < O.O1.

418 Richie G. Pou l ton and Gav in Andrews

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Fig. 3. Appra isa l of social eva lua t ion danger in social phobics (n = 64) and stut terers (n = 32) dur ing t rea tment (3 weeks).

non-significant group × time interaction for agoraphobics and social phobics [F = (3, 414) = 1.67, N.S.] and for social phobics and stutterers [F(3, 414) = 1.05, N.S.] corrected to P = 0.013 following the Bonferroni method. Agoraphobics and social phobics did not differ from each other in the amount of physical illness danger they appraised during treatment. Phobics appraised significantly more physical illness danger compared to controls.

The mean scores for appraisal of social evaluation danger (probability x cost) in social phobics, agoraphobics and stutterers were compared. There was a significant group difference between agoraphobics and social phobics [F(1, 138) = 76.29, P < 0.001], and between social phobics and stutterers [F(1, 138)= 39.29, P < 0.001]. There was a significant time effect [F(3, 414)= 55.87, P < 0.001] and a significant group x time interaction for the comparison between agoraphobics and social phobics IF(3, 414) = 8.91, P < 0.001], and for the comparison between social phobics and stutterers [(F = 3, 414)= 15.15, P < 0.001]. Univariate F-tests comparing agoraphobics and social phobics showed appraisal of evaluation danger decreased significantly between day 2 and day 5 [F(I, 138)= 8.97, P < 0.01] and between day 15 and day 19 [F(1, 138)= 21.95, P < 0.001]. Similarly univariate F-tests comparing social phobics and stutterers showed that appraisal of evaluation danger decreased significantly between day 2 and day 5 of treatment [F(I, 138)= 19.07, P <0.001] and day 15 and day 19 [F(I, 138)=24.44, P <0.001]. Social phobics appraised significantly more social evaluation danger compared to either agoraphobics or stutterers before, during and at the end of treatment (see Fig. 3 for a comparison between social phobics and stutterers).

A two factor ANOVA for appraisal of danger due to loss of control revealed no difference between groups (agoraphobics vs social phobics) [F(I, 138)= 2.61, P = 0.2] or social phobics vs stutterers [F(I, 138)=4.43, P =0.04]. There was a significant time effect [F(3, 414)=40.11, P < 0.001] and a significant group x time interaction for agoraphobics vs social phobics [F(3, 414) = 5.67, P < 0.001] and for social phobics vs stutterers [F(3,414) = 5.27, P < 0.001] Univariate F-tests revealed that for both group comparisons the significant difference was between day 2 and day 5 only--agoraphobics vs social phobics [F(1, 138)= 8.39, P < 0.01] and social phobics vs stutterers (F(I, 138)= 8.59, P < 0.01). Agoraphobics had higher loss of control danger scores at the beginning of treatment than social phobics. This difference disappeared after the first week of treatment. Both phobic groups' appraisal of loss of control danger decreased significantly during treatment.

Danger appraisal and treatment 419

The change in probability and cost estimates across treatment in the two phobic groups was examined to elucidate the relative contribution of each to the continued high appraisal of social evaluation danger. There was a significant group difference in probability estimates for agorapho- bics vs social phobics [F(I, 138)= 85.83, P <0.001] and for social phobics vs stutterers [F(I, 138) = 23.05, P < 0.001]. There was a significant time effect [F(3, 414) = 69.94, P < 0.001], and a significant group x time interaction only for social phobics vs stutterers [F(3, 414)=8.60, P < 0.001]. Univariate F-tests showed that the groups were significantly different in probability estimates between day 2 and day 5 [F(1, 138)= 9.02, P <0.01] and between day 15 and day 19 [F(1, 138)= 17.44, P < 0.001].

For cost estimates there was a significant group effect [agoraphobics vs social phobics F(I, 138) = 76.80, P < 0.001 and social phobics vs stutterers F(I, 138) = 22.72, P < 0.001]. There was a significant time effect [F(3, 414) = 35.14, P < 0.001], and a significant group x time interaction for social phobics vs stutterers only [F(3, 414) = 7.73, P < 0.001]. Univariate F-tests for socials vs stutterers revealed significant differences between day 2 and day 5 [F(I, 138) = 10.07, P < 0.01] and day 15 and day 19 IF(I, 138)= 9.93, P < 0.001]. Social phobics had higher cost and probability estimates relating to social evaluation danger compared to agoraphobics and stutterers. These differences were maintained at the end of treatment.

SUMMARY OF RESULTS

Agoraphobics had higher appraisal of physical illness danger scores and higher loss of control danger scores than did social phobics. Social phobics had significantly higher appraisal of social evaluation danger scores than did agoraphobics. Agoraphobics improved significantly on their two core concerns during treatment and their appraisals of danger at post-treatment were such that they would no longer qualify as clinically problematic. Social phobics, despite significant changes in their appraisal of social evaluation danger were still prone to appraise more danger associated with negative social evaluation than is desirable.

A non-phobic control group of stutterers was included to allow a direct comparison of danger appraisals linked to the same end of treatment task completed by social phobics (i.e. public speech). These results, comparing scores on appraisal of danger from potential negative outcomes by social phobic and non-phobic stutterers, are consistent with the results reported in the comparison between agoraphobics and social phobics. That is, social phobics were primarily concerned with social evaluation danger. While they made high danger appraisals due to loss of control at the beginning of treatment these responded rapidly to treatment, and whereas they continued to make unrealistically high appraisals of social evaluation danger at the end of treatment. That is, both their probability and cost estimates of social evaluation danger, despite decreasing significantly during treatment, were still abnormal despite highly structured, intensive cognitive behavioural treatment.

DISCUSSION

At the beginning of treatment agoraphobic and social phobic patients had high appraisal of danger scores when contemplating a relevant challenge. Their overall appraisal of danger had significantly decreased by the penultimate day of treatment when all patients completed their final treatment goal. Agoraphobics perceived their task (a 2 hour return trip by train and underground train) as dangerous due to possible physical illness (e.g. heart attack, stroke) and loss of control (e.g. going insane) but were not unduly concerned about social evaluation. Social phobics were primarily concerned with social evaluation danger when completing a public speech.

The cognitive behavioral therapy was effective in changing the irrational cognitions regarding danger for agoraphobic patients. Both probability and cost estimates of relevant negative outcomes returned to acceptable levels and these changes may have potentiated successful completion of tasks that were avoided before treatment. Despite social phobic's appraisal of social evaluation danger changing significantly during treatment, the core irrational concerns remain significantly high when compared to the control group of stutterers. It was both the probability (this is likely to happen) and the cost (the penalty is high), of being negatively evaluated that was resistant to treatment.

420 Richie G. Poulton and Gavin Andrews

There are a number of possible explanations for this finding. It may have been that the social phobic group comprised a significant number of patients with a comorbid axis II diagnosis of Avoidant Personality Disorder (APD) and that it was this more severe subgroup of social phobic patients that contributed to the overall elevated danger estimates at the end of treatment. There is growing evidence that social phobia exists on a continuum with APD sufferers being the most severely incapacitated (Herbert, Hope & Bellack, 1992; Holt, Heimberg, & Hope, 1992; Widiger, 1992; Andrews et al., 1994). In a separate study analysis of the appraisal of social evaluation danger in social phobics with (n = 18), and without (n = 45) a dual diagnosis of APD revealed no differences at any time during treatment (Poulton & Lampe, 1995).

Another possible explanation for the findings lies in the nature of the disconfirmations of negative outcomes available to the two phobic groups. Agoraphobic patients have real and tangible data to support the disconfirmation of an expected negative outcome. That is, upon completion of an exposure task they are able to see clearly that they did not have a heart attack or did not lose control. For social phobics however this is not so straight forward. They have to make estimates based on what they believe other people thought of their behavior. Given the potential for ambiguity in human interaction and communication, and their predisposition to over-predict negative evaluation, it may take longer to change attitudes when less objective data is available to evaluate their performance. Beck and Emery (1985) also make the point, that unlike other phobias where the feared consequence is unlikely to occur (e.g. snake phobia), the socially phobic individual is likely to acquit themselves poorly in social interaction due to narrowing of attention and focus on possible negative events. This preoccupation can lead to behavioural inhibition and real deficits in performance (see Stopa & Clark, 1993).

Thus, if social phobics objectively perform poorly in social situations (e.g. Beck & Emery, 1985; Stopa & Clark, 1993), and then regard their performance in a more negative way than others, it seems reasonable that in ambiguous social interactions, their overestimates of possible negative outcomes, and of the aversiveness or cost of negative outcomes, are slow to change during treatment. Indeed, they will continue to experience high levels of self-consciousness and show real performance deficits--which are objectively costly in a world that values competent social performance.

These findings imply either that treatment gains accrue at a slower rate for social phobic patients or would be different for treatments conducted over a longer time span, or measured at a later stage (cf. Hunt, 1992). Conversely, in intensive programs, specific cognitions should be targeted more assertively. The question as to whether a person given evidence of specific errors in prediction will improve more rapidly remains an empirical one, of real interest in the treatment of social phobics, if only because of the difficulty of providing this feedback in an acceptable and therapeutic fashion.

Acknowledgements--This research was supported by an Australian Postgraduate Research Award to Dr Richie Poulton. The authors would like to thank Dr Lorna Peters for helpful comments on an earlier draft of this paper.

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