Spider Phobia

Studies of recall and perceptual bias in spider phobia have been contradictory (Cameron, 1997). Disgust and fear evoked by spiders are largely independent of one another (Smits, Telch & Randall, 2002; Thorpe & Salkovskis, 1995) even though both decline with brief exposure (Smits, Telch & Randall, 2002; Thorpe & Salkovskis, 1997). Disgust as well as fear is, therefore, probably worthy of attention. Many people with spider phobia are also afraid, in the presence of spiders, of being unable to move, of making a fool of themselves, screaming and feeling faint (Thorpe & Salkovskis, 1995). Responses on measures that address these beliefs improve with brief exposure coupled with cognitive therapy, a change that is correlated with a reduction in fear (Thorpe & Salkovskis, 1997). However, it is not clear if cognitive therapy was necessary for that.

Trials in adults and children (Table 20.4) show, without exception, that exposure to live spiders, usually in a graded manner, produces improvement in measures of anxiety and behavioural tolerance. Simulated exposure by virtual reality (VR) or computer-aided presentation of somebody else being confronted by spiders (vicarious exposure), exposure with distraction, focussed or elaborated attention or with counter-conditioning (reciprocal inhibition) or exposure plus cognitive therapy or self-instruction manuals all reduce anxiety and improve tolerance. One session, an hour or more, can be sufficient. In one study (Smith et al., 1997), however, exposure to irrelevant stimuli, elevators, by computer display was as effective as similar exposure to spiders but it is not clear if sufficient subjects were tested to examine differences between the treatments. No study has included subjects with additional psychological problems. In only five is impairment of functioning addressed, all by Work Adjustment Ratings; more extensive measures of quality of life are examined in none. However, there is no consistent improvement among studies in work adjustment but several show statistical evidence of clinically significant improvement. There are few differences to suggest that any treatment is better than an other. However, very few studies predict the numbers of subjects necessary to confirm differences among treatments. Among the most controversial approaches for specific phobias, eye movement desensitisation (EMDR) has been tested most often for spider phobia. The one study that consistently supported EMDR,

Study

Comorbidity

Design (including repeated measures)

Anthony et al.

Not addressed

Two groups and two conditions: Single session exposure and modelling under distraction or attention focussed conditions; Ss identified as 'blunters' or 'monitors'

Arntz and Lavy (1993)

Arntz et al.

Excluded

Not addressed but spider phobia was 'the main psy-chopathological problem'

Two groups: Ss' Elaboration of spider stimuli in exposure; Ss prevented from elaborating

Three groups: 2 hours exposure with a placebo or low dose opioid antagonist or high dose naltrexone

Two groups: EMDR; control group

Spider Q (SPQ), Behavioural Approach Test (BAT), Diagnostic Symptom Q (DSQ), Heart Rate (HR) during BAT

All groups improved on all measures but differences among conditions and groups were not consistent across measures

Not addressed

Spider Phobia Q (SPQ), self-rating of fear and avoidance, Spider Belief Q(SBQ). Behavioural Approach Test (BAT)

Spider Phobia Q (SPQ); Fear Questionnaire (FQ); Spider Belief Q (SBQ), Behavioural Avoidance Test (BAT); heart rate and skin conductance in BAT

Heart rate, skin conductance, fear ratings; Behavioural Approach Test (BAT)

Ss improved on all measures but no difference between groups

Both groups improved on all measures except skin conductance and heart rate. These improvements had diminished one week later especially in the high dose naltrexone Ss

Improvement in fear ratings and BAT in both groups but no group consistently better than other

Not addressed

Not addressed

Not addressed

Design (including Study Comorbidity repeated measures)

De Jong et al.

Not addressed

Not addressed

Excluded. WAIS and WISC cognitive 'screening' but use not clear

Two groups: one session in vivo exposure with or without counter conditioning (music or food to counteract disgust)

One group of children: one session of eye-movement desensitisation (EMDR) followed by in vivo exposure

3 Groups of children: computer-aided vicarious exposure (CAVE), live graded exposure, or waiting list

Fraser et al. (2001)

Excluded

Two groups: three or six sessions of computer-aided vicarious exposure

Fear rating (SPQ) Behavioural Avoidance Test (BAT); valence ratings; Spider-disgust Q (SDQ); Cookie Preference Behavioural Test

Spider Phobia Q for Children (SPQ-C); Disgust Sensitivity (DQ), Disgust (two items added toDQ)

Both groups improved on SPQ, BAT and Disgust but no difference between groups

SPQ improved with treatment; results for disgust are unclear. No change in DQ

Sixty-seven percent (SPQ), 76 % (BAT), 47% (Disgust) and 77% (Valence) met statistical criteria for clinically significant improvement

Not addressed

Behavioural Avoidance Test (BAT). Other measures included self-re port of fear. Data collectors blind to treatment groups

Behavioural Assessment Test (BAT) and Subjective Units of Distress (SUD) Spider Phobia Q (SPQ), Fear Q, Phobic Targets, Work Adjustment Rating Scale (WARS), Cognitive Functioning (NART) as statistical correction

Improvement on most measures for both groups but live exposure showed greatest improvement. The CAVE group showed no greater improvement man the waiting list Ss

Both groups improved on all measures but no differences between groups. Use of NART not reported

'Large' statistical effect size for live exposure. Results of Work Adjustment Rating not fully reported but did not differ between treatments

'Large effect' size on some measures for both groups. Both improved on Work Adjustment but clinical significance unclear

(continued)

Study

Comorbidity

Design (including repeated measures)

Garcia-Palacios etal. (2002)

'No other psychiatric problems ... alcohol or drug dependence'

Two groups: virtual reality (VR) exposure versus waiting list

Gilroy et al.

Excluded. IQ assessed by National Adult Rading Test but use not clear

Three groups: live graded exposure (LGE), computer-aided vicarious exposure (CAVE); relaxation

Heading etal. Excluded (2001)

Three groups: one session of computer-aided vicarious exposure (CAVE) or therapist-aided live graded exposure

Hellstroem &

Ost (1995)

Not addressed but anxiety and depression measured

Five groups: one session of therapist-directed exposure, manual-based specific treatment at home or clinic, general manual based at home, or clinic

Anxiety Diagnostic Interview (ADIS); Fear of Spiders Q (FSQ); Behavioural Avoidance Test (BAT; Clinician rating

Improvement greater for VR group than for others on all measures

Eighty-three per cent improved to be within range of normal and non-phobic Ss (cf Jacobson et al., 1984). No other criteria addressed

Behavioural Avoidance Test (BAT), self-report ratings of fear, Spider Q (SQ), Fear Q (FQ). Work Adjustment Rating Scales (WARS) etc.

Similar to Fraser et al. (2001)

Similar to Ost (1996)

On all measures except VARS there was a greater improvement for the two treatment groups than for the relaxation group but no consistent differences between the treatment groups

Both groups improved on all measures except Work Adjustment but greater improvement for live graded exposure. No report of effect of cognitive functioning (NART)

Improvement on most measures in all groups but therapist directed treatment better than most manual based treatments

No effect on Work Adjustment (WARS)

Both groups showed 'large' effect size on all measures (except for one in the CAVE Ss

Results similar to Ost etal. (1997)

Design (including Study Comorbidity repeated measures)

Not addressed

Within Ss before and after exposure treatment

Muris et al.

Not addressed

Two groups of children in crossover: one session EMDR then in vivo exposure or vice versa

Muris & Merckelbach

Not addressed

Three groups of adults: EMDR, imaginal exposure, control group. Then all underwent in vivo exposure

Muris et al.

Not addressed

Two groups: 'Monitors' and 'Blunters' both received one session of in vivo exposure and modeling

Spider Phobia Questionnaire (SPQ); Behavioural Avoidance Test (BAT)

Muris etal. (1998)

Heart-rate, skin conductance, fear ratings; Behavioural Approach Test (BAT)

Improvement on both measures

Anxiety and Approach behaviour improved after first treatment; further behavioural improvement only in Ss given exposure second

Improvement in fear ratings and BAT in both groups but no group consistently better than other

Not addressed

Not addressed

Not addressed

Spider Phobia Q (SPQ); Spider Belief Q(SBQ), Behavioural Approach Test (BAT); heart rate, skin conductance level

Both groups improved on all measures, sustained at one week. Monitors improved to a lesser degree than blunters on SPQ and BAT but this appears to have been contradicted by the physiological measures

Not addressed

(continued)

Study

Comorbidity

Design (including repeated measures)

Muris et al.

Ost (1996)

Excluded

'No other psychiatric, problems' but depression and anxiety measured

Three groups of children: EMDR; exposure in vivo, computerised exposure. All Ss then received in vivo exposure

Two groups: one session of exposure in large or small groups of Ss

Not addressed but depression and anxiety measured

Four conditions within Ss: self-help manual, video, group and individual exposure

Spider Phobia Q (SPQ-C); Self Assessment Manikin (SAM) in presence of spider. Behavioural Avoidance Test (BAT). Rating of treatment affectiveness

Spider Phobia Q(SPQ), spider Q (SQ), fear and avoidance and handicap ratings, Fear Survey Schedule, State-Trait Anxiety. Assessor rating, Behavioural Avoidance Test (BAT), etc.

Behavioural Approach Test (BAT); Assessor's rating. Self-rating of anxiety; dropping out of treatment; Spider Phobia Q (SPQ); Spider Q; fear and avoidance ratings, Fear Survey Schedule (FSS), Self-efficacy, etc.

Improvement with in vivo exposure in all four measures. EMDR showed improvement on only one measure, (SAM); computer exposure on none

Both groups improved on most measures

Not addressed

Forty-three per cent of Ss dropped out, most Ss reporting clinically significant improvement during group treatment but measures confounded with sequence effects. All treatments showed improvements on most measures but very few differences between treatments

Seventy-six per cent showed clinically significant improvement by statistical criteria. This increased to 85 % at one year. Both groups improved in anxiety, depression and degree of handicap imposed by phobia

The best condition (group treatment) showed clinically significant improvement for 44%. Ss by statistical criteria

Design (including Study Comorbidity repeated measures)

Not addressed but anxiety and depression measured

Three groups: exposure and individual participation in group (direct), observation of group member participating in exposure (direct observation). Group watches video of S being exposed (indirect observation)

Ost etal. Excluded Two groups: one

(1991) session therapist directed exposure or self-directed exposure with instruction manual

Similar to Ost (1996)

Improvement on all measures for all groups. Inconsistent differences among groups in this improvement

Spider Q1 (SQP1) Spider Q2 (SPQ2)- by different authors, clinician rating, Behavioural Approach Test (BAT), a self-rating of anxiety

Eighty-two per cent in therapist group but only 1 2 % of self-exposure group allowed spider to crawl over their hands. On ratings and Spider Questionnaires there was greater improvement for the therapist-directed treatment

By statistical criteria, more Ss in Direct treatment compared with other groups showed clinically significant improvement. Improvement in degree of handicap imposed by phobia: improvement greatest in Direct treatment. Both groups unproved on anxiety and depression

By statistical criteria, 71 % of the therapist-directed Ss but only 6 % of the manual-guided Ss showed a clinical improvement

(continued)

Design (including

Study Comorbidity repeated measures) Outcome measures Statistical outcome Clinical significance

Design (including

Study Comorbidity repeated measures) Outcome measures Statistical outcome Clinical significance

Smith et al.

(1997)

Not addressed but 'none was taking anxiolytic medication'

Three groups, computerised: Relevant exposure (RE) and.feedback; RE no feedback; irrelevant exposure with feedback

Spider Q I; Spider Q II; Behaviour Targets; Work Adjustment Rating Scales

All groups improved on SQ I and II, Work Adjustment and Performance targets

Not addressed but Work Adjustment improved (qv)

Smits etal.

(2002)

Not addressed

Within Ss before and after exposure treatment

Fear of Spider Q(FSQ); Spider Fear Q (SFQ), Spider Belief Q(SBQ); Disgust Sensitivity and Contamination (DSQ); Armfield etal. Disgust Q. (AMDQ); Behavioural Avoidance Tests (BATs)

Improvement on all subjective measures except Disgust Sensitivity and on one of the BATs. Decline in spider-specific disgust not sufficient to explain change in fear

Not addressed

Thorpe &

Salkovskis

(1997)

Not addressed but depression, state and trait anxiety were assessed

Two groups: one session of exposure and modelling and information, untreated Ss

Two Spider Phobia Spider Qs (SPQs). Phobic Beliefs Q, modified from a published Agoraphobia Q; Beck Depression Inventory (BDI), State-Trait Anxiety Q (STAI) and ad hoc rating scales, Stroop Test of spider and disgust-related words

Improvement on all measures except Stroop test

Not addressed

in children, showed an improvement in only one of two measures of anxiety and it is not clear if that is a Type I statistical error (Muris et al, 1998). Of the other studies (Table 20.4), Muris & Merckelbach (1997) showed that improvement occurred only after in vivo exposure, which followed all treatments, including EMDR. It is not clear if enough subjects were tested in any of the quoted studies of EMDR to detect the effects of treatments. However, most reviews have dismissed claims for the effectiveness of EMDR (see, for example, Davidson & Parker, 2001).

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