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Aim: The present study is a comparative case study as part of research on the psychotherapeutic process. This research describes the perception of subjective time in two psychotherapeutic processes, one successful and one unsuccessful., Methods: We studied two psychotherapeutic processes of cognitive orientation, which were video recorded and fully transcribed in each session. First a qualitative analysis was applied for quality coding (Top-down) was performed to identify category types of subjective time, depending on psychological well-being. These were categorized as past, present, and future; each one in positive and negative forms. Secondly, two quantitative statistical analyses were applied: one of content analysis, which allowed us to observe the frequencies for the six categories, and another, a cumulative frequency analysis, which allowed us to identify a differential pattern in the analyzed cases., Results: These data showed different temporal profiles for both cases, differentiated by categories. This finding that would allow us to track the process of subjectivity in terms of specific components associated with psychotherapy success., Discussion and Conclusions: We present a mixed method, a qualitative for initial coding of patient speaking turns and a quantitative methodology such as the cumulative frequency analysis in time in a therapeutic context. Those changes are progressive and must be observed as a continuous and dynamic evolution to allow for an interpretation in a naturalistic context.

Introduction: Cognitive behavioural therapy (CBT) and pharmacological treatment with selective serotonin or serotonin-noradrenalin reuptake inhibitors (SSRI/SSNRI) are regarded as efficacious treatments for panic disorder with agoraphobia (PD/AG). However, little is known about treatment-specific effects on symptoms and neurofunctional correlates., Experimental Procedures: We used a comparative design with PD/AG patients receiving either two types of CBT (therapist-guided (n=29) or non-guided exposure (n=22)) or pharmacological treatment (SSRI/SSNRI; n=28) as well as a wait-list control group (WL; n=15) to investigate differential treatment effects in general aspects of fear and depression (Hamilton Anxiety Rating Scale HAM-A and Beck Depression Inventory BDI), disorder-specific symptoms (Mobility Inventory MI, Panic and Agoraphobia Scale subscale panic attacks PAS-panic, Anxiety Sensitivity Index ASI, rating of agoraphobic stimuli) and neurofunctional substrates during symptom provocation (Westphal-Paradigm) using functional magnetic resonance imaging (fMRI). Comparisons of neural activation patterns also included healthy controls (n=29)., Results: Both treatments led to a significantly greater reduction in panic attacks, depression and general anxiety than the WL group. The CBT groups, in particular, the therapist-guided arm, had a significantly greater decrease in avoidance, fear of phobic situations and anxiety symptoms and reduction in bilateral amygdala activation while the processing of agoraphobia-related pictures compared to the SSRI/SSNRI and WL groups., Discussion: This study demonstrates that therapist-guided CBT leads to a more pronounced short-term impact on agoraphobic psychopathology and supports the assumption of the amygdala as a central structure in a complex fear processing system as well as the amygdala's involvement in the fear system's sensitivity to treatment., (Copyright © 2016 Elsevier B.V. and ECNP. All rights reserved.)

Adaption to changing environments is evolutionarily advantageous. Studies that link genetic and phenotypic expression of flexible adjustment to one's context are largely lacking. In this study, we tested the importance of psychological flexibility, or goal-related context sensitivity, in an interaction between psychotherapy outcome for panic disorder with agoraphobia (PD/AG) and a genetic polymorphism. Given the established role of the 5HTT-LPR polymorphism in behavioral flexibility, we tested whether this polymorphism (short group vs. long group) impacted therapy response as a function of various endophenotypes (i.e., psychological flexibility, panic, agoraphobic avoidance, and anxiety sensitivity). Patients with PD/AG were recruited from a large multicenter randomized controlled clinical trial on cognitive-behavioral therapy. Pre- to post-treatment changes by 5HTT polymorphism were analyzed. 5HTT polymorphism status differentiated pre- to post-treatment changes in the endophenotype psychological flexibility (effect size difference d = 0.4, p < 0.05), but none of the specific symptom-related endophenotypes consistently for both the intent-to-treat sample (n = 228) and the treatment completers (n = 194). Based on the consistency of these findings with existing theory on behavioral flexibility, the specificity of the results across phenotypes, and the consistency of results across analyses (i.e., completer and intent to treat), we conclude that 5HTT polymorphism and the endophenotype psychological flexibility are important variables for the treatment of PD/AG. The endophenotype psychological flexibility may help bridge genetic and psychological literatures. Despite the limitation of the post hoc nature of these analyses, further study is clearly warranted.

Variation in the 5'-flanking promoter region of the serotonin transporter gene SLC6A4, the 5-HTT-linked polymorphic region (5-HTTLPR) has been inconclusively associated with response to cognitive-behavioural therapy (CBT). As genomic functions are stronger related to neural than to behavioural markers, we investigated the association of treatment response, 5-HTTLPR and functional brain connectivity in patients with panic disorder with agoraphobia (PD/AG). Within the national research network PANIC-NET 231 PD/AG patients who provided genetic information underwent a manualized exposure-based CBT. A subset of 41 patients participated in a functional magnetic resonance imaging (fMRI) add-on study prior to treatment applying a differential fear conditioning task. Neither the treatment nor the reduced fMRI sample showed a direct effect of 5-HTTLPR on treatment response as defined by a reduction in the Hamilton Anxiety Scale score ≥50 % from baseline to post assessment. On a neural level, inhibitory anterior cingulate cortex (ACC)-amygdala coupling during fear conditioning that had previously been shown to characterize treatment response in this sample was driven by responders with the L/L genotype. Building upon conclusive evidence from basic and preclinical findings on the association of the 5-HTTLPR polymorphism with emotion regulation and related brain connectivity patterns, present findings translate these to a clinical sample of PD/AG patients and point towards a potential intermediate connectivity phenotype modulating response to exposure-based CBT.

This study was intended to assess the extent to which the low-expression allele of the serotonin transporter gene promoter predicts better response to exposure-based behavior therapy in patients with panic disorder with agoraphobia (PDA). Ninety-nine patients with PDA underwent a 1-week in vivo exposure-based behavior therapy program and provided saliva samples to extract genomic DNA and classify individuals according to four allelic forms (SA, SG, LA, LG) of the 5-HTT-linked polymorphic region (5-HTTLPR). We determined whether the 5-HTTLPR genotype predicted change in avoidance behavior in PDA following treatment. After controlling for pre-treatment avoidance behavior, the 5-HTTLPR low-expression genotypes showed a more favorable response to exposure therapy two weeks following treatment, compared to the other patients. This study suggests a genetic contribution to treatment outcome following behavior therapy and implicates the serotonergic system in response to exposure-based treatments in PDA., (Copyright © 2014 Elsevier B.V. and ECNP. All rights reserved.)

Panic disorder with agoraphobia (PD/AG) is a prevalent mental disorder featuring a substantial complex genetic component. At present, only a few established risk genes exist. Among these, the gene encoding monoamine oxidase A (MAOA) is noteworthy given that genetic variation has been demonstrated to influence gene expression and monoamine levels. Long alleles of the MAOA-uVNTR promoter polymorphism are associated with PD/AG and correspond with increased enzyme activity. Here, we have thus investigated the impact of MAOA-uVNTR on therapy response, behavioral avoidance and brain activity in fear conditioning in a large controlled and randomized multicenter study on cognitive behavioral therapy (CBT) in PD/AG. The study consisted of 369 PD/AG patients, and genetic information was available for 283 patients. Carriers of the risk allele had significantly worse outcome as measured by the Hamilton Anxiety scale (46% responders vs 67%, P=0.017). This was accompanied by elevated heart rate and increased fear during an anxiety-provoking situation, that is, the behavioral avoidance task. All but one panic attack that happened during this task occurred in risk allele carriers and, furthermore, risk allele carriers did not habituate to the situation during repetitive exposure. Finally, functional neuroimaging during a classical fear conditioning paradigm evidenced that the protective allele is associated with increased activation of the anterior cingulate cortex upon presentation of the CS+ during acquisition of fear. Further differentiation between high- and low-risk subjects after treatment was observed in the inferior parietal lobes, suggesting differential brain activation patterns upon CBT. Taken together, we established that a genetic risk factor for PD/AG is associated with worse response to CBT and identify potential underlying neural mechanisms. These findings might govern how psychotherapy can include genetic information to tailor individualized treatment approaches.

Objectives: The objectives of this study were to verify the degree of anxiety, respiratory distress, and health-related quality of life in a group of asthmatic patients who have experienced previous panic attacks. Additionally, we evaluated if a respiratory physiotherapy program (breathing retraining) improved both asthma and panic disorder symptoms, resulting in an improvement in the health-related quality of life of asthmatics., Methods: Asthmatic individuals were assigned to a chest physiotherapy group that included a breathing retraining program held once a week for three months or a paired control group that included a Subtle Touch program. All patients were assessed using the Diagnostic and Statistical Manual of Mental Disorders IV, the Sheehan Anxiety Scale, the Quality of Life Questionnaire, and spirometry parameter measurements., Results: Both groups had high marks for panic disorder and agoraphobia, which limited their quality of life. The Breathing Retraining Group program improved the clinical control of asthma, reduced panic symptoms and agoraphobia, decreased patient scores on the Sheehan Anxiety Scale, and improved their quality of life. Spirometry parameters were unchanged., Conclusion: Breathing retraining improves the clinical control of asthma and anxiety symptoms and the health-related quality of life in asthmatic patients.

D-cycloserine (DCS)-augmented exposure therapy has proven efficacy in the treatment of acrophobia, social phobia, panic disorder and OCD. Here we studied whether DCS can also improve the effect of cognitive behavioral therapy (CBT) in patients with agoraphobia and panic disorder. To this end, 39 patients with the diagnoses of agoraphobia and panic disorder were treated with 11 sessions of CBT including three individual in-vivo exposure sessions (flooding), augmented with either 50mg of DCS (N=20) or placebo (N=19) in a randomized double blind design. Primary outcome was the total score of the panic and agoraphobia scale. Both groups profited considerably from therapy and DCS did not significantly improve this outcome (p=0.475; η(2)p = 0.01). However, there was a statistical trend (p=0.075; η(2)p = 0.17) in the more severely ill patients that DCS accelerated symptom reduction in the primary outcome at post-therapy. No serious adverse effects occurred during the trial. We conclude that in patients with agoraphobia and panic disorder, DCS seems to lack an additional benefit to efficient cbt, probably due to a floor effect. Nonetheless, the acceleration of symptom reduction in severely ill patients might represent a valuable treatment option deserving further investigation., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Work is an important domain of life. It is therefore clear that problems at the workplace and mental disorders will have negative interactions. Job-related anxieties are of special importance as any workplace causes or intensifies anxiety by its very nature. A common final pathway of mental disorders in general and workplace-related anxieties in particular is workplace phobia. Similarly to agoraphobia, it is characterised by panic when approaching or even thinking of the stimulus, in this case the workplace. Workplace phobia has serious negative consequences for the further course of illness. It impairs the ability to work, and can lead to sick leave and early retirement. It requires special therapeutic interventions. This paper describes workplace-related anxieties and workplace phobia and gives a conceptual framework for their understanding.

Background: Treated anxiety increased in the UK by over 30% since 1994. Medication and psychological treatment is most common, but outcomes are sometimes poor, with high relapse rates. Lifestyle has a potential role in treatment, but is not considered in clinical guidelines. Panic disorder is potentially influenced by lifestyle factors., Methods: 16 week unblinded pragmatic randomised controlled trial in 15 East of England primary care practices (2 Primary Care Trusts). Participants met DSM-IV criteria for panic disorder with/without agoraphobia. Follow-up at 20 weeks and 10 months. Control arm, unrestricted routine GP care. Trial Arm, Occupational therapy-led lifestyle treatment comprising: lifestyle review of fluid intake, diet pattern, exercise, caffeine, alcohol and nicotine; negotiation of positive lifestyle changes; monitoring and review of impact of changes., Primary Outcome Measure: Beck Anxiety Inventory., Data Analysis: Intention-to-treat analysis provided between-group comparisons using analysis of co-variance. Bonferroni method to adjust p-values., Results: From 199 referrals, 36 GP care and 31 lifestyle arm patients completed to final follow-up. Significantly lower lifestyle arm BAI scores at 20 weeks (p<0.001), non-significant (p=0.167) at 10 months after Bonferroni correction. 63.6% lifestyle arm, and 40% GP arm patients (p=0.045) panic-free at 20 weeks; 67.7% and 48.5% (p=0.123) respectively at 10 months., Limitations: Final study size/power calls for caution in interpreting findings., Conclusions: A lifestyle approach may provide a clinically effective intervention at least as effective as routine GP care, with significant improvements in anxiety compared with routine GP care at the end of treatment. Further study is required before suggesting practice changes.

Objectives: There are no studies available that have examined the factorial invariance of dimensions underlying the Symptom Checklist-90-Revised (SCL-90-R) across at least three distinct samples. In the following study, we wished to determine whether a dimensional model comprising eight primary factors previously identified in psychiatric out-patients, phobics and the general population (Arrindell & Ettema, 2003) could be extended to a homogeneous sample of pain patients comprising females suffering from peri partum pelvic pain (PPPP) syndrome (N = 413). The internal consistency and discriminant validity of the dimensions were also examined., Method: The SCL-90-R and measures of disability, pain-related fear, pain intensity and fatigue were administered to the participants. The multiple group method was used to determine factorial invariance. Pearson correlations were determined between the SCL-90-R and aforementioned measures., Results: The factorial invariance of an 8-dimensional model of primary factors underlying the SCL-90-R, namely, agoraphobia, anxiety, depression, somatization, cognitive-performance deficits, interpersonal sensitivity-mistrust, acting-out hostility and sleep difficulties, was extended with success to the present sample of PPPP patients. In spite of substantial correlations between the internally consistent SCL-90-R symptom dimensions, some evidence of discriminant validity was reported in that specific subscales showed different patterns of correlations with measures of disability, pain-related fear, pain intensity and fatigue., Conclusions: The 8-dimensional system based on the work of Arrindell and Ettema (2003) was invariant across psychiatric patients, phobics, the general population and pain patients. The invariance of the SCL-90-R hostility dimensions may have implications for a re-formulation of Watson and Clark's tripartite model of general distress, specific anxiety and specific depression.

Leisure or recreational rehabilitation is not much developed in psychiatric rehabilitation. I present some definitions and a (very) brief history of the notion of leisure, as well as the role of leisure in health. I then describe a novel classification of leisure activities relevant to people with psychiatric disabilities. Following that, I conceptualize the process of psychiatric leisure rehabilitation, illustrated by a case study. I conclude with the benefits of psychiatric leisure rehabilitation and with suggestions for further study and development in this field. Leisure or recreational activities are central in modern life. Not so for persons who have serious and disabling mental disorders. This is manifest even in psychiatric rehabilitation, which mostly addresses vocational and residential--rather than leisure--environments (Anthony, Cohen, Farkas & Gagne, 2002; Corrigan, 2003). Yet leisure is important for persons with psychiatric disabilities, perhaps especially so for those who are not successful or satisfied in vocational environments. This paper outlines a conceptual framework for psychiatric leisure rehabilitation, based on a novel classification of leisure activities, and illustrates this with a case vignette. But first, some definitions and a (very) brief history of the notion of leisure is in order, as well as a presentation of facts about the role of leisure in health (physical and mental).

This study examined whether physical therapy with vestibular rehabilitation exercises would benefit patients with agoraphobia and vestibular dysfunction. Nine patients went through a 2-week no-treatment baseline phase, a 4-week behavioral treatment phase focusing on self-directed exposure, and an 8-12-week vestibular rehabilitation phase (weekly sessions). On the main outcome measure, clinical global impressions (CGI) ratings of severity, behavioral treatment was accompanied by a reduction in severity (effect size d=0.8; P<.10). On the supplementary measures, the Hamilton Anxiety Scale (Hamilton-A) and the Chambless Mobility Inventory (MI), no significant improvements were noted. After vestibular rehabilitation therapy, further improvement occurred in CGI severity (d=0.65; two-tailed P<.10), and significant improvements occurred in the supplementary measures. The physical therapist identified motion-induced dizziness and disturbances in balance in most patients. These improved with rehabilitation. Although the results can be attributed to other explanations, they are not inconsistent with the hypothesis that vestibular dysfunction maintains agoraphobic symptoms in some patients.

Patients entering a 4-week inpatient alcoholism treatment program were screened for anxiety symptoms. Those with panic disorder with or without agoraphobia were randomly assigned to two groups. The treatment group received 12 hours of cognitive-behavioral treatment (CBT) for panic disorder in addition to the regular alcoholism treatment program: the control group received the regular program. Dropouts from the treatment group were also followed. Problem drinking and anxiety symptoms were measured at the start of the study, and at 3, 6, and 12 months posttreatment. Abstinence from drinking, and anxiety and mood symptoms improved after treatment in all of the groups; there were few differences in outcome between the groups. We concluded that this particular intervention had not been more effective than the regular alcohol treatment program in reducing problem drinking in those with panic disorder.

Objective: Conflict and conflict resolution in intimate relationships are not only among the most important factors influencing relationship satisfaction but are also seen in association with clinical symptoms. Styles of conflict will be assessed in patients suffering from panic disorder with and without agoraphobia, in alcoholics and in patients suffering from rheumatoid arthritis., Methods: 176 patients and healthy controls filled out the Styles of Conflict Inventory and questionnaires concerning severity of clinical symptoms., Results: A cluster analysis revealed 5 types of conflict management. Healthy controls showed predominantely assertive and constructive styles, patients with panic disorder showed high levels of cognitive and/or behavioral aggression. Alcoholics showed high levels of repressed aggression, and patients with rheumatoid arthritis often did not exhibit any aggression during conflict., Conclusions: 5 Clusters of conflict pattern have been identified by cluster analysis. Each patient group showed considerable different patterns of conflict management.

There were studied 2 groups of the patients with a diagnosis of agoraphobia (according to ICD = 10). The first group included 34 patients which didn't use a specialized psychiatric service; the second one included 25 patients which needed an active therapy under conditions of psychiatric hospital. Dynamics of a disease was investigated by the method of retrospective (3 years) and following prospective (3 years) evaluation. The first group was characterized by relatively favourable outcome of chronic anxious-phobic disorders (APD) with the phenomena of a stable agoraphobia (5.8% of patients with a decrease of social adaptation): a limited agoraphobic avoidance (2 cases in the average), a rare and only psychogenic exacerbation (23 cases). Comorbid disorders were presented as minor depression (53%), somatophormic disorders (single isolated cardialgias and the conversive disorders--28%), personal disorders of hyperthimic (53%) and hysteric (35.5%) type. The second group was characterised by relatively worse outcome of chronic APD with the phenomena of a stable agoraphobia (32.0% of the patients with a decrease of social adaptation), that was associated with more generalized avoidance behaviour (more than 2 cases), with a gradual increase of both the severity of panic attacks and agoraphobia in limits of either periodic long-term aggravations (46%) or a continuous progredient course (29%). As compared with the 1-st group the second group was also characterised by significantly higher average number in a month of the panic attacks (4.9 + 1.1 vs 2.4 + 0.4; p < 0.01) and hospitalization (2.5 + 0.6 vs 0.2 + 0.2 + 0.1; p < 0.05) during all period of prospective observation. More severe comorbid disorders were revealed: slow-progredient schizophrenia (20% vs 0% in the first group; p < 0.01), a major depressive disorder (28% vs 3%; p < 0.01), dysthymic disorder (32% vs 3%; p < 0.05); personal disorders were presented mostly by the deviations of schizoid type (59%).

Objective: Comorbidity between anxiety and substance use disorders was examined. The hypothesis was tested that social phobics may report greater problem alcohol use (if alcohol is used to manage social anxiety) while problem use of sedative-hypnotics may be greater in people with panic (who may be over-prescribed anxiolytics because they repeatedly seek medical assistance)., Method: Self-reported lifetime rates of drug and alcohol problems were assessed with the computerised Diagnostic Interview Schedule-Revised. Subjects were 146 consecutive patients treated for panic disorder (with and without agoraphobia) and social phobia at the Clinical Research Unit for Anxiety Disorders., Results: High prevalences of alcohol problems (three times that expected) and problem use of sedative hypnotics (eight times that expected) were found in all diagnoses. Social phobics exhibited comparatively high rates of problem alcohol use, but no diagnostic specific differences in problem sedative-hypnotic use were found., Conclusion: Routine screening for drug and alcohol problems is necessary for patients with anxiety disorders.

Recently, there has been increased interest in the extent to which chronic pain patients fear and avoid activities that are thought to be related to the experience of pain. To date, however, few studies have evaluated the nature and extent of nonpain fears in these patients. The purpose of the present study was to address this paucity. The Fear Questionnaire was administered to 130 patients with physically unexplained chronic pain and 93 patients with a chronic condition unrelated to pain. Results indicated that the chronic pain patients were more fearful and avoidant of social interactions/situations and blood/injury than were the patient controls. Agoraphobia was minimal and did not differ significantly between groups. As well, the proportions of chronic pain patients indicating definite avoidance of particular situations related to blood/injury phobia (i.e., injection/minor surgery, hospitals, sight of blood, and thoughts of injury/illness) and social phobia (i.e., being watched/stared at, and speaking/acting to an audience) were significantly greater when compared to the patient controls. These results indicate that nonpain fear and avoidance are common in patients with chronic pain. Implications regarding the significance of these fears and avoidance behaviours on the experience and maintenance of pain symptoms and related disability are discussed.

The aim of this study was to examine cognitive mediators of situational fear in agoraphobia. Patients suffering from panic disorder with moderate or severe agoraphobia were randomly assigned to receive either cognitive therapy or guided mastery therapy in a 6-week inpatient group program. The results were consistent with a self-efficacy model of agoraphobia. Across test occasions, and when the other cognitive variables were controlled for, self-efficacy made a significant contribution to the prediction of situational fear or changes in situational fear in 5 out of 5 cases. Catastrophic beliefs were related to situational fear in 1 of the 5 cases.

Forty-eight depressed panic-agoraphobic patients--clinically matched for severity of depression with 35 primary chronic depressives--had significantly better adjustment in most areas of social functioning, especially those related to interpersonal contact, work, leisure activities, and sexual life. Even when depressed, panic-agoraphobic patients appear to possess sufficient interpersonal skills--that is, by learning on significant others--to engage in a range of social activities, both at home and beyond. These data, which are open to different interpretations, nonetheless suggest that anxiety and mood disorders differently affect certain key areas of social adjustment.

Both epidemiological and clinical studies have demonstrated a high prevalence of panic disorder among alcoholic patients. In contrast, little attention has been given to studying alcohol abuse and/or dependence in patients suffering from panic disorder. One hundred and fifty-five consecutive referrals for treatment for panic disorder were interviewed using a modified version of the Schedule for Affective Disorders and Schizophrenia--Lifetime Version, modified for the study of anxiety disorders. Thirty-two patients (20.7%) had a lifetime history of alcohol abuse and/or dependence. Although the lifetime comorbidity rate of either agoraphobia and/or social phobia seems without any influence on the risk of alcohol-related disorder, alcoholic patients suffering from panic disorder appear to be more likely to have a history of depression and other addictive disorders. The majority of patients with primary alcoholism were male, and those who became alcoholics after they developed panic disorder were more likely to be female. The comparison between patients with primary and secondary alcoholism did not indicate any difference in the comorbidity rate with other psychiatric disorders nor the severity of panic disorder.

Many anxiety disorder patients who present for behaviour therapy are already taking anxiolytic medications. The present study added a new subscale to the Mobility Inventory labelled 'Without Medication' to assess possible reliance on medication for coping with phobic situations. 121 Patients with panic-related disorders were administered the scale. The results supported the reliability and validity of the existing Mobility Inventory subscales in general and of the new subscale in particular. It appears to reliably assess a clinically important domain that is not measured in traditional self-report measures of phobic avoidance.

The effects of self-controlled exposure in vivo therapy were compared between assertive and unassertive agoraphobics and between agoraphobics with high and low marital satisfaction. Assessments were made at the pretest, at the posttest after four therapy sessions, and at the follow-up one month later. Assessments were carried out by the therapist, by an independent observer, and by the patient. No significant differences were found between the groups with high and low marital satisfaction. The only significant difference between the groups with high and low assertiveness was shown at the posstest by the phobic anxiety scale; compared with high assertive patients, low assertive patients improved more.

Twenty male and 20 female agoraphobics, matched for age and marital status, were systematically compared using self-report questionnaire measures of symptoms and hostility, and clinical observations. The males differed significantly from the females as follows: the males were less phobic of social situations but more preoccupied with somatic symptoms and related fears. The females were more phobic of mental illness, more extrapunitive, and reported fewer obsessional symptoms. Two distinct but overlapping clinical sub-groups of males were defined. The sub-group in which separation anxiety, extreme dependence on spouse, denial of hostility and hypochondriasis were prominent, responded poorly to behavioural treatment; the sub-group in which a fear of loss of control of aggressive impulses and generalised anxiety were prominent, responded comparatively well to behaviour therapy.

With reference to a case study, the author describes the possibility of combined analytic psychotherapy and directive and social measures. At the same time, it is shown that in the case of serious neuroses with various secondary social-impediments, the lasting success of a treatment can only be guaranteed if there is an approximately simultaneous change in the inner psychic state and the external social reality. This is achieved by a treatment setting which combines elements of a psychoanalytic psychotherapy with supportive and directive treatment techniques. The course of the treatment if discussed from both psychoanalytic and sociopsychiatric viewpoints; particular attention is paid to the interdependent conditions of inner and external reality.

Fifteen agoraphobics took part in a study to investigate their responses to repeated presentations of a phobic motion pciture. Five patients were shown the film supraliminally, five were shown it subliminally, and the remaining five formed a control group. Subjective feelings were assessed with visual analogue scales, and three physiological measures, heart rate, skin conductance, and respiratory rate, were recorded. An earlier report showed that both subliminal and supraliminal presentation produced significant improvements in phobic fear and avoidance, and the present results show that the subliminal group found the procedure much less stressful than the supraliminal group. The physiological changes during treatment showed no consistent pattern and appeared to be independent of clinical response. The results show that repeated exposure to subliminal phobic motion pictures is not anxiety provoking to agoraphobic patients and so may be appropriate therapy for those unable to tolerate other forms of treatment.