The September BABCP Article of the Month is from Behavioural and Cognitive Psychotherapy and is entitled “Understanding agoraphobic avoidance: the development of the Oxford Cognitions and Defences Questionnaire (O-CDQ)” by Rosebrock, L., Lambe, S., Mulhall, S., Petit, A., Loe, B., Saidel, S., . . . Freeman, D.

Many patients with mental health disorders become increasingly isolated at home due to anxiety about going outside. Importantly, this anxious avoidance of everyday situations such as public transport, shops, or crowds – agoraphobia – is not limited to a single disorder. Agoraphobia symptoms are a common feature in depression (Kennedy et al., 2007), social anxiety (Chambless, 1985), panic disorder (Clark, 1986), and psychosis (Freeman et al., 2019). Agoraphobia causes significant distress. On the severe end of the spectrum, people may not leave their house for months – or even years – at a time.

The cognitive perspective of agoraphobia is that avoidance of everyday situations is a response to beliefs or worries that something bad may happen or harm may come to the person. Traditionally, agoraphobia has been particularly linked to worries of being trapped or having a panic attack. However, agoraphobic avoidance can occur in response to a range of different worries. In depression, this might be due to fears of failing; in social anxiety, this might be due to fears of being judged; in psychosis, this might be due to fears of being attacked. Although these worries may be characteristic of a specific disorder, they are not limited to that disorder. A person can have any number of worries which they respond to by avoiding situations that activate those worries.

Even when situations are entered, individuals may use subtle behaviours – “defences” – to reduce the feelings of anxiety. They may try to complete tasks as quickly as possible, identify easy exits, or avoid eye contact. Similarly, these defences are not limited to a single disorder and may be used across different disorders.

Existing self-report measures of these beliefs and associated defences have typically been developed for an individual disorder. Our aim with this study (Rosebrock et al., 2022) was to develop a single brief measure capturing key beliefs that feature in many disorders which may drive agoraphobic avoidance and other defences. 198 patients with psychosis and agoraphobia and 1947 non-clinical individuals across the spectrum of agoraphobia completed the new questionnaire and other clinical measures.

The new questionnaire – the Oxford Cognitions and Defences Questionnaire (O-CDQ) – consists of three subscales: threat cognitions (14 items), anxious avoidance (11 items), and within-situation behaviours (8 items). It is highly correlated with other clinical questionnaires and demonstrates excellent validity. It is easy to use and takes 5 minutes to administer.

This questionnaire was used in the gameChange study – a randomised controlled trial testing a virtual reality therapy for psychosis patients with agoraphobic avoidance (Freeman et al., 2022). Patients who received gameChange showed significant reductions in agoraphobic avoidance and distress. Importantly, the threat cognitions and within-situation behaviours subscales were mediators of outcomes in the therapy: reductions in avoidance and distress were due to shifts in threat cognitions and less use of defences.

We hope that this questionnaire can prove a helpful tool for understanding the beliefs that may be driving agoraphobic avoidance within both research and clinical settings. In a clinical context, the questionnaire may help therapists identify specific beliefs to target using cognitive behavioural approaches and therefore help people feel more confident leaving the house and engaging in previously avoided activities.

References:

Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470. doi: 10.1016/0005-7967(86)90011-2.

Chambless, D. L. (1985). The relationship of severity of agoraphobia to associated psychopathology. Behaviour Research and Therapy, 23(3), 305-310. doi: 10.1016/0005-7967(85)90009-9.

Kennedy, N., Foy, K., Sherazi, R., McDonough, M., & McKeon, P. (2007). Long-term social functioning after depression treated by psychiatrists: A review. Bipolar Disorders, 9(1–2), 25–37. doi: 10.1111/j.1399-5618.2007.00326.x

Freeman, D., Taylor, K. M., Molodynski, A., & Waite, F. (2019). Treatable clinical intervention targets for patients with schizophrenia. Schizophrenia Research, 211, 44-50. doi: 10.1016/j.schres.2019.07.016.

Freeman, D., Lambe, S., Kabir, T., Petit, A., Rosebrock, L., Yu, L. M., … & West, J. (2022). Automated virtual reality therapy to treat agoraphobic avoidance and distress in patients with psychosis (gameChange): a multicentre, parallel-group, single-blind, randomised, controlled trial in England with mediation and moderation analyses. The Lancet Psychiatry, 9(5), 375-388.

Rosebrock, L., Lambe, S., Mulhall, S., Petit, A., Loe, B., Saidel, S., . . . Freeman, D. (2022). Understanding agoraphobic avoidance: The development of the Oxford Cognitions and Defences Questionnaire (O-CDQ). Behavioural and Cognitive Psychotherapy, 50(3), 257-268. doi:10.1017/S1352465822000030.

Biography: Dr Laina Rosebrock is a Research Clinical Psychologist in the Oxford Cognitive Approaches to Psychosis (O-CAP) team at the University of Oxford. She specializes in the development and delivery of cognitive behavioural therapies, particularly using virtual reality (VR), for individuals with a variety of mental health diagnoses including depression, anxiety, PTSD, and psychosis.

From Paul Salkovskis, the Editor-in-Chief of BCP: Why I chose this article

Cognitive-behavioural approaches to the understanding and treatment of mental health issues have increasingly embraced trans-diagnostic and pan-diagnostic factors alongside the more specific issues linked to particular problems. Our field has for many years been unified by acceptance of the importance of what have been variously called avoidance and escape or safety seeking behaviours, but measures have tended to be disorder specific and theoretically neutral. In this paper, the O-CAP team have brought their excellent research strategy to bear on the measurement of safety seeking behaviours and linked this to the threat beliefs which underpin them. The development and publication of this validated measure has far reaching implications.