Development of exposure-based treatments has marked a breakthrough in psychosocial treatment of anxiety disorders: 60-75% of agoraphobics and obsessive-compulsives show good improvement. However, residual disability generally remains, and these figures ignore the problems of treatment refusal, drop-out, and relapse. Attempts to explain the highly variable outcome have yielded few cross-validated findings. The one exception is marital dissatisfaction, which often shows substantial correlations with poor status at follow-up for agoraphobics. Preliminary data indicate that relatives' perceptions of, and responses to obsessive-compulsives contribute strongly to prediction of relapse. Such findings warrant a more careful exploration of the effects of the family environment on exposure outcome. Expressed Emotion (EE), defined as relatives' criticism of, and/or emotional over-involvement with the patient, has consistently predicted relapse for schizophrenics and depressed patients when patients returned to high EE homes after treatment. The purpose of the proposed studies is twofold: (a) to extend the prediction research on EE to severe anxiety disorders, and (b) to explore the construct of EE, as assessed by the Camberwell Family Interview, with this population. Fifty patients with panic disorder with agoraphobia and 50 with obsessive-compulsive disorder and their closest relative(s) will form the study sample. All patients will be behaviorally treated via exposure methods. Pretreatment EE will be examined as a predictor of relapse and change with treatment at 6-months and 1-year follow-up and of treatment drop-out and failure, controlling for likely confounding variables. Possible contributors to EE or to its effects on patients' symptoms will be explored through correlational analyses of EE with variables such as relatives' verbal and nonverbal behavior during interactions with the patients as scored by the Kategoriensystem fuer partnerschaftliche Interaktion (KPI); relatives' attributions concerning the patient's disorder; patients' perceptions of relatives' criticalness; and patients' and relatives' psychopathology. This information will provide findings which may guide the development of family treatment interventions to be added to exposure treatment for severe anxiety disorders.
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