E&r. Res. Thrr. Vol. 32. No. 6, pp. 643-645, 1994 Copyright 0 1994 Elsevier Science Ltd

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Proximity and anticipation of a negative outcome in phobias

GAVIN ANDREWS,* SHARON FREED and MAREE TEFSSON

Clinical Research Unit For Anxiety Disorders, University of New South Wales at St Vincent’s Hospital, 299 Forbes St, Darlinghurst, NS W 2010, Australia

(Received 22 July 1993)

Summary-Thirty-five patients being treated for one of three anxiety disorders were asked to rate the likelihood of a negative outcome prior to entering a feared situation, while in the situation and after leaving the situation. Ratings made in anticipation were consistently higher than ratings made either in the situation or after leaving it. In contrast, normal Ss, about to undertake tourist rides perceived as being mildly dangerous, rated the likelihood of negative outcome as highest when actually in the situation.

INTRODUCTION

In a phobic individual “the tendency to think in absolute, extreme terms increases as one approaches the danger situation” (Beck & Emery, 1985, p. 34). Such a response to danger seems logical, the immediacy and magnitude of the danger determining the extent of anticipatory worrying. Williams and Watson (1985) found partial support for this position when height phobics estimated an increased probability of falling from being on the ground and at balcony railings at increasing heights in a IO-storey building. Our experience with phobic patients in a cognitive-behaviour therapy program (Andrews & Moran, 1988) has been different, in that they often resist embarking on graded exposure tasks because of fear, and yet when they finally enter the situation, find themselves much less apprehensive than they had expected to be. If this observation is confirmed by systematic investigation, it would mean that avoidance behaviour is driven more by anticipatory anxiety than by actual fear in the phobic situation, and therefore that anticipatory anxiety is likely to be an important issue in the maintenance and treatment of phobias.

METHOD

Subjects

The diagnosis of 35 patients referred for treatment of phobias was established by clinical interview and then confirmed using the Composite International Diagnostic Interview scored for DSM-III-R. There were 17 patients who met criteria for panic disorder with agoraphobia, 11 with social phobia and 7 with panic disorder without avoidance who met criteria for height phobia and judged the height phobia to be independent of their panic disorder. The non-phobic control Ss were recruited from persons waiting to take one of two tourist rides which are often reported to cause anxiety in non-phobic people.

Procedure

We asked each S to rate on a questionnaire scale of 1-8 (‘very unlikely’ to ‘very likely’) the probability of a specified negative outcome. Each task and rated negative outcome was diagnosis dependent, being targeted to both the situation and central reason for avoidance in each phobia, and to the possible danger for the control group. Even though the questions differed from group to group they were constant for any individual, so that each individual acted as their own control across the measurement occasions.

Patients in the agoraphobic group were sent alone on specified bus or train trips and asked to rate the probability that they would “have a heart attack, lose control or collapse”. The social phobic patients were asked to undertake specified speaking or eating tasks in front of strangers and asked to rate the probability that they would feel “silly and embarrassed and be noticed to be so by other people”. The height phobics were asked to climb a specified distance up a ladder and asked to rate the probability of “falling and sustaining serious injury”. The questionnaire was completed just prior to entering the situation, while in the situation, and then just after leaving the situation, in all cases within a 20-min time span.

Part of the non-phobic control group was chosen from people queueing to ride an aerial gondola over a ravine. This sample of convenience was asked while waiting, while in the gondola and when on the other side of the ravine to rate the probability that “the car will fall off the cable or get stuck over the ravine ?” The remainder of the control group were queueing for an elevator up a high observation tower. They were asked before, during and after the ride to rate the probability that “the elevator will get stuck and you will be trapped?” Thus, the questions to the control group were about conceivable malfunctions that could be dangerous and were also taken over a 20-min period.

RESULTS

All three phobic groups rated the probability of a negative outcome higher prior to entering the situation than while in it [social phobic group 4.9 (SD = 1.6). 3.9 (SD = 1.2); agoraphobic group 2.9 (SD = 1.8), 2.5 (SD = 1.6); height phobic

*Author for correspondence.

643

644 CASE HISTORIES AND SHORTER COMMUNlCATIONS

8

7 E t

6 t

Q BOCIALPHB + AGPHB +- HEIGHTPHB -0 CONTROL

t_; 3 4 5

Fig. I. The rated mean likelihood of a negative o%c!kT?s three groups of phobic patients (n = 35) encountered a phobic situation and 20 non-phobic controls encountered a situation perceived as mildly

dangerous.

group 4.0 (SD = 2.5) 1.3 (SD = 0.5)]. The non-phobic Ss rated the probability of a negative outcome lower prior to entering the situation than while in it [I.9 (SD = 0.9) 2.3 (SD = 1.7)]. The data for all four groups before entering, while in and after leaving the situation are displayed in Fig. 1.

These data were analysed using a repeated-measures MANOVA. There was a significant interaction effect between group and time for the three phobic groups compared to the non-phobic group [F(1,50) = 12.18, P < O.OOl] and for the social phobic and height phobic groups compared to the non-phobic group [F(l,50) = 7.70, P i 0.01 and F(1,50) = 11.18, P < 0.005, respectively]. There was no significant interaction effect for the agoraphobic group vs the non-phobic group. The non-phobic group scores described a quadratic trend [F(l,l9) = 4.83, P -c 0.051.

DISCUSSION

The hypothesis that the prediction of a negative outcome would increase with increasing proximity to the feared situation, was true in the case of normal Ss but not true for the phobic groups, for in these groups the probability of a negative outcome was rated higher prior to entering the situation than when in it or after leaving it. Compared to the non-phobic group the differences were significant for the social and height phobic groups. They were not significant for the agoraphobic group even though the overall finding was supported. Further work is needed to determine whether the agoraphobic finding is a type 2 error. There are a number of caveats. Rather than have a common situation that may have been relevant to all groups we chose to target the special fears and situations avoided by each patient group, for those fears and situations had generated the hypothesis that anticipatory fears were higher than fear in the situation. The non-phobic control Ss were recruited while they waited for the tourist ride. We presumed correctly that the gondola and elevator ride were both situations that would elicit mild fears in the majority of the population.

Why do phobic patients overestimate the risk prior to entering the situation? Butler and Mathews (1983) have shown that anxious individuals are particularly prone to cognitive errors and overestimate the personal risk in an ambiguous situation. Similarly, Wardle (1984) showed that fearful patients have inaccurate and fearful expectations of dental procedures, and Rachman, Lopatka and Levitt (1988) showed that a high proportion of panic patients overestimated the fear they would experience. Rachman and Bichard (1988) concluded that the overprediction of fear is common, especially among fearful people. We have presented data elsewhere to show that the patients in the present study have high levels of trait anxiety (Andrews, Pollock & Stewart, 1989) and hence are likely to be ‘fearful people’.

There are some data on changes in overprediction with increasing proximity to the feared event or situation. Students rated negative events more likely as exams approached (Butler & Mathews, 1987). and in the only report on a patient group that systematically explored the proximity issue, Williams and Watson (1985) showed that simple height phobics rated the likelihood of falling as increasing as they moved towards the balcony railing. The height phobics in the present study behaved differently but the difference may be explained because, as they were panic patients as well, they could be expected to overpredict the risk (Rachman er al., 1988).

The present data are replicated in the companion paper (Poulton & Andrews, 1994, this issue, pp. 63942) in which phobic and non-phobic groups approach and perform a task of the same salience. If phobic individuals are most anxious at the prospect rather than the actuality of entering a feared situation then unless they enter the situation they will nevers learn that the situation is actually less fear-provoking than they predicted. It is therefore no surprise that exposure therapy, which initially appears counter-intuitive, is so efficacious at gradually reducing the overprediction of fear. On the basis of the present study and from our previous work (Andrews & Moran, 1988; Franklin, 1990; Mattick, Peters & Clarke, 1989), cognitive procedures, aimed at the control of anticipatory anxiety by reducing irrational thinking, are also important in enabling patients to contain their anticipatory anxiety sufficiently to facilitate them entering the situations they fear.

CASE HISTORIES AND SHORTER COMMUNICATIONS 645

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