BEHAVIORTHERAPY16, 292--302 (1985)

Imaginal and In Vivo Exposure: A Comparison with

Obsessive-Compulsive Checkers
EDNA B. FOA

GAIL STEKETEE
JONATHAN B. GRAYSON
Temple University

The efficacy of imaginal and in vivo exposure was compared in 19 obsessive-

compulsives who manifested checking rituals. Response prevention was not in-
stituted in either group. No difference between the two procedures was detected
either at posttreatment or at follow-up; both were moderately effective in ame-
liorating obsessive-compulsive symptoms. There appears to be a tendency for
patients treated with in vivo exposure to improve further at follow-up, whereas
those treated with imaginal exposure maintained the level of gains achieved at
posttreatment. In comparison with a treatment regimen which includes both ex-
posure and response prevention, the exposure procedures investigated here yielded
inferior outcomes. The finding of no difference between in vivo and imaginal
exposure modalities is incongruent with studies on phobics. Possible explanations
for this discrepancy are discussed.

The superiority of treatment by exposure in vivo over imaginal exposure

h a s b e e n r e p e a t e d l y d e m o n s t r a t e d i n r e s e a r c h w i t h f e a r f u l v o l u n t e e r s (e.g.,
B a r l o w , L e i t e n b e r g , A g r a s , & W i n c z e , 1969; B a n d u r a , B l a n c h a r d , & R i t -
ter, 1969), as w e l l as w i t h s i m p l e p h o b i c p a t i e n t s (c.f., M a t h e w s , 1978).
W i t h a g o r a p h o b i c s t h e p i c t u r e is m o r e a m b i g u o u s . I n t w o s t u d i e s o n t h i s
p o p u l a t i o n , actual c o n t a c t w i t h f e a r e d s t i m u l i y i e l d e d g r e a t e r i m p r o v e -
ment than imaginal exposure. Using a crossover design Stern and Marks
(1973) c o m p a r e d t w o s e s s i o n s e a c h o f l o n g a n d s h o r t e x p o s u r e i n f a n t a s y
a n d i n p r a c t i c e ; l o n g i n v i v o e x p o s u r e p r o v e d m o s t effective. H o w e v e r ,
the use of a tape recorder rather than a live therapist to present imaginal
scenes and the confounding of the order of the treatments (imaginal always

Preparation of this paper was supported by NIMH grant 31634 awarded to the first author.
Requests for reprints should be addressed to Edna B. Foa, Temple University, % E.P.P.I.,
Henry Ave., Philadelphia, PA 19129.

292 0005-7894/85/0292-030251.00/0
Copyright 1985 by Association for Advancement of Behavior Therapy
All rights of reproduction in any form reserved.
 OBSESSIVE-COMPULSIVE CHECKERS 293

preceded in vivo exposure) renders interpretation of these findings diffi-

cult. To remedy these shortcomings Emmelkamp and Wessels (1975)
employed a factorial design comparing four sessions each of prolonged
exposure in vivo with imaginal exposure, both delivered by a therapist.
Again, on most variables in vivo exposure produced better gains.
In contrast, equivalent effects of these two exposure media with ago-
raphobics were reported by Matbews, Johnston, Lancashire, Munby, Shaw,
and Gelder (1976) who compared eight weekly sessions each of imaginal
flooding, in vivo exposure and their combination. In an attempt to rec-
oncile the discrepancy between their results and those of Emmelkamp
and Wessels, Mathews et al. suggested that in their study the instructions
to practice between sessions might have washed out group differences
among treatment procedures. This interpretation, however, is not con-
gruent with results obtained by Chambless, Foa, Groves, and Goldstein
(1982) who contrasted eight biweekly sessions of imaginal flooding fol-
lowed by 4 months of supportive psychotherapy with an attention control
condition followed by 4 months of weekly in vivo exposure. Although
their patients were not instructed to practice between sessions, imaginal
exposure was as effective as in vivo exposure at the end of the trial.
The Chambless et al. results must be interpreted with caution because
of the time confound; the imaginal flooding and the in vivo flooding were
not conducted at the same period. Their design, however, did allow the
investigation of the long-term effects of imaginal and in vivo exposure;
all of the preceding studies reported only short-term outcome which may
have obscured the relative efficacy of imaginal and in vivo exposures.
Mathews (1978) suggested that the effects of imaginal treatment may be
delayed, whereas in vivo exposure produces immediate effects. Indeed,
only in the shorter trials was exposure in vivo found superior to exposure
in fantasy. Long-term follow-up, then, may be required to adequately
assess the relative efficacy of the two exposure modalities.
With obsessive-compulsives, Rabavilas, Boulougouris, and Stefanis
(1976) compared two sessions each of short and long fantasy and short
and long practice. On target symptoms no differences between fantasy
and practice emerged. Because of the brevity of each of the procedures
and the absence of long-term follow-up, this study does not provide ad-
equate information about the differential efficacy of imaginal and in vivo
exposure with obsessive-compulsives. Foa, Steketee, Turner, and Fischer
(1980) found that the combination of 90 min of imaginal and 30 rain of
in vivo was as effective as 120 min of in vivo exposure over 10 sessions.
The combined treatment was more effective in maintaining the gains of
checkers at follow-up than was exposure in vivo only. This study, how-
ever, did not provide information about the efficacy ofimaginal exposure
alone. Moreover, the inclusion of response prevention in both conditions
may have obfuscated the impact of each exposure procedure alone. In
the present study a comparison between exposure in imagination and
exposure in vivo immediately after treatment and at follow-up was con-
ducted with obsessive-compulsives who exhibited checking rituals.
294 FOA, STEKETEE, AND GRAYSON

TABLE 1
ACTUARIALDATA FOR OBSESSIVE-COMPULSIVECHECKERSIN THE TWO TREATMENT GROUPS

Exposure Exposure
in imagination in vivo Total
(n = 10) (n = 9) (n = 19)

Age 34.7 33.4 34.1

Symptom duration 14.8 8.9 12.0
WAIS vocabulary 14.0 13.2 13.6
Beck depression score 17.0 17.8 17.9
Number hospitalized 3 2 5

METHOD
Subjects
Individuals referred to the Behavior Therapy Unit of Temple Univer-
sity with a primary diagnosis of obsessive-compulsive disorder according
to DSM III (1980) participated in this study. Criteria for inclusion were:
presence of overt checking or repeating compulsions, symptoms severe
enough to interfere with everyday functioning, absence of overt psychosis,
alcoholism or drug addiction; no previous treatment by prolonged ex-
posure methods, age range of 18 to 60, and agreement to participate in
the study.
Twenty-six patients were considered for the study. Four refused to
participate and three dropped out, two from the imaginal group and one
from the in vivo group. A total of 19 subjects completed the trial. The
mean age of the entire sample was 34.1 years (range 19 to 55) and the
mean symptom duration was 12.0 years (range 1 to 36).
Procedure
Using a serial assignment procedure (Pocock & Simon, 1975) with
balancing for level of depression and therapist, patients were assigned to
two treatment groups: imaginal exposure (n = 10) and exposure in vivo
(n = 9). Demographic characteristics of these two groups are given in
Table 1. When t tests were performed, groups did not differ significantly
on any of these pretreatment variables.
Information gathering. After an initial assessment patients were seen
by their therapist for 6 to 8 hr during which information about the history
and nature of their complaints was gathered, including listing the ritualistic
behaviors and situations that elicited discomfort. This material served as
the basis for planning the treatment. Patients were hospitalized if they
lived more than a 2-hr commuting distance from the clinic. A total of
five patients were hospitalized (for distribution, see Table 1).
Treatment
Each patient received 15 daily 2-hr sessions conducted over a 3 week
period. During the 4th week, patients were visited by the therapist in their
 OBSESSIVE-COMPULSIVE CHECKERS 295

homes for 4 hr on each of 2 consecutive days in order to facilitate gen-

eralization from the treatment facility to the patient's home environment.
Four therapists conducted the treatment. All were experienced in behavior
therapy and treated an approximately equal number of patients from each
group. The two treatments are described below:
Exposure in imagination (EX1). On the basis o f the initial interviews,
six scenes were constructed for each patient. The scenes varied with respect
to the degree of anxiety they elicited. The first scene provoked 50 to 60
SUDs (subjective units of discomfort ranging from 0 to 100, Wolpe, 1973,
p. 120). A new scene was presented each day until a scene evoking 100
SUDs was presented in the sixth session. From session 7 to 15, variants
o f the most disturbing of the scenes were presented. When additional
feared material emerged during conversation or flooding sessions, this
was also incorporated into the scenes. During imagery, patients were
instructed not to fantasize themselves carrying out rituals. All patients
reclined in a comfortable chair with their eyes closed during the 2-hr
flooding session and were instructed to imagine the scenes described by
the therapist as vividly as possible. Scenes were taped during each session
for later playback by the patient at home for an additional 4 hr. The
following is an example of an imaginal scene, condensed here for the sake
o f brevity:

"You just got up and finished putting on your clothes. The thought occurs to
you that you need to undress, otherwise your husband will die in a car accident.
You decide not to undress. You say to yourself." 'I am not going to engage in any
rituals, even if my husband dies.' Suddenly the doorbell tings. You open the door
and a policeman stands there telling you that your husband was involved in a car
accident. He asks you to go with him to identify his body. Your daughter is already
there. She accuses you o f causing your husband's death. She says, 'You should
have undressed; you were selfish; you care only about yourself. Now, because you
failed to perform your rituals, Dad is dead . . . . "

Exposure in vivo (EXV). Subjects in this group were exposed in vivo

to their discomfort-evoking stimuli throughout each 2-hr therapy session.
Anxiety-evoking stimuli were introduced in a gradual manner, starting
with items evoking 50 SUDs. The therapist modelled when necessary and
encouraged confrontation with feared situations for the entire session.
Each day a more difficult encounter was added to the previous ones, the
most feared circumstances being introduced by the 6th day. All situations
were presented during the remaining nine sessions of treatment. For their
homework assignment, patients were instructed to further expose them-
selves daily to the same stimuli for an additional 4 hr. Homework was
continued on the weekends. The exposure between sessions was super-
vised by hospital staff or by a designated relative who were in regular
contact with the therapist. Patients were allowed to ritualize as they wished
with the exception of treatment sessions and homework periods.
One patient feared running over people in her car. To relieve anxiety
she checked her rear view mirror constantly and retraced her route to
296 FOA, STEKETEE~ AND GRAYSON

TABLE 2
TIME OF LAST FOLLOW-UP IN MONTHS FOR OBSESSIVE-COMPULSIVE CHECKERS TREATED
WITH IMAGINAL OR IN VIVO EXPOSURE

3-6 mos. 6-9 mos. 9-12 mos. 12-18 mos. Total

Exposure in imag-
ination 2 1 2 4 9
Exposure in vivo 2 2 2 3 9
Total 4 3 4 7 18

look for bodies. Additionally, upon arriving home, she examined her car
for evidence of blood, read the newspaper and listened to the news for
reports o f a hit-and-run accident. During the exposure in vivo treatment,
the patient drove on increasingly crowded streets. If she inadvertently
checked her mirror or route during the session or the homework period,
she was instructed to reexpose herself (drive alone) immediately in another
location. Checking which occurred outside o f therapy or homework pe-
riods was not restricted or followed by exposure.
Measurements
Assessments were conducted on the following occasions: before treat-
ment, after treatment (3 days after patients completed treatment and
returned to their daily routine), and at follow-ups scheduled 3, 6, 12 and
18 months after termination of treatment. One subject was unavailable
for follow-up. The mean time to follow-up for the remaining subjects in
the in vivo and imaginal treatment groups were 10.8 and 10.0 months
respectively. The frequency distribution o f the time to the last follow-up
for each group is given in Table 2.
Measures taken on each occasion included symptom ratings by two
independent assessors (a psychiatrist and a psychologist who were blind
to treatment assignment) and by the patient, as well as a variety o f paper
and pencil tests.
Fear and obsessions. Several indicators of the degree o f fear/discomfort
associated with obsessional situations were used:
Main fear. The worst fear (e.g., driving, touching urine) was rated by
the assessors and by the patient on a Likert-like scale ranging from 0 (not
at all upsetting) to 8 (severely upsetting).
Avoidance. Assessors and patients rated the degree o f avoidance o f
situations associated with the main fear (e.g., avoiding driving, public
bathrooms) on a nine point scale, 0 indicating "never avoids" and 8
indicating "invariably avoids."
Obsessions. Assessors rated the degree to which "persistent useless
thoughts" came into the patient's mind during the 3 days prior to eval-
uation. Zero indicated "complete absence o f such thoughts" and 8 indi-
cated "having such thoughts nearly all the time."
 OBSESSIVE-COMPULSIVE CHECKERS 297

Compulsive behavior. The following measures of the severity of ritu-

alistic behavior were employed:
Target ritual The severity of the main compulsion (e.g., checking
related to driving, washing) was rated by patients and assessors on a 0 to
8 scale, 0 indicating "no difference from normal" and 8 indicating "five
times as lengthy or frequent."
Urges to ritualize. The assessor rated patients' frequency or intensity
of urges to ritualize after being exposed to feared situations. Ratings ranged
from 0 (no urges) to 8 (extreme urge).
Compulsions. The assessor rated patients on the severity of their
overall compulsive behavior. Ratings ranged from 0 (none) to 8 (very
severe).
General obsessive-compulsive symptomatology was measured as fol-
lows:
Obsessive-compulsive symptoms. The assessor rated the patient's
overall obsessive-compulsive symptomatology on a Likert-like scale rang-
ing from 0 (not at all symptomatic) to 8 (severely symptomatic).
Maudsley obsessional-compulsive inventory (MOC1). This is a 30 item
true-false self-administered questionnaire which measures obsessive-
compulsive symptomatology (Hodgson & Rachman, 1977).
Compulsion checklist. The assessor completed a checklist o f 38 items
which lists everyday activities (e.g., washing clothes, brushing teeth), each
rated on a 0 to 3 scale with a total score range of 0 to 114. This measure
was modified from Marks, Hallam, Connolly, and Philpott (1977).

RESULTS
Since interrater reliability was found to be quite high in previous studies,
ranging from .82 to .97 (Foa, Grayson, Steketee, Doppelt, Turner, &
Latimer, 1983), assessors' ratings were averaged to yield a single score.
Means for each measure were calculated separately for each of the treat-
ment groups at pretreatment, posttreatment and the latest follow-up. These
are presented in Table 3. One-way ANOVAs were performed on the
pretreatment scores of the three groups. No differences emerged.
In order to compare the efficacy of imaginal and in vivo exposure, two
sets of two-way ANOVAs (treatment x time) were conducted on each
outcome measure, one comparing scores at pretreatment and posttreat-
merit and the other comparing pretreatment and follow-up. This was done
to avoid loss of information for subjects who were missing some data at
follow-up.
Analyses revealed that at both posttreatment and at follow-up, the two
groups showed significant improvement on 11 of. the 12 measures, with
significance levels ranging from .01 to .001. On the remaining measure,
self-rating of avoidance, levels approached significance at posttreatment
(17 < .07) and at follow-up (/7 < .06). Only one interaction of treatment
by time was evident at posttreatment: on assessor-rated time spent rit-
ualizing, imaginal exposure effected significantly greater improvement
298 FOA, STEKETEE, AND GRAYSON

TABLE 3
MEANS, STANDARD DEVIATIONSAND NUMBER OF SUBJECTS FOR OUTCOME MEASURES AT
PRE- AND POSTTREATMENT AND FOLLOW-UP FOR THE TWO TREATMENT GROUPS:
EXPOSURE IN IMAGINATION(EXI), EXPOSURE IN VIvO (EXV)

Pretreatment Posttreatment Follow-up

Fear and Obsession

Main fear, assessor
EXI 6.55 (.64) 10 5.00(1.27) 10 4.28 (2.61) 9
EXV 6.44 (.88) 9 5.44 (1.33) 9 4.89 (1.45) 9
Main fear, self
EXI 7.05 (1.12) 10 4.60(2.07) 10 4.00(1.67) 6
EXV 7.79 (.67) 9 5.71 (1.38) 7 3.50 (2.19) 6
Avoidance, assessor
EXI 5.10 (1.29) 10 3.70 (2.36) 10 3.94 (2.54) 9
EXV 6.11 (1.17) 9 4.39 (1.73) 9 3.33 (1.68) 9
Avoidance, self
EXI 6.10 (1.85) 10 4.10 (2.23) 10 4.17 (1.72) 6
EXV 5.56 (2.56) 9 5.00 (1.83) 7 3.17 (2.40) 6
Obsessions, assessor
EXI 6.15 (1.13) 10 4.60(1.51) 10 4.72(2.72) 9
EXV 6.25 (1.28) 8 4.72 (1.70) 9 4.06 (1.33) 9
Compulsions
Target ritual, assessor
EXI 6.95 (.76) 10 3.10(2.55) 10 4.50 (2.98) 9
EXV 7.11 (.93) 9 5.78 (2.34) 9 4.56 (1.53) 9
Target ritual, self
EXI 8.00 (0.00) 10 4.40 (2.66) 10 4.50 (2.35) 6
EXV 8.00 (0.00) 9 4.57 (1.81) 7 3.33 (2.25) 6
Urge to ritualize, assessor
EXI 6.85 (1.47) 10 5.00(2.57) 10 4.78 (2.53) 9
EXV 6.88 (.84) 8 6.33 (1.30) 9 5.33 (1.87) 9
Compulsions, assessor
EXI 5.80 (1.25) 10 3.40 (2.69) 10 3.67 (2.78) 9
EXV 5.63 (.92) 8 4.39 (1.97) 9 3.50 (1.54) 9
General O-C Symptomatology
Obsessive-compulsive symptoms, assessor
EXI 6.10(.91) 10 3.95 (1.32) 10 4.22 (2.53) 9
EXV 5.89 (1.27) 9 4.50 (1.68) 9 4.00 (1.03) 9
MOCI
EXI 17.10 (6.70) 10 12.60 (4.65) 10 10.00 (5.73) 6
EXV 20.68 (8.47) 9 14.50 (6.35) 8 9.67 (6.31) 6
Compulsion checklist
EXI 28.50 (16.31) 10 15.65 (12.40) 10 14.06 (15.74) 9
EXV 37.33 (17.18) 9 20.44 (8.64) 9 16.06 (9.32) 9
 OBSESSIVE-COMPULSIVECHECKERS 299

than in vivo treatment (F(1, 17) = 5.50, p < .03). At follow-up, assessor-
rated avoidance showed a tendency for in vivo exposure to be superior
(F(1, 16) = 3.20, p < .09). Thus, on nearly all measures both exposure
media were equally effective.
DISCUSSION
The results reported in this paper indicate that for obsessive-compul-
sives with checking rituals both exposure in vivo and in fantasy delivered
by a therapist produced significant and lasting benefits. Both modalities
were equally effective at posttreatment and at follow-up. These findings
are consistent with the results of the only other study in which these two
procedures were compared with obsessive-compulsives (Rabavilas, Bou-
lougouris, & Stefanis, 1976). They are also in accord with case reports
indicating that prolonged imaginal exposure is effective with obsessive-
compulsives (Boulougouris & Bassiakos, 1973; Stampfl, 1969). The find-
ings reported here, then, add to the body o f literature, which suggests that
in contrast to simple phobics, for the more complex anxiety disorders
such as obsessive-compulsives and agoraphobics, we may have prema-
turely abandoned the use of imaginal exposure.
Why do simple phobics respond better to in vivo than to imaginal
exposure, whereas obsessive-compulsives benefit equally from both pro-
cedures? To address this question the processes underlying the effective-
ness of treatment by exposure should be considered. Lang (1977) suggested
that for fear reduction to occur, an individual must attend to fear relevant
information in a manner that activates the fear structure contained in his
or her memory. He proposed that if information remains in storage and
is not accessed, the fear structure will not be available for modification
and fear behavior will persist. One indicator that is taken as evidence
that the fear structure has been accessed is an increase in heart rate during
exposure to feared situations. 1 Consistent with Lang's hypothesis is the
finding that in phobics modification of fear was related to heart rate
response; those who showed greater initial response when imagining their
feared object benefited more from treatment by systematic desensitization
than did none responders (Lang, Melamed, & Hart, 1970).
Perhaps, then, in vivo presentations activate the fear structure o f simple
phobics more effectively than imaginal exposure, whereas for obsessive-
compulsives the fear structure may be activated equally by both exposure
media. Some support for this hypothesis comes from physiological data
of simple phobics and obsessive-compulsives. Watson, Gaind, and Marks
(1972) found that for simple phobics the main initial heart rate response
during fear relevant images was 8 bpm, whereas the average response
during in vivo exposure to the same stimuli was 28 bpm. This difference
was obtained despite the fact that the in vivo presentation followed the

1 Heart rate has been repeatedly used as an index of fear and has been found to increase
during anxiety arousing situations (e.g., Borkovec & Sides, 1979; Grayson, Foa, & Steketee,
1982; Hare, 1973; Nunes & Marks, 1975).
300 FOA, STEKETEE, AND GRAYSON

imaginal one during which habituation had already occurred. Conversely,

with obsessive-compulsive ritualizers Boulougouris (1977) reported no
differences between obsessive fantasy and flooding in vivo on either pulse
rate or subjective report of anxiety.
Several factors may mediate this difference between obsessive-com-
pulsives and phobics. Obsessive-compulsives may be better imagers than
phobics; there is some data which suggest a relationship between level of
physiological responding to fear material and ability to imagine. Phobics
who could imagine clearly showed greater heart rate response to fear
relevant scripts than did poor imagers (Lavin, Cook, & Lang, 1982).
Another possible explanation for the difference between simple phobics
and obsessive-compulsives may lie in the greater complexity of the latter's
fear structure. Lang (1977) has suggested that a certain degree of match
between the exposure situation and the patient's fear structure must exist
for the structure to be activated and that some elements may be partic-
ularly important. Phobics, he proposed, are characterized by strongly
coherent fear structures so that even a partial match can evoke the struc-
ture. Foa and Kozak (in press) suggested that obsessive-compulsives may
have less coherent structures, necessitating a greater degree of matching
with the exposure situation. Exposure in vivo, they proposed, may com-
mand attention better, but it poses more restrictions than does imaginal
exposure on the closeness of the match between the internal fear structure
and the external cues. Therefore, patients with simple, more coherent
structures may respond better to in vivo exposure which promotes atten-
tion. For patients with complex and less coherent fear structures, the
greater flexibility ofimaginal exposure may compensate for the superiority
of in vivo exposure on other dimensions.
It should be noted that although both exposure treatments effected
significant and lasting changes in obsessive-compulsive symptoms, the
degree of improvement was only moderate in comparison to treatment
that combined exposure and response prevention (Foa & Goldstein, 1978;
Marks, Hodgson, & Rachman, 1975). Indeed, in a direct comparison with
obsessive-compulsive washers, exposure in vivo alone yielded only mod-
erate improvement, significantly inferior to that obtained by exposure and
response prevention (Foa, Steketee, Grayson, Turner, & Latimer, 1984).
REFERENCES
Bandura, A., Blanchard,E. B., & Ritter, B. (1969). Relativeefficacyof desensitizationand
modelingapproachesfor inducingbehavioral,affectiv¢and attitudinalchanges.Journal
of Personality and Social Psychology, 13, 173-199.
Barlow, D. H., Leitenberg,H., Agras, W. S., & Wincze,J. P. (1969), The transfer gap in
systematic desensitization:An analogue study. Behaviour Research and Therapy, 7,
191-196.
Borkovec, T. D., & Sides, J. (1979). The contributionof relaxationand expectancyto fear
reduction via graded imaginal exposure to feared stimuli. Behaviour Research and
Therapy, 17, 529-540.
Boulougouris, J. C. (1977). Variablesaffectingthe behavior modificationof obsessive-
 OBSESSIVE-COMPULSIVECHECKERS 301

compulsive patients treated by flooding. In J. F. Boulougouris & A. D. Rabavilas (Eds.),

The treatment of phobic and obsessive-compulsive disorders. Oxford: Pergamon Press.
Boulougouris, J. P., & Bassiakos, L. (1973). Prolonged flooding in cases with obsessive-
compulsive neurosis. Behaviour Research and Therapy, 11, 227-231.
Chambless, D. L., Foa, E. B., Groves, G. A., & Goldstein, A. J. (1982). Exposure and
communicationstrainingin the treatment of agoraphobia. BehaviourResearch and Ther-
apy, 20, 219-231.
Diagnostic and Statistical Manual of Mental Disorders. (3rd ed.). (1980). Washington, DC:
American Psychiatric Association Task Force on Nomenclature and Statistics.
Emmelkamp, M. G., & Wessels, H. (1975). Flooding in imagination vs. flooding in vivo:
A comparison with agoraphobics. Behaviour Research and Therapy, 13, 7-15.
Foa, E.B.,&Goldstein, A. (1978). Continuousexposure and complete response prevention
in the treatment of obsessive-compulsive neurosis. Behavior Therapy, 9, 821-829.
Foa, E. B., Grayson, J. B., Steketee, G. S., Doppelt, H. G., Turner, R. M., & Latimer, P.
R. (1983). Success and failure in the behavioral treatment of obsessive-compulsives.
Journal of Consulting and Clinical Psychology, 51, 287-297.
Foa, E. B., & Kozak, M. J. (in press). Treatment of anxiety disorders: Implications for
psychopathology. In J. D. Maser and A. H. Tuma (Eds.), Anxiety and the anxiety
disorders. Hillsdale, NJ: Lawrence Erlbaum.
Foa, E. B., Steketee, G., Grayson, J. B., Turner, R. M., & Latimer, P. (1984). Deliberate
exposure and blockingof obsessive-compulsive rituals: Immediate and long term effects.
Behavior Therapy.
Foa, E. B., Steketee, G., Turner, R. M., & Fischer, S.C. (1980). Effects ofimaginal exposure
to feared disasters in obsessive-compulsive checkers. Behaviour Research and Therapy,
18, 1-7.
Grayson, J. B., Foa, E. B., & Steketee, G. (1982). Habituation during exposure treatment:
Distraction versus attention focusing. Behaviour Research and Therapy, 20, 323-328.
Hare, R. D. (1973). Orienting and defensive responses to visual stimuli. Psychophysiology,
10, 453-464.
Hodgson, R. J., & Rachman, S. (1977). Obsessional-compulsive complaints. Behaviour
Research and Therapy, 15, 389-395.
Lang, P.J. (1977). Imagery in therapy: An information processing analysis of fear. Behavior
Therapy, 8, 862-886.
Lang, P., Melamed, B., & Hart, J. P. (1970). A psychophysiological analysis of fear mod-
ification using automated desensitization. Journal of Abnormal Psychology, 31, 220-
234.
Lavin, D. N., Cook, E. W., & Lang, P. J. (1982). Fear imagery and fear behaviour:
Psychophysiological analysis of clients receiving treatment for anxiety disorder. Psy-
chophysiology, 19, 571-572.
Marks, I. M., Hallam, R. S., Cormolly, J., & Philpott, R. (1977). Nursing in behavioral
psychotherapy. London: Royal College of Nursing of the United Kingdom.
Marks, I. M., Hodgson, R., & Rachman, S. (1975). Treatment of chronic obsessive-
compulsive neurosis by in vivo exposure: A 2-year follow-up and issues in treatment.
British Journal of Psychiatry, 197, 349-364.
Mathews, A. (1978). Fear-reduction research and clinical phobias. Psychological Bulletin,
85, 390--404.
Mathews, A. M., Johnston, D. W., Lancashire, M., Munby, M., Shaw, P. M., & Gelder, M.
G. (1976). Imaginal flooding and exposure to real phobic situations: Treatment out-
come with agoraphobic patients. British Journal of Psychiatry, 129, 362-371.
Nunes, J. S., & Marks, I. M. (1975). Feedback of true heart rate dm'ing exposure in vivo.
Archives of General Psychiatry, 32, 933-936.
302 FOA, STEKETEE, A N D G R A Y S O N

P o c o c k , S. J., & S i m o n , R . ( 1 9 7 5 ) . S e q u e n t i a l t r e a t m e n t a s s i g n m e n t w i t h b a l a n c i n g f o r
p r o g n o s t i c f a c t o r s i n t h e c o n t r o l l e d c l i n i c a l t r i a l . Biometrics, 31, 1 0 3 - 1 1 5 .
R a b a v i l a s , A . D . , B o u l o u g n u r i s , J. C., & S t e f a n i s , C. ( 1 9 7 6 ) . D u r a t i o n o f f l o o d i n g s e s s i o n s
i n t h e t r e a t m e n t o f o b s e s s i v e - c o m p u l s i v e p a t i e n t s . Behaviour Research and Therapy,
14, 3 4 9 - 3 5 5 .
Stampfl, T.G. (1969). Implosive therapy: The theory, the subhuman analogue, the strategy
a n d t h e t e c h n i q u e : P a r t I. T h e t h e o r y . I n S. G . A r m i t a g e (Ed.), Behavior modification
techniques in the treatment of emotional disorders. B a t t l e C r e e k , M I : V . A . P u b l i c a t i o n ,
22-37.
S t e r n , R . , & M a r k s , I. ( 1 9 7 3 ) . B r i e f a n d p r o l o n g e d f l o o d i n g : A c o m p a r i s o n i n a g o r a p h o b i c
p a t i e n t s . Archives of General Psychiatry, 28, 2 7 0 - 2 7 6 .
W a t s o n , J. P . , G a i n d , R . , & M a r k s , I. M . ( 1 9 7 2 ) . P h y s i o l o g i c a l h a b i t u a t i o n t o c o n t i n u o u s
p h o b i c s t i m u l i . Behaviour Research and Therapy, 10, 2 6 9 - 2 7 8 .
W o l p c , J. ( 1 9 7 3 ) . The practice of behavior therapy. L o n d o n : P e r g a m o n P r e s s .

RECEIVED" J u n e 7, 1 9 8 4
FINAL ACCEPTANCE: D e c e m b e r 13, 1 9 8 4

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