© 2008 The Royal College of Psychiatrists
Reading about... self-help books for phobias and panic disorder
King’s College Institute of Psychiatry, London; Autonomous University of Barcelona and Sant Joan de Deu Mental Health Services, Barcelona, Spain
King’s College Institute of Psychiatry, London, UK, email: i.marks{at}iop.kcl.ac.uk
In brief, a few self-help books and a computer-aided system were successfully tested in RCTs and are available for people with phobia/panic symptoms. (Most self-help materials available have not been tested in RCTs.) Some phobia/panic charities guide self-help.
I.M.M. is the author of Living with Fear and shares intellectual property rights in FearFighter.
For many people with phobias and panic disorder, reading about how to deal with their problem is a key to effective self-management of their disorder. Such self-help is achieved alongside varying amounts of professional advice given face-to-face, by phone, book or internet. This seems to be true for disorders like diabetes, hypertension, asthma and phobia/panic. In a randomised controlled trial (RCT) carried out two decades ago, people with phobia/panic improved to a similar extent regardless of whether self-exposure guidance was given by a book, a computer program, or face-to-face by a psychiatrist (Ghosh et al, 1988). All participants in this trial attended a clinic (outpatients) and were rated by a psychiatrist four times over 6 months, which may have aided them to achieve better results. Two of the participants in the book group had bought it in a shop before being enlisted for the trial, but had not read the book until the trial began. They were then asked by the psychiatrist to do so (i.e. read the book and follow its advice) and their condition improved.
Hundreds of people with phobia/panic around the UK now receive self-help computer/internet guidance from FearFighter, a treatment recommended by NICE (National Institute for Health and Clinical Excellence, 2006), perhaps the first such recommendation by any government regulatory agency given to such a self-help device for anxiety.
Different people need varying amounts of guidance with self-help. Some manage entirely alone, like the founder of a British network of 23 self-help groups Triumph Over Phobia (TOP) did. She went to Canada by boat because she feared flying. When in Toronto, she bought Living with Fear and followed its self-exposure advice unaided. She then flew for the first time ever to return to England, and founded TOP. Triumph Over Phobia groups around the UK use Living with Fear and are led by lay people, usually ex-sufferers who overcame their phobia/panic by self-exposure. Users of FearFighter on the internet get up to an hour in all of live support by phone and/or email over 3 months. A few people doing self-help need far more support before attaining independence. The more such contact, the less apt the term self-help. Fortunately just an ounce of contact can make a ton of difference to adherence to self-help – internet self-help via free, unscreened and non-moderated access tends to have huge dropout rates (Eysenbach, 2005), far higher than with systems offering brief personal contact.
Phobia/panic sufferers can find a horde of self-help pamphlets, books, audiotapes, CD-ROMs and internet systems. Reliable self-help materials can lessen stigma and empower and motivate users by showing how others have successfully overcome similar problems. Their ultimate value, however, can be hard to gauge without evidence other than their popularity, which is not always a reliable guide.
Randomised controlled trials are often regarded as a gold standard, though there are limits to what they can test. Some people benefit from reading self-help books or websites even though they would not enter a trial of the same. Randomised controlled trial attendance and rating regimes may enhance compliance and so be an unreliable guide to the benefit obtained from finding the same self-help material outside the trial. Nor is compliance a reliable guide to efficacy. For instance, relaxation without exposure has high compliance rates but low efficacy for phobia/panic.
Criteria for inclusion
While acknowledging the limits of RCTs, this paper describes self-help materials in the form of books and computer systems which were tested in such trials. For books we searched Medline and Psychinfo databases for the terms ‘panic,’ ‘phobia,’ ‘self-help,’ and ‘bibliotherapy’ in English-language publications from 1980 onwards and currently available to the public, and checked their reference lists (the ones we examined were from the UK, the USA and Australia). For computer-aided self-help around the world we searched an extensive, recent review (Marks et al, 2007). We included only materials which had been tested in RCTs in patients (not analogue or student volunteers) who had panic and/or phobia and which are generally available. We excluded handheld devices as these were mostly aids to homework rather than self-help guides per se.
The foregoing criteria were met by four books and one computer system that we found – two further computer systems are noted but not yet widely available. All guided self-help by cognitive–behavioural therapy (CBT) including repeated practice of self-exposure and cognitive methods in varying combinations. We also describe five UK organisations promoting self-help for phobia/panic.
Self-help book guides
The UK
Living with Fear, by Isaac M. Marks (2001, 2nd edition)
This addresses phobia/panic and other anxiety disorders. It gives clinical
vignettes, summarises each section, and defines anxiety-related concepts and
the difference between normal and abnormal fear. The last chapter details
step-by-step how to plan and do structured self-exposure therapy, monitor and
rate progress with an exposure homework diary, use cognitive and coping
techniques, and prevent relapse. In an RCT
(Ghosh et al, 1988,
op. cit.) people with phobia/panic improved as much guided by the book as
those guided face-to-face.
The USA
Mastery of your Anxiety and Panic, by Michelle G. Craske & David H. Barlow (2007)
This is a detailed step-by-step self-help guide for people experiencing
panics by symptom monitoring, psychoeducation, interoceptive exposure,
breathing retraining, cognitive restructuring, and relapse prevention. It
includes self-ratings, exercises with self-assessment ‘quizzes’
after each chapter, and clear information on each technique. Some of the
information (e.g. on the physiology of anxiety) seems rather technical. In an
RCT, the book plus minimal professional contact was effective for panic
disorder (Hecker et al,
2004).
Coping with Panic: A Drug-Free Approach to Dealing with Anxiety Attacks, by George Clum (1999)
In several RCTs this self-help text was effective for people with panic,
both with and without minimal professional contact (Febraro, 2005). It gives
detailed information about aetiology, emphasises cognitive factors, and
describes techniques to overcome panic, some of them ineffective, such as
relaxation without exposure and distraction
(Marks, 1987).
Australia
Overcoming Shyness and Social Phobia: A Step-by-Step Guide, by Ronald M. Rapee, (1998)
This is a well-structured and concise guide. It emphasises cognitive
restructuring through paper and pencil homework and behavioural experiments,
and guides self-exposure and attention training. Among its strengths is its
chapter on motivation and self-control techniques. In a recent RCT, people
with social phobia improved slightly after using the book alone, and more so
after using the book with therapist assistance
(Rapee et al,
2007).
Self-help computer guides
The UK
FearFighter, www.fearfighter.com
This NICE-recommended system gives password-protected guidance on
self-exposure therapy for panic/phobias. Its nine steps are largely
individually tailored. They describe phobias and panic, and advise on how to
start and complete self-exposure, find a co-therapist, identify fear triggers,
work out personalised problems and goals, set individualised self-exposure
homework tasks, keep homework diaries, do coping exercises during exposure,
and prevent relapse. Licensed primary care trusts around England and Wales
give passwords to briefly-screened patients, allowing them unlimited access to
FearFighter on the internet, plus 1 hour of phone/email support over
3 months. The treatment was effective in two RCTs and is widely available.
Australia
Panic Online, britta.klein{at}med.monash.edu.au
This password-protected system for self-help of panic disorder includes
education, self-monitoring, cognitive restructuring, coping strategies, and
quizzes at the end of self-assessment sections. Users enter their panic
information online weekly and/or email their therapist directly to obtain
feedback. In a recent RCT (Klein et
al, 2006) the program yielded positive results, but it is not
yet generally available.
Computer-Aided Vicarious Exposure (CAVE)
Computer-aided vicarious exposure is a personalised computer game to teach
users exposure therapy as they direct a phobia-inducing screen figure to
approach them and remain in usually avoided, feared situations shown on the
screen until that figure’s fear score drops. A therapist is present as
an uninvolved observer. Computer-aided vicarious exposure reduced spider
phobia in adults in several RCTs (Marks
et al, 2007), but is not generally available.
Self-help guided by the UK phobia/panic charities and websites
Anxiety care, www.anxietycare.org.uk
This website gives information on anxiety, resources for people with
anxiety disorders, an online support group, and a helpline.
First steps to freedom, www.first-steps.org
Users find here information about anxiety disorders and a helpline
telephone number. A fee is required for some of the services.
National Phobics Society, www.phobics-society.org.uk
This gives information about anxiety disorders, with a list of UK self-help
groups, and a phone and email helpline. Fee-paying members can access an email
contact list and a chat room.
No panic, www.nopanic.org.uk
No panic has information about anxiety disorders, a helpline, and
a night-time ‘anxiety crisis line’.
Triumph Over Phobia (TOP), www.triumphoverphobia.com
This website describes phobia/panic and obsessive–compulsive
disorder. Triumph Over Phobia runs 23 lay-led self-help groups around
the UK which teach people with phobia/panic or obsessive–compulsive
disorder how to overcome their problem.
References
- BARLOW, D. H. & CRASKE, M. G. (2007) Mastery of your Anxiety and Panic. Workbook (4th edn). Oxford University Press.
- CLUM, G. (1999) Coping with Panic: A Drug-Free Approach to Dealing with Anxiety Attacks. Self Change Systems.
- EYSENBACH, G. (2005) The law of attrition. Journal of Medical Internet Research, 7, 11.
- FEBBRARO, G. A. (2005) An investigation into the effectiveness of bibliotherapy and minimal contact interventions in the treatment of panic attacks. Journal of Clinical Psychology, 61, 763 –779.[CrossRef][Medline]
- GHOSH, A., MARKS, I. M. & CARR, A. (1988)
Therapist contact and outcome of self-exposure treatment for phobias.
British Journal of Psychiatry,
152, 234
–238.
[Abstract/Free Full Text] - HECKER, J. E., LOSEE, M. C., ROBERSON-NAY, R., et al (2004) Mastery of your anxiety and panic and brief therapist contact in the treatment of panic disorder. Journal of Anxiety Disorders, 18, 111 –126.[CrossRef][Medline]
- KLEIN, B., RICHARDS, J. C. & AUSTIN, D. (2006) Efficacy of internet therapy for panic disorder. Journal of Behavior Therapy and Experimental Psychiatry, 37, 213 –238.[CrossRef][Medline]
- LIDREN, D. M, WATKINS, P. L., GOULD, R. A., et al (1994) A comparison of bibliotherapy and group therapy in the treatment of panic disorder. Journal of Consulting and Clinical Psychology, 62, 865 –869.[CrossRef][Medline]
- MARKS, I. M. (1987) Fears, Phobias and Rituals. Oxford University Press.
- MARKS, I. M. (2001) Living with Fear. Understanding and Coping with Anxiety (2nd edition). McGraw-Hill.
- MARKS, I. M., CAVANAGH, K. & GEGA, L. (2007) Hands-on Help: Computer-aided Psychotherapy (Maudsley Monograph No. 49). Psychology Press.
- NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (2006) Computerised cognitive behaviour therapy (CCBT) for the treatment of depression and anxiety: Technology Appraisal No. 97. NICE.
- RAPEE, R. (1998) Overcoming Shyness and Social Phobia: A Step-by-Step Guide. Jason Aronson.
- RAPEE, R., ABBOTT, M. J., BAILLIE, A. J., et al
(2007) Treatment of social phobia through pure self-help and
therapist-augmented self-help. British Journal of
Psychiatry, 191, 246
–252.
[Abstract/Free Full Text]
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