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.Since parents play an important role in both the etiology and mainten-ance of their children s anxiety, dealing with inadequate parental rearingstyle and addressing parental cognitions may strengthen the effects ofbehavioural interventions.In a study by our research group [14], 79 phobicchildren in mental health clinics were randomly assigned to a CBTcondition or a waiting list control condition.Half of the families received anadditional cognitive parent training programme.Phobic children showedmore treatment gains from CBT than from a waiting list control condition.At three-months follow-up, 68% of the children no longer met the criteriafor any anxiety disorder.No significant outcome differences were foundbetween families with or without additional parent training.Thus, phobicchildren as well as adults may profit from CBT.In conclusion, the effects of exposure in vivo are now well established foragoraphobia, simple phobia and social phobia, not only in adults, but alsoin children.Although recent years have witnessed a number of alternativeapproaches for the treatment of phobias (e.g.cognitive interventions,medications, applied relaxation), there is neither evidence that thesetreatments are more effective than exposure in vivo, nor that thesetreatments enhance the effects of exposure in vivo.If anything, stoppingtaking medications is the most robust variable predicting relapse.Exposurein vivo is still the treatment of choice for specific phobia, social phobia,agoraphobia and childhood phobias.REFERENCES1.van Hout W.J.P.J., Emmelkamp P.M.G.(2002) Exposure in vivo.In TheEncyclopedia of Psychotherapy (Eds M.Hersen, W.Sledge), pp.693 697.AcademicPress, New York. PSYCHOTHERAPEUTIC INTERVENTIONS FOR PHOBIAS: COMMENTARIES __ 2232.van Hout W.J.P.J., Emmelkamp P.M.G., Scholing A.(1994) The role of negativeself-statements in agoraphobic situations: a process study of eight panicdisorder patients with agoraphobia.Behav.Modif., 18: 389 410.3.Emmelkamp P.M.G., Bruynzeel M., Drost L., van der Mast C.A.P.G.(2001)Virtual reality exposure in acrophobia: a comparison with exposure in vivo.CyberPsychol.Behav., 4: 335 339.4.Emmelkamp P.M.G., Krijn M., Hulsbosch L., de Vries S., Schuemie M.J., vander Mast C.A.P.G.(2002) Virtual reality treatment versus exposure in vivo: acomparative evaluation in acrophobia.Behav.Res.Ther., 40: 509 516.5.Krijn M., Emmelkamp P.M.G., Biemond R., de Wilde de Ligny, Schuemie M.J.,van der Mast C.A.P.G.(submitted) Treatment of acrophobia in virtual reality:the role of immersion and presence.Behav.Res.Ther.6.Emmelkamp P.M.G.(2003) Behavior therapy with adults.In Bergin andGarfield s Handbook of Psychotherapy and Behavior Change, 4th edn (Ed.M.Lambert).John Wiley & Sons, New York.7.Hope D.A., Heimberg R.G., Bruch M.A.(1995) Dismantling cognitive-behavioral group therapy for social phobia.Behav.Res.Ther., 33: 637 650.8.Scholing A., Emmelkamp P.M.G.(1993) Cognitive and behavioral treatments offear of blushing, sweating or trembling.Behav.Res.Ther., 31: 155 170.9.Mersch P.P.A., Emmelkamp P.M.G., Lips C.(1991) Social phobia: individualresponse patterns and the long-term effects of behavioral and cognitiveinterventions: a follow-up study.Behav.Res.Ther., 29: 357 362.10.Mersch P.P., Jansen M., Arntz A.(1995) Social phobia and personality disorder:severity of complaints and treatment effectiveness.J.Personal.Disord., 9: 143 159.11.Öst L.G., Jerremalm A., Johansson J.(1981) Individual response patterns andthe effect of different behavioral methods in the treatment of social phobia.Behav.Res.Ther., 19: 1 16.12.Kendall P.C.(1994) Treating anxiety disorders in children: results of arandomized clinical trial.J.Consult.Clin.Psychol., 62: 100 110.13.Nauta M.H., Scholing A., Emmelkamp P.M.G., Minderaa R.B.(2001) Cognitive-behavioural therapy for anxiety disordered children in a clinical setting: doesadditional cognitive parent training enhance treatment effectiveness? Clin.Psychol.Psychother., 8: 330 340.14.Nauta M.H., Scholing A., Emmelkamp P.M.G., Minderaa R.B.(2003) Cognitive-behavioural therapy for anxiety disordered children in a clinical setting: noadditional effect of a cognitive parent training.J.Am.Acad.Child Adolesc.Psychiatry, 42: 1270 1278.4.5 Behavioural Experimentation and the Treatment of PhobiasYiannis G.Papakostas, Vasilios G.Masdrakis and George N.Christodoulou1Barlow et al. s critical and comprehensive review of an extensive body ofresearch demonstrates the efficacy of current psychological treatments in1Department of Psychiatry, Athens University Medical School, 74 Vasilissis Sophias Avenue,Athens, GR 115 28, Greece PSYCHOTHERAPEUTIC INTERVENTIONS FOR PHOBIAS: COMMENTARIES __ 225disputation.Nevertheless, the findings from a recent study [3] that adoptedthis strategy while comparing cognitive therapy (CT) to interoceptiveexposure (IE) in the treatment of panic disorder without agoraphobia areinteresting and may be relevant to our discussion.While both treatmentswere equally effective, the IE seemed, at least when applied in isolatedformat, somewhat less acceptable for patients than CT.Some patients foundIE exercises strange, shameful, and aversive.Some patients also complainedabout the IE rationale, which they found not very convincing.The higherdrop out rate may be related to this issue [3].Thus, the possibility that therationale given to patients might have an impact on the attrition rate, as thisstudy implies, an issue stressed by other investigators as well [4], needs tobe systematically addressed in future studies.At least theoretically, behavioural experimentation, as a hypothesis to beempirically tested strategy, may be more suitable whenever advancedcognitive formulations about a clinical condition exist.Regarding phobias,this might be the case with panic disorder and social phobia.However, inspecific phobias perhaps because of their circumscribed nature, theirpossible relationship to conditioned fear [5] and the paucity of empiricallytested cognitive models the application of behavioural experimentationseems less guaranteed.Things seem more complicated in agoraphobia,whose conceptualization still poses a dilemma for clinicians.Whereas earlybehaviourists targeted agoraphobia and ignored panic or considered it as asecondary phenomenon, nowadays cognitive-behavioural therapists viewagoraphobia as secondary to panic.Therefore, as long as the cognitiveapproach runs short of theories about agoraphobia as an entity on its owna notable exception is the, as yet untested, theory of Guidano and Liotti[6] the merits of behavioural experimentation employed in this conditionare questionable
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