Journal of Behavior Therapy and Experimental Psychiatry
The effects of acceptance versus control contexts on avoidance of panic-related symptoms
Introduction
Although individuals with anxiety disorders typically avoid situations and stimuli that have been associated with panic (Barlow, 2002), clinical researchers are now focusing on experiential avoidance, a more general type of avoidance. Experiential avoidance refers to an individual's attempts and efforts to avoid, suppress, or otherwise alter the form of negatively evaluated private events such as bodily sensations, emotions, thoughts, and memories (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). For instance, a person with agoraphobia not only avoids public places but also avoids experiencing thoughts and emotions associated with panic in these places (Friman, Hayes, & Wilson, 1998). When avoidance is not or no longer possible, a person may then resort to actual escape behavior (Forsyth & Eifert, 1996). The function of experiential avoidance is to control or minimize the impact of aversive experiences.
Clients typically consider avoidance and escape behavior to be the solution rather than the problem. As a consequence, many clients are apprehensive about cognitive-behavioral exposure-based strategies that target avoidance behavior and encourage clients to approach feared situations and experience fearful emotions (Barlow & Craske, 1994). Client receptivity of this strategy might be enhanced by employing techniques from recently developed acceptance-based approaches in behavior therapy (e.g., Hayes, Strosahl, & Wilson, 1999; Roemer & Orsillo, 2002; Teasdale, Segal, & Williams, 1995). These approaches attempt to alter the impact of fear emotions and cognitions by teaching clients to “let go of their struggle” through the use of techniques aimed at reducing avoidance of experiencing anxiety rather than reducing anxiety per se.
Metaphors are one technique to help patients learn to mindfully observe and accept negatively valenced cognitive-affective responses. Metaphors employ figurative language to synthesize emotionally relevant experiences in a nonconfrontative and nonthreatening way. They help people recognize their behavioral and emotional problems and point to possible, frequently unexpected, behavioral alternatives (Heffner, Greco, & Eifert, 2003; McCurry & Hayes, 1992; Otto, 2000). Metaphorical stories may also indirectly suggest contingencies, in which acceptance is reinforced and emotional avoidance and control is punished. For instance, the futility of fighting with one's own thoughts and feelings has been likened to being in a tug of war with oneself where “good” thoughts attempt to fight “bad” thoughts (Hayes et al., 1999; Heffner & Eifert, 2004). The harder one team pulls, the harder the other team pulls back. Such a tug of war is exhausting and can never be won because both teams belong to the client. Rather than continuing this senseless fight, the metaphor suggests an acceptance solution that clients typically do not think of, which is to end the fight in an instant by simply dropping the rope. All team members would still be there and clients could observe and stay with their thoughts and feelings simply watching them come and go.
Preliminary studies indicate that acceptance techniques produce an overall decrease in clinically significant affective disturbance, particularly interoceptive-oriented distress, over short as well as protracted time periods (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Strosahl, Hayes, Bergan, & Romano, 1998; Teasdale et al., 1995). One treatment program (Kabat-Zinn et al., 1992) that emphasized mindful observation of symptoms in a group of 22 patients with various anxiety disorders found positive effects after treatment completion which were maintained three years later (Miller, Fletcher, & Kabat-Zinn. 1995).
An acceptance rationale is also supported by research suggesting that client attempts to control anxiety may have negative paradoxical effects (Ascher, 1989). For example, Wegner (1994) found that attempts to control anxiety in the face of ongoing stress exacerbate physiological arousal. Increased tension during relaxation training was also reported in a study by Heide and Borkovec (1983). Likewise, studies suggest that adding slow diaphragmatic breathing (“BR”) might not increase the effectiveness of interoceptive exposure treatment for PD (Craske, Rowe, Lewin, & Noriego-Dimitri, 1997) and even lead to poorer outcomes compared to treatment without BR (Schmidt et al., 2000).
In a more general way, active coping efforts that attempt to minimize the experience of anxiety may (paradoxically and unintentionally) maintain pathological anxiety and increase the anxiogenic effects of interoceptive stimulation (Craske, Street, & Barlow, 1989). For instance, Spira, Zvolensky, Eifert, and Feldner (2002) found that avoidant coping strategies (e.g., denial, mental disengagement, substance abuse) predicted more frequent and intense CO2-induced physical and cognitive panic symptoms than acceptance-based coping strategies. These findings are consistent with earlier studies showing that attempts to avoid aversive private events are largely ineffective and may be counterproductive (Cioffi & Holloway, 1993; Pennebaker & Beall, 1986).
We recently examined the effects of suppression versus acceptance on response to an anxiety-producing CO2 challenge in persons scoring either high or low on a measure of emotional avoidance (Feldner, Zvolensky, Eifert, & Spira, 2003). Half of the participants were instructed to inhibit the challenge-induced aversive emotional state, whereas the other half was instructed to simply observe their emotional response. Individuals high in emotional avoidance responded with greater levels of anxiety and affective distress, but not physiological arousal, when attempting to suppress compared to observing bodily sensations. No such difference was found in the low emotional avoidance group. Further strong evidence that experiential avoidance exacerbates aversive emotional responses and may constitute a risk factor in the development and maintenance of anxiety disorders comes from a recent experiment by Karekla, Forsyth, and Kelly (in press). After several trials of inhaling CO2 enriched air, individuals high in experiential avoidance endorsed more panic symptoms, more severe cognitive symptoms, and more fear, panic, and uncontrollability than their less avoidant counterparts. Interestingly, as in all our studies, the magnitude of autonomic responses did not discriminate between groups.
Based on the acceptance rationale that was examined in a pain context (Hayes, Bissett, Korn, Zettle, & Rosenfarb, 1999), we wanted to assess whether creating an acceptance context compared to a control context leads to less behavioral avoidance and self-reported anxiety in highly anxiety sensitive individuals. Anxiety sensitivity is an individual difference dimension referring to the fear of arousal-related bodily sensations based on the belief that such sensations have negative somatic or social consequences (Reiss, Peterson, Gursky, & McNally, 1986). For example, if persons believe bodily sensations are a sign of imminent personal harm, they will likely experience elevated levels of anxiety when confronted with somatic perturbation. We chose to examine highly anxiety sensitive individuals because a diminished sense of control over terminating bodily sensations is particularly anxiety-provoking for individuals that already fund such somatic sensations aversive (Zvolensky, Eifert, & Lejuez, 2001). Studies also indicate that anxiety sensitivity may act as a specific vulnerability variable in the development of panic attacks (Donnell & McNally, 1990; Schmidt, Lerew, & Jackson, 1999), is elevated among persons with panic disorder (Taylor, Koch, & McNally, 1992), predicts anxious responding to biological challenge independent of other risk variables (Zvolensky & Eifert, 2001), and has been associated with greater avoidance in individuals with pain-related fear (Asmundson & Taylor, 1996).
In the current study, we focused on avoidance because it is a core aspect of anxiety disorders and can be readily measured in terms of duration and frequency (Eifert & Wilson, 1991). We measured avoidance as latency to begin inhaling CO2-enriched air. Inhalation of CO2-enriched air functions as an unconditioned stimulus that individuals work to avoid (Lejuez, O’Donnell, Wirth, Zvolensky, & Eifert, 1998) and reliably produces episodes of autonomic arousal including shortness of breath, tachycardia, sweating, and dizziness (Forsyth, Eifert, & Thompson, 1996) As such, it is suitable as an experimental panic provocation strategy and anxiety analogue (Zvolensky & Eifert, 2001).
We hypothesized that creating an acceptance context, rather than a context emphasizing symptom control, would lead to less avoidance and subjective anxious responding. Although there is not much research suggesting specific differences between control context versus uninstructed participants, we suspected that attempts to control essentially uncontrollable symptoms might have paradoxical negative effects (Ascher, 1989; Hayes et al., 1996), and increase avoidance and anxiety in control context compared to no-instructions participants. Physiological measures were included as a “manipulation check” to ensure that all groups experienced similar and sufficient levels of physiological responding.
Section snippets
Participants
We screened 482 female undergraduates by administering the Anxiety Sensitivity Index (ASI). We also administered a medical screening questionnaire routinely employed in our laboratory (Forsyth & Eifert, 1998). This questionnaire asks participants to indicate whether they had any medical problems such as heart disease, epilepsy or a seizure disorder, hypertension, or lung disorders (e.g., emphysema). We also asked them to report any personal history of psychopathology, including panic attacks
Behavioral avoidance measures
We analyzed the latency to begin each trial using group×time analysis of variance (ANOVA). All significant interaction effects were tested by examining simple effects using the Bonferroni correction procedure to control for family wise error rate (0.05/number of comparisons, Keppel, 1991). The other avoidance measures (drop-out, return visit) were analyzed separately using a Chi-square statistic.
Self-report measures
Using ANOVA we first examined pre-experimental questionnaire data to determine whether the
Discussion
The aim of this study was to compare the effects of creating an acceptance versus control context during aversive interoceptive stimulation. Consistent with our hypothesis, acceptance context participants, compared to control context participants, began the final CO2 trial sooner and were more likely to return for a similar study. Control context participants took progressively longer to begin the trials. In fact, control context participants may have taken progressively longer to initiate
Acknowledgements
The authors wish to thank John Forsyth, Kevin Larkin, and Kent Parker for their helpful comments on the manuscript. We also appreciate the technical assistance of Qamer Zia Malik and Robert Phipps and acknowledge the contributions of Ibtissam Bouachrine, Jonathan Burnworth, Nicole Hipple, Jennifer Summers, Loren Tenney, Kristen Tennis, Matthew Feldner, Carl Lejuez, Adam Spira, and Michael Zvolensky.
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