The effects of distraction during exposure to phobic stimuli

doi:10.1016/0005-7967(93)90106-5

Behaviour Research and Therapy

Volume 31, Issue 6, July 1993, Pages 549-558

https://doi.org/10.1016/0005-7967(93)90106-5 Get rights and content

Abstract

Theoretical conceptualizations regarding the role of attentional focus during exposure-based treatments for fear and anxiety suggest that distraction interferes with the mechanisms required for fear reduction, typically by preventing emotional and/or cognitive processing of the phobic stimulus and response. The present discussion reviews the current literature and demonstrates the paucity of empirical evidence supporting such notions. Seemingly conflicting findings are integrated upon close examination of the various qualitative dimensions of the distracters employed. These characteristics, which differed substantially across studies, include the nature of the attentional demand posed by the distracter (e.g. cognitive vs sensory demand) as well as the distracter's affective quality (e.g. neutral vs relaxing). The effects of differing dimensions of distraction on fear reduction, in addition to interaction with aspects of the exposure situation, are discussed. The need for further investigation of the qualitative dimensions of distraction, including their operational specification, is recognized. Finally, recommendations for future research are made.

References (52)

A. Arntz et al.
Attention, not anxiety, influences pain
Behaviour Research and Therapy
(1991)
M. Baum
Distraction during flooding (exposure): concordance between results in animals and man
Behaviour Research and Therapy
(1987)
M.G. Craske et al.
Instructions to focus upon or distract from internal cues during exposure treatment of agoraphobic avoidance
Behaviour Research and Therapy
(1989)
M.G. Craske et al.
Attention versus distraction during in vivo exposure: Snake and spider phobias
Journal of Anxiety Disorders
(1991)
J.B. Grayson et al.
Habituation during exposure treatment: distraction versus attention- focusing
Behaviour Research and Therapy
(1982)
J.B. Grayson et al.
Exposure in vivo of obsessive-compulsives under distracting and attention-focusing conditions: Replication and extension
Behaviour Research and Therapy
(1986)
S.J. Rachman
Emotional processing
Behaviour Research and Therapy
(1980)
S.J. Rachman
Agoraphobia: a safety-signal perspective
Behaviour Research and Therapy
(1984)
S.J. Rachman
The return of fear: review and prospect
Clinical Psychology Review
(1989)
S.J. Rachman et al.
The overprediction of fear
Clinical Psychology Review
(1988)

S.J. Rachman et al.

Synchrony and desynchrony in fear and avoidance

Behaviour Research and Therapy

(1974)

S.J. Rachman et al.

Panics and their consequences

Behaviour Research and Therapy

(1985)

S.J. Rachman et al.

Match and mismatch in the prediction of fear—I & II

Behaviour Research and Therapy

(1986)

S.J. Rachman et al.

Experimental analyses of panic III—claustrophobic subjects

Behaviour Research and Therapy

(1988)

S.J. Rachman et al.

Experimental analyses of panic II—panic patients

Behaviour Research and Therapy

(1988)

S. Rachman et al.

Does escape behavior strengthen agoraphobic avoidance? A replication

Behavior Therapy

(1986)

O. Van Den Bergh et al.

Brief exposure to fear stimuli: Imagery ability as a condition of fear enhancement and fear decrease

Behavior Therapy

(1989)

F.N. Watts

Desensitization as an habituation phenomenon: I. Stimulus intensity as a determinant of the effects of stimulus lengths

Behaviour Research and Therapy

(1971)

F.N. Watts

The control of spontaneous recovery of anxiety in imaginal desensitization

Behaviour Research and Therapy

(1974)

K.D. Allen et al.

Videotaped modeling and film distraction for fear reduction in adults undergoing hyperbaric oxygen therapy

Journal of Consulting and Clinical Psychology

(1989)

A. Bandura

Self-efficacy: toward a unifying theory of behavioral change

Psychological Review

(1977)

A. Bandura

Self-efficacy conception of anxiety

Anxiety Research

(1988)

D.H. Barlow

Causes of sexual dysfunction: the role of anxiety and cognitive interference

Journal of Consulting and Clinical Psychology

(1986)

D.H. Barlow

Anxiety and its disorders: The nature and treatment of anxiety and panic

(1988)

R.J. Barry et al.

Heart rate deceleration is not an orienting reflex; heart rate acceleration is not a defensive reflex

The Pavlovian Journal of Biological Science

(1985)

T.D. Borkovec et al.

Consequence of increasing the functional impact of internal emotional stimuli

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Too little, too much, or just right? Does the amount of distraction make a difference during contamination-related exposure?
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Citation Excerpt :
Given these discrepant results, it is important to investigate specific factors that may influence outcome. Although several aspects may be relevant, one potentially important factor relates to the level of difficulty (i.e., cognitive load) of the distraction tasks (e.g., Kamphuis & Telch, 2000; Podină, Koster, Philippot, Dethier, & David, 2013; Rodriguez & Craske, 1993, 1995; Telch et al., 2004). Studies investigating distraction use during exposure have employed a wide variety of tasks with differing levels of complexity.
The extant literature has shown mixed results regarding the impact of distraction use on exposure outcome; however, a wide variety of distraction tasks have been utilized across studies. In order to better understand these discrepant findings, we aimed to evaluate the impact of differing levels of distraction on exposure outcome. Additionally, treatment acceptability and changes in self-efficacy were assessed to evaluate how these may differ as a function of distraction use.
In Experiment 1 (N = 176 participants tested), distraction tasks were experimentally validated through assessing changes in reaction time when completing concurrent tasks. Based on Experiment 1, distraction tasks were selected for use in Experiment 2, in which contamination-fearful participants were randomly assigned to one of four conditions: no, low, moderate, or high distraction during an exposure session. Participants (N = 124) completed a behavioural approach test and self-efficacy measure pre- and post-exposure and at one-week follow-up. Treatment acceptability was assessed immediately following the exposure session.
There were no significant differences between conditions for changes in behavioural approach pre-to post-exposure or at one-week follow-up. However, increases in self-efficacy pre-to post-exposure were greatest for moderate distraction, and treatment acceptability was highest with moderate and high distraction.
Participants were not assessed for clinical severity, were not treatment-seeking, and only one specific type of fear was investigated.
Distraction (at any level) did not appear to negatively impact exposure outcome (all conditions improved pre-to post-exposure and at follow-up), but utilizing moderate to high amounts of distraction increased treatment acceptability.
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In this chapter we summarize the differences between pharmacological and psychosocial treatments for social anxiety disorder (SAD). Using empirical evidence we first describe both psychosocial and pharmacological treatments used, their effectiveness, and their advantages and disadvantages. Though practitioners may utilize many treatments, we limit our discussion to those with empirical support. Then, using data from meta-analyses and individual trials, we compare both treatment modalities (alone and in combination). After discussing both treatment options, we turn to learning theory and translational research and present data on novel pharmacological and psychosocial treatments guided by this research. Finally, we describe how these findings may affect clinical practice.
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Over the last 30 years, researchers have disagreed over the consequences of diverting attention from threat for exposure efficacy, which is an important theoretical and clinical debate. Therefore, the present meta-analysis assessed the efficacy of attentionally focused exposure against distracted and attentionally uninstructed exposure regarding distress, behavioral, and physiological outcomes. We included 15 randomized studies with specific phobia, totaling 444 participants and targeting outcomes at post-exposure and follow-up. Results indicated no difference between the efficacy of distracted exposure as opposed to focused or uninstructed exposure for distress and physiology. For behavior, at post-exposure, results were marginally significant in favor of distracted as opposed to focused exposure, while at follow-up results significantly favored distraction. However, concerning behavior, uninstructed exposure was superior to distraction. Moderation analyses revealed that, regarding distress reduction and approach behavior, distracted exposure significantly outperformed focused exposure when the distracter was interactive (g = 1.010/g = 1.128) and exposure was spread over the course of multiple sessions (g = 1.527/g = 1.606). No moderation analysis was significant for physiological measures. These findings suggest that distraction during exposure could be less counterproductive than previously considered and even beneficial under certain circumstances. Theoretical implications and future directions for research are discussed.
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This chapter summarizes the data to date comparing pharmacological and psychosocial treatments for social anxiety disorder (SAD). It begins by briefly describing the pharmacological and psychosocial treatments of choice and support for their efficacy. The discussion is primarily of those treatments with significant empirical support. Following this, the chapter presents data from metaanalyses and individual trials comparing both treatment modalities (alone and in combination). Data on novel pharmacological and psychosocial treatment combinations that are born from learning theory and translational research are also presented. Finally, the chapter describes how these findings may affect clinical practice. In short, pharmacotherapy, psychosocial treatment, and their combination offer roughly equivalent outcomes overall. Thus, decisions to employ one strategy over the other must rely on other factors (cost, side-effects, and long-term outcome).
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What, exactly, do individuals with social phobia fear? Whereas fear of anxiety-related bodily sensations characterizes and defines panic disorder, is there a fundamental focus of anxiety that unifies individuals under the diagnostic category of social phobia? Current conceptualizations of social phobia suggest several possible candidates, including the fear of negative evaluation, embarrassment, and loss of social status. However, it is argued here that these conceptualizations are fundamentally flawed and confusing, and the lack of clarity with respect to this question has hampered our ability to conceptualize and treat patients with social phobia in a manner that is tailored to individual differences in symptom presentation. In the present article, I will propose a novel conceptualization of core fear in social phobia, demonstrate how this conceptualization can be used to classify individuals with social phobia in a manner that eliminates confusion and accounts for symptom heterogeneity, and illustrate its potential utility for both clinical practice and research.
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Cognitive-behavioral theory suggests that anxiety-control strategies such as neutralization, distraction and various forms of safety behavior have the potential to diminish the effectiveness of and/or interfere with exposure treatment. Yet, it is common practice when treating individuals with anxiety disorders to employ various anxiety-control strategies as a means of assisting clients/patients with difficult exposure situations. Questions surrounding the issue of which anxiety-control strategies help vs. hinder exposure-based treatments (and under which circumstances) have been a topic of much investigation and continue to be a focus of theoretical debate. The present article reviews several key studies which collectively shed some light on this debate. The evidence suggests that clients' anxiety-control strategies may be less likely to become counter-productive when: (i) they promote increases in self-efficacy, (ii) they do not demand excessive attentional resources, (iii) they enable greater approach behavior and integration of corrective information (via ‘disconfirmatory experiences’), and (iv) they do not promote misattributions of safety. Theoretical and clinical implications of these findings are discussed, and future directions for research in this area are suggested.

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The effects of distraction during exposure to phobic stimuli

Abstract

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Anxiety Disorders

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Clinical Psychology Review

Clinical Psychology Review

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behavior Therapy

Behavior Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Videotaped modeling and film distraction for fear reduction in adults undergoing hyperbaric oxygen therapy

Journal of Consulting and Clinical Psychology

Self-efficacy: toward a unifying theory of behavioral change

Psychological Review

Self-efficacy conception of anxiety

Anxiety Research

Causes of sexual dysfunction: the role of anxiety and cognitive interference

Journal of Consulting and Clinical Psychology

Anxiety and its disorders: The nature and treatment of anxiety and panic

Heart rate deceleration is not an orienting reflex; heart rate acceleration is not a defensive reflex

The Pavlovian Journal of Biological Science

Consequence of increasing the functional impact of internal emotional stimuli