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BEHAVIOR THERAPY 30, 273-283, 1999 Moving From the Laboratory to the Real World and Back Again: Increasing the Relevance of Laboratory Examinations of Anxiety Sensitivity GEORG H. EIFERT West Virginia University JOHN P. FORSYTH University at Albany, State University of New York MICHAEL J. ZVOLENSKY C. W. LEJUEZ West Virginia University Laboratory-based experimental research has led to important breakthroughs in our understanding and treatment of anxiety disorders as well as other types of psychopa- thology. Despite the importance of this work, the relevance of laboratory-based re- search using clinical and nonclinical populations has been understated--particularly given concerns about the ecological and external validity of this research. Although some of these issues have been addressed elsewhere, there continues to be less em- phasis on laboratory-based investigations compared to other types of research (e.g., treatment outcome). There also is continued misunderstanding regarding what ques- tions can be examined and answered by experimental studies. As an introduction to this special series on the relevance of laboratory examinations of anxiety, we suggest that advances in laboratory preparations can make significant contributions to cur- rent behavior therapy. We also suggest that observations in clinical practice can spur innovations in laboratory research. One theme echoed by the articles in this miniseries is the need for a renewed commitment to reestablishing a link between laboratory- based research and clinical application as a means to further advance the science and practice of behavior therapy over the long-tenn. Portions of this paper were presented in symposia conducted at the 31 st Annual Conference of the Association for Advancement of Behavior Therapy (1997, November), Miami, FL, and at the Annual Meeting of the Anxiety Disorders Association of America (1998, March), Boston, MA. Address correspondence to Georg H. Eifert, Department of Psychology, West Virginia Uni- versity, Morgantown, WV, 26506-6040; e-mail: [email protected]. 273 005-7894/99/0273-028351.00/0 Copyright 1999 by Association for Advancement of Behavior Therapy All rights for reproductionin any form reserved.

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Page 1: Moving from the laboratory to the real world and back again: Increasing the relevance of laboratory examinations of anxiety sensitivity

BEHAVIOR THERAPY 30, 273-283, 1999

Moving From the Laboratory to the Real World and Back Again: Increasing the Relevance of Laboratory

Examinations of Anxiety Sensitivity

GEORG H. EIFERT

West Virginia University

JOHN P. FORSYTH

University at Albany, State University of New York

MICHAEL J. ZVOLENSKY

C. W. LEJUEZ

West Virginia University

Laboratory-based experimental research has led to important breakthroughs in our understanding and treatment of anxiety disorders as well as other types of psychopa- thology. Despite the importance of this work, the relevance of laboratory-based re- search using clinical and nonclinical populations has been understated--particularly given concerns about the ecological and external validity of this research. Although some of these issues have been addressed elsewhere, there continues to be less em- phasis on laboratory-based investigations compared to other types of research (e.g., treatment outcome). There also is continued misunderstanding regarding what ques- tions can be examined and answered by experimental studies. As an introduction to this special series on the relevance of laboratory examinations of anxiety, we suggest that advances in laboratory preparations can make significant contributions to cur- rent behavior therapy. We also suggest that observations in clinical practice can spur innovations in laboratory research. One theme echoed by the articles in this miniseries is the need for a renewed commitment to reestablishing a link between laboratory- based research and clinical application as a means to further advance the science and practice of behavior therapy over the long-tenn.

Portions of this paper were presented in symposia conducted at the 31 st Annual Conference of the Association for Advancement of Behavior Therapy (1997, November), Miami, FL, and at the Annual Meeting of the Anxiety Disorders Association of America (1998, March), Boston, MA.

Address correspondence to Georg H. Eifert, Department of Psychology, West Virginia Uni- versity, Morgantown, WV, 26506-6040; e-mail: [email protected].

273 005-7894/99/0273-028351.00/0 Copyright 1999 by Association for Advancement of Behavior Therapy

All rights for reproduction in any form reserved.

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This miniseries grew out of two related symposia conducted at the 1997 meeting of the Association for Advancement of Behavior Therapy and the 1998 meeting of the Anxiety Disorders Association of America. Both sympo- sia critically examined the relevance of laboratory-based experimental research for understanding and treating anxiety-related problems.

Thirty years ago, the clinical relevance of laboratory-based anxiety research was unquestioned. Some of the most prominent behavior therapy techniques, such as systematic desensitization, were derived from basic experimental re- search with both humans and nonhuman animals (Wolpe, 1958). In the 1970s and early 1980s, however, there was growing criticism of laboratory studies in general and the use of analogue populations in particular (see Borkovec & Rachman, 1979; Kazdin, 1978, for reviews). In essence, critics questioned the external validity, practical utility, and value of experimental research for understanding the psychological processes that contribute to clinical prob- lems in the natural environment.

Although there currently appears to be somewhat less controversy sur- rounding the utility of laboratory investigations, the issue of how laboratory experimentation can contribute to our understanding of the dysfunctional processes involved with anxiety disorders remains somewhat unclear (Cahill, Carrigan, & Evans, 1998). Indeed, the current treatment-outcome-oriented zeitgeist--with its emphasis on the development, evaluation, and dissemina- tion of empirically supported therapies (e.g., G. T. Wilson, 1996)--has made it more difficult to ascertain how laboratory research contributes to treatment development or a better understanding of factors involved in the etiology and maintenance of abnormal behavior. The disproportionate amount of attention to treatment development and outcome evaluation, in turn, may suggest the incorrect conclusion that laboratory research does not offer an adequate degree of external validity.

Questions regarding the relevance of laboratory research using clinical and nonclinical populations have been shaped, in part, by the evolution of psy- chometric concerns concerning internal and external validity of research (Brunswik, 1955; Campbell & Stanley, 1967; Meehl, 1954). Within this con- text, early behavior therapists were committed to laboratory-based research as a primary mode of investigation (e.g., Lang & Lazovik, 1963; Wolpe, 1958). As echoed by several researchers, there is a need for a renewed focus and effort in theory-driven basic research to adapt to the changes affecting psychological service delivery (Evans, 1997; Forsyth, 1997; Jacobson, 1997; Kollins, 1997; K. G. Wilson, 1997). Yet, some have suggested that labora- tory-based investigations are not directly applicable to problems in the natu- ral environment. In particular, it has been argued that the high degree of experimental control characteristic of laboratory-based research often fails to yield a rich source of clinically relevant information that can be employed in naturalistic conditions (cf. Chorpita, 1997).

Due to their high degree of experimental control (Eysenck, 1987), labora- tory-based studies have been instrumental in isolating many basic psycholog-

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ical processes that underlie, in part, the etiology and maintenance of anxiety disorders. By using this information, researchers can isolate psychological principles and then effectively develop psychosocial interventions that utilize these principles to correct faulty learning processes (cf. Eifert, Schulte, Zvo- lensky, Lejuez, & Lau, 1997). Researchers also can use the laboratory to eval- uate treatment components, thereby refining existing protocols (K. G. Wilson, 1997). The papers in this miniseries highlight the value of laboratory-based research, using both clinical and nonclinical populations, within conceptual, experimental, and treatment contexts. One theme shared by the papers in this miniseries is the notion that experimental precision and control (i.e., internal validity) need not limit the scope, generality, or clinical relevance of experi- mental research as long as laboratory preparations involve independent and dependent variables that are clinically useful.

To meet the goal of developing clinically useful laboratory-based investi- gations of anxiety, researchers need to make the laboratory relevant to per- sons with anxiety disorders. Although basic research efforts are still needed to elucidate general principles of behavior, a subset of researchers also is needed to further develop these experimental paradigms if we are to obtain both precision and scope in a manner that contributes to the science-based practice of behavior therapy. Toward this end, we first discuss concerns re- garding the validity of laboratory investigations. Second, we highlight exam- ples from the contributors of this special series illustrating how a renewed focus on theory-driven laboratory research can help bridge the gap between science and practice (Hayes, 1998) and contribute to an improved under- standing of clinical processes (cf. Plaud & Eifert, 1998). Throughout our dis- cussion, we suggest changes to laboratory-based research strategies on several fronts as a means to create credible analogues of dysfunctional experiences of anxious and fearful behavior and to increase communication between re- searchers and clinicians.

Validity of Laboratory Research In this miniseries, McNally (1999) cautions that the post-hoc nature of

most naturalistic studies limits their explanatory power. Although naturalistic studies are advantageous in providing a large degree of scope and a wealth of clinically relevant data, such advantages often come at the expense of preci- sion and control (Meehl, 1954). Experimental research, on the other hand, strives to elucidate the nature and parameters of psychological processes, thereby providing comprehensive explanations at different levels of analysis. Indeed, the high degree of internal validity of laboratory investigations enhances their explanatory power, permitting causally-oriented hypothesis testing. In contrast, even the most sophisticated prospective monitoring tech- niques employed in naturalistic conditions invite interpretation-related errors such as inferring causation from correlation (McNally). Experimental stud- ies, on the other hand, offer insights into the etiology and maintenance of par-

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ticular disorders at different levels of analysis. For instance, they can investi- gate separately behavioral, biological, and cognitive aspects of responding as well as the relations between these aspects of anxiety-related responding. Perhaps laboratory investigations will be most convincing and clinically use- ful to researchers and clinicians when they involve methodological prepara- tions (procedures) that are realistic and generalizable to real-world phenom- ena. The determination of what is "clinically useful" is largely a function of the type of question being asked; specifically, whether one is primarily con- cerned with external validity or ecological validity.

Banaji and Crowder (1989) have argued that external validity (i.e., general- izability) and ecological validity (i.e., the extent to which laboratory prepara- tions represent stimuli in the natural environment) are related but also distinct concepts. Although high ecological validity is frequently related to high gen- eralizability, tasks or stimuli with low ecological validity may still have high generalizability to real-world phenomena. Drawing from experimental re- search on memory, Banaji and Crowder contend that laboratory research using highly constrained and standardized ("artificial") stimuli such as non- sense syllables has permitted greater generalizability to actual memory phe- nomena than have naturalistic studies of memory in real-world settings. Other researchers also have commented on the distinctions between external validity and ecological validity. Mook (1983), for example, suggested that ecological validity is important insofar as researchers desire to generalize results to persons who resemble those in a specified population. As such, if a researcher is interested in evaluating a theoretical prediction, ecological validity may be less of a concern. Thus, decisions regarding the use of appro- priate methodological procedures as a means to increase the clinical utility of the results of laboratory-based research are not straightforward. For example, cognitive tasks such as dot probe and Stroop color-word tests may be useful in detecting sensitivity to particular types of threat cues, but are low in eco- logical validity. Low ecological validity, however, does not necessarily limit the utility of such cognitive methods, especially when considering their high degree of generalizability to cognitive processes that occur in naturalistic contexts (McNally, Foa, & Donnell, 1989).

The use of electric shock in the study of anxious responding is another good example of how to address concerns about ecological validity by devel- oping credible analogues of dysfunctional experiences of anxious and fearful behavior. In the past, experimental researchers have frequently employed electric shock as an aversive stimulus in studies of anxiety and stress pri- marily because it reliably produces avoidance and escape behavior and its parameters can be easily controlled (cf. Azrin, 1959; Baron, 1991). Nonethe- less, the dissimilarity of bodily responses typically produced by shock (pri- marily pain) and those involved in intense anxiety makes it more difficult to generalize from studies using shock to anxiety-related responding experi- enced by persons in the natural environment (Forsyth & Eifert, 1996a; For- syth, Eifert, & Thompson, 1996). Further, the low degree of ecological valid-

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ity associated with shock may have led to premature conclusions that certain learning principles such as classical conditioning cannot account for fear acquisition (see Forsyth & Eifert, 1996a, 1998a, for a discussion of this issue). In such cases, researchers could use biological challenge methods (e.g., hyperventilation, caffeine ingestion, or inhalations of carbon dioxide-enriched air) to produce arousal and fearful responding that is both topographically and functionally similar to anxious responding in the natural environment (Beck, Shipherd, & Zebb, 1996; Forsyth & Eifert, 1996a; Forsyth & Eifert, 1998b; Rapee, Brown, Antony, & Barlow, 1992; Lejuez, O'Donnell, Wirth, Zvolen- sky, & Eifert, 1998; Zvolensky, Lejuez, & Eifert, 1998a).

How Can We Make the Lab More Relevant? Realistic Preparations

Stewart and colleagues (Samoluk, Stewart, Sweet, & MacDonald, 1999) have been instrumental in developing realistic experimental preparations of ad-lib alcohol consumption to examine the relation between anxiety prob- lems and excessive drinking behavior. More specifically, they have employed an alcohol challenge paradigm that offers researchers an opportunity to manipulate and assess directly anxiety-related responding and drinking behavior as a function of different social manipulations. Similar to other "closed systems" (McNally, 1999), we can draw a greater range of inferences from results obtained in this experimental context compared to results from self-report studies of drinking, while maintaining a realistic quality that par- alms the types of experiences encountered in the natural environment.

The article presented by Samoluk et al. (1999) in this miniseries discusses an accumulating body of evidence suggesting that individuals high in anxiety sensitivity (AS; fear of anxiety symptoms) may be at heightened risk for alcohol problems. They present a study that investigates differences in self- reported drinking motives between high and low AS individuals in a solitary or social drinking context using realistic analogue methods and unobtrusive measures of ad-lib alcohol consumption. These experimental results strengthen the validity of previous self-report correlational findings suggesting the use of high anxiety sensitivity as a potential marker for a pattern of context-dependent drinking that is associated with problematic alcohol use. The results also high- light the general importance of examining individual difference factors such as anxiety sensitivity in attempting to explain which individuals are most likely to show risky or maladaptive patterns of anxiety coping.

Analogue Populations Although we have primarily focused on issues concerning laboratory-

based anxiety research, a second analogue approach to understanding re- sponding is represented in the study of highly anxious individuals who do not have a diagnosable anxiety disorder (i.e., nonclinical populations). First pio- neered in the study of anxiety-related responding by Lang and Lazovik

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(1963), the analogue sample approach offers researchers an opportunity to answer theoretical questions about the entire continuum of anxious respond- ing. Similar to laboratory-based research in general, the main criticism of this analogue approach (cf. Luborsky, Singer, & Luborsky, 1975) has been the question of generalizability from a nonclinical to a clinical population.

Almost 20 years ago, Borkovec and Rachman (1979) made a convincing case for the unique contributions of laboratory research with nonpatient pop- ulations. These authors argued that the potential problem of generalizability is not really an issue provided we use "similar eliciting conditions and pro- duce intense responses" (p. 260; see also Sallis, Lichstein, & McGlynn, 1980). In this context, one of their other conclusions also is worth reiterating, namely, that "describing an experiment as an analogue is a description and not a criticism" (p. 260). Indeed, studies investigating nonclinical and animal populations have traditionally contributed greatly to our knowledge base relating to anxiety and other types of abnormal behavior (see Mineka & Zin- barg, 1996). For instance, the use of nonclinical persons, varying in their risk of a specified individual difference variable (e.g., anxiety sensitivity), permits one to answer questions about etiologic mechanisms without concern that a hypothesized risk factor is inflated due to the disorder itself (e.g., Newman, Moffitt, Caspi, & Silva, 1998; Zvolensky, Lejuez, & Eifert, in press). Creat- ing clinically relevant phenomena in populations without known pathology permits a "cleaner" examination of the variables and processes involved.

Norton and colleagues have identified this advantage of using nonclinical participants in their research on nonclinical panic attacks. Norton, Pidlubny, and Norton (1999) discuss individuals who experience panic attacks but do not seek treatment (probably because panic does not interfere sufficiently with their life functioning). These nonclinical panickers exhibit lower levels of psychopathology compared to anxiety disorder patients. Studying such persons enables us to examine mechanisms of panic that are relatively uncon- taminated by other psychopathology and before individuals develop the full- blown disorder. This is particularly useful for testing predictions about mech- anisms that are related to potential causes of panic attacks and the prevention of full-blown PD. To enhance generalizability of results to clinical popula- tions, Norton and colleagues also make valuable recommendations for apply- ing stricter criteria for defining panic attacks in nonclinical persons.

Laboratory Information that Is Useful to Naturalistic Observations of Anxiety

Anxiety often has been defined as involving changes in three loosely con- nected "response systems" or "modalities": overt behavior, physiological activ- ity, and verbal-cognitive activity (cf. Eifert & Wilson, 1991; Lang, 1971). Although assessing changes in these response classes has yielded valuable in- formation, we need to focus on finding and employing laboratory assess- ments of anxiety-related responding that can mirror more closely the emo- tional experience of anxiety and fear as it occurs in the natural environment.

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At the same time, we must be careful to acknowledge that none of these indi- ces directly assesses or measures anxiety or fear. At best, we can measure correlates of anxiety and fear, but no methods exist that objectively and unequivocally measure the emotional experience of anxiety and fear (cf. Zin- barg, 1998). The psychological experience of anxiety and fear seems in- effable in this regard based on current available technology; however, this does not mean that the processes involved in producing the psychological ex- perience of anxious and fearful behavior are beyond our reach. Indeed, exper- imental research can make a contribution toward elucidating such processes.

Physiological responding. As ambulatory physiological monitoring equip- ment becomes more available and affordable, it has been possible to extend laboratory physiological assessments into clinical and naturalistic settings. In this way, we can monitor physiological changes over extended periods of time. In this series, Hofmann, Bufka, and Barlow (1999) discuss how ambu- latory monitoring equipment can be used to identify naturally occurring bio- logical events (hyperventilation) and a patient's response to such events (see also Hofmann & Barlow, 1996). Both articles provide nice examples of how laboratory methods can enhance clinical practice.

Behavioral disruption. In a related fashion, the laboratory can be used to understand behavioral disruption (e.g., escape and/or avoidance) commonly observed in persons suffering from anxiety-related problems. Although be- havioral approach/avoidance tests (BATs) are useful for assessing anxiety problems that involve overt situational avoidance behavior (e.g., specific pho- bias, agoraphobia), such methods are less suitable for individuals who do not engage in overt situational avoidance behavior but instead engage in cogni- tive avoidance (e.g., "tuning out"). Drawing from methods used in animal research to assess behavioral impairment and disruption, researchers can as- sess how much a stimulus interrupts or disrupts ongoing behavior ("operant suppression index"; cf. Blackman, 1977). This behavioral index also could be relevant for humans, because patients frequently report that when they expe- rience a panic attack, they find it hard to focus on and continue with what they were doing at the time of the attack (see Lejuez et al., 1998, for a discus- sion of this issue).

Functional analysis of language and emotion. Given that behavioral re- searchers have traditionally focused on the experimental analysis of (non- verbal) animal behavior, results from such research may have limited gener- alizability and relevance to understanding and treating complex human problems (Staats & Eifert, 1990). More recently, however, clinical behavior analysts have extended their functional approach to comprehensive in-depth analyses and treatment of human clinical problems that involve language, thinking, and emotion (e.g., Anderson, Hawkins, & Scotti, 1997; Forsyth, in press; Forsyth & Eifert, 1996b; Friman, Hayes, & Wilson, 1998; Hayes & Wilson, 1993; Kohlenberg & Tsai, 1991; Strosahl, Hayes, Bergan, & Romano, 1998). Instead of dealing with what emotion and language are, the emphasis is on the conditions that produce what we call emotions, the function that

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emotions and language serve, and on changing the circumstances that pro- duce emotions.

For example, the primary function of anxious behavior is experiential avoidance--an individual's attempt to control and unwillingness to experi- ence aversive thoughts and feelings (Hayes, Wilson, Gifford, Follette, & Stro- sahl, 1996). This view has led Friman and colleagues (1998) to suggest that " . . . all of the anxiety disorders could be cogently classified as experiential avoidance disorders" (p. 147). Indeed, many presumed psychological and experiential vulnerabilities for anxiety disorders seem to make sense only in the context of nonacceptance or experiential avoidance. It is important to note, however, that currently there are few experimental data directly ad- dressing these notions, and both the theoretical underpinnings and tech- niques of acceptance-based interventions are overdue for laboratory scrutiny and refinement.

S u m m a r y

The goal of this special series is to demonstrate that experimental research is both relevant and indispensable for the continued advancement of our understanding and treatment of anxiety disorders. Experimental research allows tight control of relevant parameters of independent variables and allows for a systematic analysis of effects of such variables in a "closed sys- tem" (McNally, 1999). As such, this type of research complements naturalis- tic observations in the field and controlled protocol-driven treatment studies with anxiety patients. In particular, experimental research can provide infor- mation that cannot be gleaned from treatment outcome studies or randomized clinical trials; namely, the systematic study of variables that may, either in whole or in part, contribute to the etiology and maintenance (as well as treat- ment) of dysfunctional fear and anxiety. We hope that the articles in this series encourage more clinically relevant laboratory research for anxiety and other disorders and greater integration of laboratory and naturalistic approaches.

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