This is a competing renewal proposal comprised of two major components. The primary objective of the first study is to conduct a longitudinal follow-up of agoraphobics treated in the previous NIMH-protocol consisting of behavioral (Flooding), cognitive (Paradoxical Intention) and physiologically-based (Relaxation Training) treatments. The role of individual differences, response profiles, stressful life events, and marital adjustment will be examined with regard to synchrony/desynchrony, concordance/disconcordance, maintenance, relapse, need for interim treatment and booster sessions, and treatment generalization across the tridimensional systems. Moreover, the clinical and social significance of the treatments, on a long-term basis, will be examined by comparing the treated subjects to normative, non-phobic cohorts. The second major aim of the competing renewal proposal is to undertake a comparative outcome study of highly promising combined treatment strategies consisting of Cognitive Therapy plus Flooding, Relaxation Training plus Flooding vs. Flooding alone. Although Flooding may be a necessary condition in the effective treatment of agoraphobia, its overall efficacy does not exceed 50% if non-responders and drop-outs are considered. Flooding cannot be regarded as a panacea for agoraphobia, and recent research suggests that the addition of congnitive mediational strategies and/or psycho-physiologically-based self-control coping strategies may significantly enhance efficacy, synchrony, tolerability and maintenance of treatment effects for this disorder, which is estimated to afflict 5-11 million Americans. Thus, this outcome study will examine the differential efficacy of combining cognitive and physiologically-based treatments with Flooding and examine possible differential response patterns across the tripartite channels of cognition, behavior and psychophysiology. The second objective is to monitor criteria such as drop-out, attrition and relapse rates and the need for booster sessions as an integral component of treatment outcome. Seventy-two agoraphobics would be randomly assigned to one of the three conditions with treatment consisting of 18 three-hour sessions in groups of four lead by protocol therapists whose treatment integrity would be objectively monitored. Subjects would complete a comprehensive assessment battery at pre, mid, and post-treatment and 3, 6, 12 and 24-month follow-up phases. The proposed objective would address a number of unique, promising and critical areas of clinical-research in agoraphobia and related anxiety disorders.
