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Where Have They Gone? Tracking Movement Patterns to Document the
Process of Situational Exposure in Agoraphobia
Andrew J. White, Katja Umpfenbach, and Georg W. Alpers
University of Mannheim
Therapists typically have limited information about how unaccompanied situational exposure is undertaken.
To address this issue, we present a method of assessing movement patterns and concurrent arousal collected
during situational exposure. We illustrate how this provides both objective and useful accounts of this
important treatment component. In this case study, recordings of global positioning system-derived position
and heart rate were obtained from a 47-year-old female patient suffering from panic disorder with agoraphobia
who received treatment through an outpatient clinic. Ambulatory assessment of movement and accompanying
physiology (heart rate) during situational exposure is described. Visualizations of positional and physiological
data recorded during exposure sessions revealed (a) that the patient actually confronted feared environmental
cues, (b) that she experienced elevated physiological arousal, and (c) good therapeutic compliance. These
depictions were used to plan subsequent exposure sessions and we discuss how this information provided
unique insights into the process of exposure. Assessment of movement patterns using commercially available
technology can yield clinically relevant information about treatment progress. We conclude that this method
could extend traditional self-report measures of agoraphobic avoidance. Future directions, such as the
possibility of using movement information to refine follow-up assessment, and the limitations of this approach
are discussed.
Keywords: agoraphobia, ambulatory assessment, GPS, heart rate, movement patterns, panic disorder with
agoraphobia
It is common knowledge that movement can be accurately
tracked with cheap, reliable global positioning system (GPS) de-
vices. To date, however, these tools have neither been integrated
into routine clinical practice nor into research concerning the core
features of mental illness, or the mechanisms underlying therapeu-
tic treatments. Although potentially useful for many clinical dis-
orders, GPS technology seems particularly well suited to track
agoraphobic avoidance. Avoidance behavior is a central feature of
panic disorder with agoraphobia (PD/A) and to varying degrees
characterizes all anxiety disorders (American Psychiatric Associ-
ation, 2013). Although avoidance serves a protective function
when individuals encounter threats, among individuals with anx-
iety disorders, this disruptive behavior markedly interferes with
daily functioning (Hofmann, Alpers, & Pauli, 2009). Not only is it
associated with high costs for individuals, their family and friends,
but according to learning accounts of fear, avoidance serves to
maintain fear and prevent extinction of fear responses (Lovibond,
Montpetit, Minard, Brady, & Menzies, 2009).
There is some precedence for using technology to enhance
clinical practice. Although hitherto not adopted within clinical
psychology, GPS has been used by health researchers to mea-
sure physical activity (for a review, see Maddison & Ni
Mhurchu, 2009), exposure to environmental contaminants (El-
gethun, Fenske, Yost, & Palcisko, 2003), to document adoles-
cent travel patterns (Wiehe et al., 2008), and to assess driving
style (Porter & Whitton, 2002), to name a few uses. Within
psychology, a growing body of literature also supports the use
of simple technology to provide therapy-relevant information to
clinicians (Boschen & Casey, 2008;Clough & Casey, 2011;
Eonta et al., 2011;Morris & Aguilera, 2012). Eonta and col-
leagues (2011) showed, for example, how digital photos of a
patient’s living room could be used to objectively track hoard-
ing behavior.
ANDREW J. WHITE is a graduate student in the Doctoral Center in Social
and Behavioral Science (CDSS) at the University of Mannheim. In 2010,
he received a master of clinical psychology from La Trobe University,
Melbourne, Australia. His research focuses on ambulatory assessment of
anxiety disorders, mobile health interventions, and body image.
KATJA UMPFENBACH received her PhD in psychology at the University of
Mannheim in 2013 after working as a research assistant at the Otto Selz
Institute. She is in the process of completing her training as a behavior
therapist.
GEORG W. ALPERS is a licensed clinical psychologist in Germany since 1997
and received his PhD in psychology in 2002 from Philipps-Universität, Mar-
burg. He is a professor in the Department of Psychology at the University of
Mannheim, where he holds the chair for clinical and biological psychology and
psychotherapy. His areas of professional interest include ambulatory assess-
ment, emotions, and visual perception in psychological disorders.
THIS STUDY WAS PARTIALLY SUPPORTED by the German Federal Ministry
of Education and Research (project number 01GV0617). We wish to
acknowledge the kind efforts of the patient, who volunteered to participate
in this study. For comments on earlier drafts of this article, we thank
Florian Bublatzky, Antje Gerdes, Andre Pittig, Anne Dyer, Eliza Berdica,
Josepha Zimmer, Isabel Thielmann, Fatih Kavcioglu, Michael Witthöft,
and Frauke Steiger. We also thank Dieter Kleinböhl for helping to develop
the R scripts used to extract time-stamped GPS coordinates from TCX
files.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
Georg W. Alpers, University of Mannheim, 68131 Mannheim, Germany.
E-mail: alpers@uni-mannheim.de
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Professional Psychology: Research and Practice © 2014 American Psychological Association
2014, Vol. 45, No. 3, 171–179 0735-7028/14/$12.00 DOI: 10.1037/a0036538
171
Although situational exposure is a well-established treatment for
agoraphobic avoidance (Chambless et al., 1998;Deacon &
Abramowitz, 2004), objective depictions of how exposure is un-
dertaken and how reductions in agoraphobic avoidance manifest
are lacking. This is somewhat surprising because within the field
of ambulatory assessment, there has been an increase in the num-
ber of targets (e.g., behavioral, cognitive) that can be precisely
monitored (Trull & Ebner-Priemer, 2009). For example, within-
and between-session changes in anxious responding during expo-
sure have been well documented using physiological and self-
reported measures (Alpers, 2009;Alpers & Sell, 2008;Alpers,
Wilhelm, & Roth, 2005;Bornas, Gelabert, Llabrés, Balle, &
Tortella-Feliu, 2011;Wilhelm & Roth, 1998). Nonetheless, quan-
tification of behavioral avoidance has typically centered around
the length of time participants remain in exposure contexts (e.g.,
Baker et al., 2010). A more fine-grained assessment of behavior,
however, is generally missing and would help expand current
conceptions about how environmental conditions affect patients as
they approach feared situations.
Among clinicians and researchers, there is a heavy reliance on
self-report measures to provide insights into the personal experi-
ence of anxiety and to quantify pre- and posttreatment changes in
avoidance (e.g., Mobility Inventory for Agoraphobia; Chambless,
Caputo, Jasin, Gracely, & Williams, 1985). Although these mea-
sures are quick to administer, and boast high internal consistency
and test–retest reliability, there is a paucity of evidence supporting
their external or ecological validity.
Measurement of physiology offers useful insights into the pro-
cesses of anxiety and has been widely used to test hypotheses
about the mechanisms underlying situational exposure. Physiolog-
ical measures, such as heart rate (HR), are used to evaluate
whether initial fear reactivity is predictive of enhanced treatment
outcome (Alpers et al., 2005;Meuret, Seidel, Rosenfield, Hof-
mann, & Rosenfield, 2012), and are often collected in conjunction
with self-reported variables during behavioral avoidance tasks
(BATs; e.g., Baker et al., 2010). In the case of panic disorder, HR
recordings are typically justified on the grounds that tachycardia is
the most common and most severe panic attack symptom reported
by patients (Cox, Swinson, Endler, & Norton, 1994). Further, there
is strong evidence that HR increases, in conjunction with negative
thoughts, coincide with exposure to feared situations (Kenardy,
Oei, Weir, & Evans, 1993). However, to relate the often divergent
findings from the physiological response domain with meaningful
outcome measures (e.g., treatment progress), it remains important
to clarify the often complex relationships between psychophysio-
logical, behavioral, and subjective reports (Cacioppo, Berntson, &
Andersen, 1991).
BATs are commonly used to examine agoraphobic avoidance on
a behavioral level. BATs assess clinical symptoms associated with
behavior disorders and involve individuals confronting a feared
situation under controlled settings and measurement of their ap-
proach or avoidance along predefined dimensions, for example,
steps taken toward feared object; duration in a fear-relevant situ-
ation; or proximity to feared situation (Antony & Barlow, 2010).
Although they provide a more ecologically valid index of avoid-
ance than clinical scales, the behaviors targeted in BATs have,
until now, been examined along a limited number of dimensions.
This is particularly problematic when conclusions are drawn about
avoidant behaviors since it is rare that the various facets of
avoidant responding (e.g., hesitation, reliance on safety signals)
are comprehensively examined. To avoid narrow conceptualiza-
tions of avoidance, we argue that GPS can be used to accurately
assess a range of behavioral dimensions as individuals confront
feared situations under complex environmental conditions. For
example, GPS technology offers a means of objectively and un-
obtrusively tracking the location of an individual while outdoors
(Kerr, Duncan, & Schipperjin, 2011), and has been found to be
more accurate than self-reported activity diaries (Badland, Dun-
can, Oliver, Duncan, & Mavoa, 2010). We propose that monitoring
outdoor movement with GPS devices can extend our understand-
ing of avoidant behavior, and can help researchers to explore the
interactions between other emotional response domains (physio-
logical, self-report) as participants confront standardized fear-
inducing situations.
In summary, among studies in which the mechanisms of situa-
tional exposure are examined, equal priority has not been given to
these three response domains—physiological and self-report re-
sponses dominate, and when behavioral measures are included,
they are commonly based on BAT performance. We argue that
more objective accounts of change within and between exposure
sessions can be obtained by including measures of movement
behavior from actual exposure embedded in a therapeutic context.
In the current case study, we documented a patient’s movement
patterns and accompanying HR during driving exposure to primar-
ily assess the benefits of this approach within therapeutic settings.
Monitoring physiology during driving had the additional advan-
tage that measures were not so strongly affected by exercise
activation (Alpers, Abelson, Wilhelm, & Roth, 2003;Alpers et al.,
2005). We explored whether collection and analysis of physiolog-
ical and movement data yielded more detailed assessments of
homework compliance. Compliance is typically rated by calculat-
ing the percentage of homework completed, or number of assign-
ments completed (for a review, see Mausbach, Moore, Roesch,
Cardenas, & Patterson, 2010). Recent research suggests, however,
that assessing the quality rather than quantity of homework com-
pleted is a better index of compliance (Cammin-Nowak et al.,
2013). Further, guided by current models of feedback that stress
the benefits of feedback that is objective, specific, and linked to
personal goals (Archer, 2010), we examined the extent to which
graphical depictions of movement and accompanying physiology,
provided as feedback to the patient, were of therapeutic benefit.
Method
Participant
A 47-year-old German woman with a 12-year history of mod-
erate agoraphobic avoidance who met Diagnostic and Statistical
Manual for Mental Disorders–Fourth Edition (DSM–IV) criteria
for panic disorder with agoraphobia (300.21) agreed to participate
in the study. The patient left school without matriculating at the
age of 16 and then trained for 2 years to become an office clerk.
She met her husband at the age of 16, and moved into an apartment
with him the following year. After her training, she worked in a
firm for 5 years before taking leave to give birth to her daughter.
She then joined a company where her husband also worked and
has since remained in this position. She indicated that her present-
ing problem reduced her capacity to work and placed a strain on
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172 WHITE, UMPFENBACH, AND ALPERS
the relationship with her husband. She revealed that she began to
avoid shopping centers in 2001, and felt increasingly hesitant
about driving unaccompanied in her car, traveling on public trans-
port (especially buses and trains), and spending time in crowded
places. She received psychological and psychopharmacological
(Opipramol) treatment for this problem in 2001, when she initially
received her diagnosis, based on a German version of the Struc-
tured Clinical Interview for DSM–IV (SCID) interview (First,
Spitzer, Gibbon, & Williams, 1996). We confirmed this diagnosis
using a SCID-I and II interview in the second and third sessions.
During anamnesis, the patient reported that although the earlier
therapy had helped to attenuate her symptoms, following this, she
periodically felt weak, dizzy, and stressed while traveling on
public transport or driving. She claimed that these physiological
symptoms led her to develop a fear of losing consciousness. As
these beliefs became particularly embedded, she became increas-
ingly reliant on the support of her husband, who was often required
to drive her to shopping centers. During the current treatment, she
reported taking 37.5 mg of Venlafaxine daily.
Materials
A Garmin 310XT sports watch with an accompanying HR belt
was used to capture physiological activation and positional data
(GPS). HR, latitude, and longitude were recorded at a sampling
rate of 1 Hz. A city map, downloaded from OpenStreetMap
(http://www.openstreetmap.org/) was used to set goals for the
patient—specifically, to plan the walking and driving paths that
would be undertaken during the situational exposure sessions.
Clinical symptoms were assessed using German versions of sev-
eral standardized clinical scales: Body Sensation Questionnaire
and Agoraphobic Cognitions Questionnaire (BSQ and ACQ;
Chambless, Caputo, Bright, & Gallagher, 1984), Mobility Inven-
tory (MI; Chambless et al., 1985), Brief Symptom Inventory (BSI;
Derogatis, 1993), and the Beck Depression Inventory-II (BDI-II;
Beck, Steer, & Brown, 1996).
Procedure
Before data collection, the patient provided informed consent
and agreed to the publication of this clinical case. Psychological
treatment was delivered by a therapist in her third year of psycho-
therapy training. As part of our institute’s standard diagnostic
procedures, clinical scales were administered on intake (T0), and
after the 10th (T10), 20th (T20), and 30th session (T30, the final
session).
After confirmation of diagnosis, psychoeducation was provided
around the nature of PD/A according to Barlow and Craske’s
(1994) manual. One week before the day of each exposure, the
therapist and patient set goals for the initial exposure that involved
tracing her intended walking or driving path onto a city map.
Before each recorded exposure session and while at the clinic, the
HR belt and sports watch were attached just beneath the sternum
and to the left wrist, respectively. The patient was provided with
her previously completed city map and asked to refer to this during
exposure. Before the driving exposure sessions on which we focus
in this study, the patient undertook four unaccompanied exposure
tasks: two fixed-route train exposures in Sessions 12 and 13 as part
of the client’s commute to and from the session, and two city-
based walking exposures during Sessions 13 and 15. Walking
exposures were targeted at the patient’s specific fears (walking
unaccompanied through the city and entering a department store).
Movement depictions were presented to the patient in the ses-
sion after each recorded exposure. Although not recorded in Ses-
sion 13, HR was recorded in Session 15, which allowed us to
present movement and accompanying HR plots. When discussing
the results from the walking exposure sessions, the patient ex-
plained that entering large shopping centers was still anxiety-
provoking. Therefore, it was agreed that as part of each driving
exposure, she drive to and enter a shopping center. Driving expo-
sure was conducted in Sessions 24 and 28 and in total, the patient
attended 30 therapy sessions that were 50 min in duration.
Data Analysis
After exposure, data were wirelessly transferred from the
Garmin device to a computer (Garmin ANT agent software, Ver-
sion 2.3.3) using a Garmin ANT⫹USB stick that was provided
with the watch. The resultant file contained time-stamped infor-
mation about HR, longitude, latitude, and altitude (TCX, Training
Center XML). Garmin’s online software tool, Garmin Connect
was used to initially view the coordinate data. This Web-based
software allowed convenient visualization of HR and movement
trajectory.
1
This will suffice for those who want to obtain quick
depictions of the route traveled and the accompanying HR re-
sponse; however, we also outline an approach that affords more
detailed analysis of movement patterns.
To more precisely examine the relationship between position
and HR, we first developed an extraction script,
2
developed in the
statistical programming language R (R Development Core Team,
2013), to read TCX files and convert these to matrices composed
of time-stamped vectors of positional coordinates. To more di-
rectly visualize the correspondence between physiological activa-
tion and position, we embedded HR (indicated by color) into the
path plot (see Figure 1) using R’s ggmap (Kahle & Wickham,
2013) package.
Results
Clinical Scales
BSQ, MI, and BSI summary statistics indicated that between
intake and the 10th session, the patient experienced initial
increases in general and phobic anxiety, fear of somatic symp-
toms associated with anxiety and panic, as well as agoraphobic
avoidance (see Table 1). In particular, the patient’s MI scores
indicated that she almost always avoided heights, shopping
centers, crowded city sections, and driving in areas far from
home, particularly when alone. A 1-month gap in therapy and
the patient’s report that she felt pressured by her husband to
demonstrate that therapy was helping her to change likely
contributed to these initial increases. Moreover, large between-
session mood fluctuations were a feature of the patient’s pre-
sentation that partly explained these increases. Between Ses-
1
A desktop version of this software is also available.
2
This code can be found at: https://github.com/shiroandy/garmin-tcx-
parser.
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173
MOVEMENT PATTERNS DURING SITUATIONAL EXPOSURE
sions 10 and 20, these scale scores indicated symptom
attenuation that confirmed the therapist’s impression that the
patient responded favorably to treatment, and particularly to the
two walking exposures. Decreases in MI and BSI (anxiety
scale) scores between T20 and T30 also indicated that further
reductions in agoraphobic avoidance and general anxiety symp-
toms were achieved. Somewhat unexpected was that ACQ
scores were considerably lower than in other studies of indi-
viduals with PD/A (e.g., Telch, Brouillard, Telch, Agras, &
Taylor, 1989), and appeared to fall within subclinical range
(Bibb, 1988). Compared with BSQ scores, this suggested that
the patient’s worries about her somatic symptoms were more
severe than her fear-related cognitions. Finally, BDI-II scores
indicated that the patient experienced minimal depression
throughout treatment. In summary, these scale scores suggested
that the extent to which the patient confronted feared situations
Figure 1. First driving exposure: GPS track with color-coded HR embedded in path (above) with accompa-
nying HR (beats per minute) plotted against time (below).
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174 WHITE, UMPFENBACH, AND ALPERS
unaccompanied, increased throughout therapy and that greatest
reductions in phobic anxiety were achieved between Sessions
10 and 20.
Driving Exposure
During the first driving exposure session for which we collected
data, the patient drove for ⬃15 min away from the city and paused
to undertake exposure in a small shopping center for 2 hr. There-
after, the driving exposure continued for another 30 min (see
Figure 1). This plot showed that the patient complied well with the
therapist’s instructions; the driving exposure was completed as
planned and also appeared to allow enough time to undertake the
exposure in the shopping mall. The accompanying HR suggested
that the patient experienced quite high levels of arousal at the
commencement of exposure that temporarily subsided and then
increased to the initial level as she approached the shopping mall.
On the second leg of this exposure, the patient’s HR was notice-
ably lower and for most part was below 100 bpm. This, to some
extent, was an expected finding because the patient reported ex-
periencing fewer problems while driving in the vicinity of home.
The depiction of the second driving exposure (see Figure 2) also
confirmed that the patient undertook the task as planned. The
accompanying plot of HR showed that her physiological arousal
was particularly high at the commencement of exposure and the
HR overlaid on the GPS track indicated that it marginally reduced
on entering the car park of the large shopping center. After
completing the exposure within the shopping center that lasted ⬃2
hr, the patient continued the driving exposure, during which time
a further decline in HR was apparent.
Comparing the two driving exposure depictions allowed the
therapist to determine that the patient experienced greater difficul-
ties driving in unfamiliar (second driving exposure), compared
with familiar (first driving exposure), areas. Although this chal-
lenged the idea that the gains would simply transfer from the first
to the second driving exposure, an important feature, depicted in
both figures, was that HR decreased throughout the exposure.
Further, plots allowed the therapist and patient to gauge the diffi-
culty of each exposure, which helped clarify the sorts of routes that
would be most beneficial for subsequent driving exposure.
Patient Response to Feedback
When asked about the usefulness of the above plots, the patient
indicated that seeing her exposure trajectory and accompanying
HR reductions contributed to her sense of accomplishment and
helped increase her motivation to practice confronting the feared
situations. For example, toward the end of therapy the patient
drove herself to the clinic more often and reported that she had
driven her daughter to a neighboring city. This provided some
evidence that the depictions helped to reinforce the idea that
despite experiencing strong anxiety symptoms during exposure,
completing challenging driving tasks was possible.
The feedback also provided the therapist and patient with an
opportunity to discuss the anxiety she experienced in considerable
detail after each driving exposure. For both driving exposure
sessions, the patient was able see that her HR decreased during the
second leg of the journey after undertaking the shopping center
exposure. This, in turn, helped the therapist to demonstrate that
given enough time anxiety symptoms could be expected to sub-
side. Further, the therapist noted that HR plots helped the patient
to quickly realize that she had overpredicted her fear and arousal
before exposure.
The plots helped guide and enrich the therapeutic dialogue
concerning the onset, character, and time course of emotions as she
drove through unfamiliar areas. For example, the therapist was
able to initiate a discussion about the experience of crossing a high
bridge. Finally, the therapist also noted that the depictions facili-
tated comparison of different exposure sessions, which helped
guide discussions about the patient’s progress and helped in the
planning of suitably challenging exposure tasks.
Discussion
We outlined a method of documenting the movement and
arousal of a patient with PD/A undertaking situational exposure to
establish whether this yielded useful accounts of how this impor-
tant treatment component was undertaken. Our findings indicated
that the depictions provided the patient with therapeutically ben-
eficial feedback, facilitated the planning of additional exposure
tasks and allowed the therapist to gauge compliance.
We found that providing feedback to the patient about her
movement and arousal patterns during exposure positively influ-
enced her motivation to practice confronting additional feared
situations. Inspecting changes in physiological parameters served
to highlight the patient’s achievements and to strengthen her sense
of accomplishment. Discussing this personalized, detailed feed-
back also enriched follow-up discussions about the experience of
completing exposure, and also helped plan additional, suitably
challenging exposure paths. We found that discussing the plots in
therapy helped the patient to quickly reach the conclusion that her
anticipatory anxiety (as indexed by her elevated HR) at the begin-
ning of exposure was greater than what she experienced during the
confrontation of the most feared situation. This, in turn, supported
the rationale for situational exposure outlined during therapy.
Table 1
Clinical Scale Scores on Intake and After Sessions 10, 20,
and 30
Scale
Measurement time
T0 T10 T20 T30
ACQ
a
1.86 1.64 1.31 1.57
Physical Concerns Factor 1.71 1.42 1.5 1.57
Loss of Control Factor 2.00 1.86 1.71 1.57
BSQ
a
2.53 3.53 2.41 2.76
MI
Accompanieda 1.42 1.54 1.25 1.07
Alonea 2.23 3.30 2.37 1.78
BDI-II
b
6515
BSI
Anxiety Scale c 59 76 50 37
Phobic Anxiety Scale
c
60 80 44 44
Note. ACQ ⫽Agoraphobic Cognitions Questionnaire; BSQ ⫽Bodily
Symptoms Questionnaire; MI ⫽Mobility Inventory; BDI-II ⫽Beck
Depression Inventory; BSI ⫽Brief Symptom Inventory; T0 ⫽intake
assessment; T10 ⫽assessment after session 10; T20 ⫽assessment after
session 20; T30 ⫽assessment after session 30.
a
Mean scores.
b
Summary scores.
c
T-scores.
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175
MOVEMENT PATTERNS DURING SITUATIONAL EXPOSURE
Documenting movement and accompanying physiology can
provide an accurate measure of homework compliance, an impor-
tant factor associated with successful therapy (Mausbach et al.,
2010). Our results indicated that the patient complied with the
therapist’s instructions as evidenced by a close correspondence
between GPS paths and the planned routes. When this is not the
case, the depictions can help the therapist to explore why this is so.
More nuanced applications are also conceivable. For example, for
patients who fear leaving their house, plots of GPS trajectories
collected over successive, unaccompanied exposure sessions could
objectively document the distance traveled from home throughout
therapy. This information could help therapists determine depen-
dence on safety signals, identify additional anxiety cues, and to
plan future exposure sessions. Among patients who suggest that
their physiological arousal is life threatening, HR plots might
provide reassuring counterevidence. Further, combining self-
report and physiological data with movement pattern depictions
could serve as a powerful psychoeducational tool.
Practical Implications
As we present results from a single case, it is important to
elaborate on several patient characteristics that may have contrib-
uted to the successful application of our method. Despite already
Figure 2. Second driving exposure: GPS track with color-coded HR embedded in path (above) with accom-
panying HR (beats per minute) plotted against time (below).
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176 WHITE, UMPFENBACH, AND ALPERS
having sought treatment in 2001, the patient’s condition was
chronic, and greatly limited the extent to which she could under-
take daily tasks—a report confirmed by her elevated score on the
alone subscale of the MI. The patient also appeared particularly
motivated to change as she realized that her problem was a burden
on the relationship with her husband. Another particularly relevant
factor was that the patient was not concerned about having her
position or HR monitored during exposure. We attribute this to the
patient’s positive attitude toward technology, which did not appear
to hinge on her educational level and job experience, and also to
the time we spent discussing the rationale for data collection. On
this note, we cannot rule out that reactivity to ambulatory assess-
ment may influence results—for some, the recording may elicit
greater arousal, and thus, distract the patient during exposure; for
others, the device may be viewed as a safety signal and therefore
reduce arousal and ostensibly enhance motivation (Alpers, 2009).
More complicated psychophysiological recordings have been used
in research studies without much indication of reactivity (e.g.,
Alpers, Abelson, Wilhelm, & Roth, 2003;Alpers et al., 2005;
Wilhelm, Alpers, Meuret, & Roth, 2001). Nonetheless, we recom-
mend discussing patient expectations before recording and enquir-
ing about the patient’s experience of wearing devices that monitor
GPS and physiology. Finally, as the patient took medication
throughout treatment, it could be argued that the anxiolytic effects
of the drug were largely responsible for her willingness to engage
in exposure and the gains she experienced. Given the low dose of
Venlafaxine taken, and the chronic nature of the patient’s avoid-
ance, however, it is unlikely that medication substantially ac-
counted for our findings. How well our method generalizes to
other patients with PD/A therefore requires further investigation.
Although we collected data from two exposure sessions, the
quantity of data collected will affect the conclusions that can be
drawn. We are confident that when patients are clear about the
goals of exposure, movement data from a single session can
provide useful insights into various facets of exposure (e.g., com-
pliance, the extent to which challenging situations were confronted
as planned, and momentary physiological arousal). When changes
in avoidance over time wish to be examined, particular attention
should be paid to the instructions given to patients as these will
affect the extent to which separate exposure sessions are compa-
rable. At a more general level, discussing depictions of their
movement and HR collected during exposure should bolster the
patient’s sense of self-efficacy in overcoming agoraphobic reac-
tions. Particularly among patients with negative cognitive schemas
who cannot attribute positive gains to their motivation during
exposure, visualization of progress is a tangible supplement to the
therapist’s encouragement and observations.
To achieve valid recordings, we found it crucial to spend time
configuring the device and training the therapist. We think that ⬃1
hr should suffice for novice users to learn how to configure a
commercially available device. In our case, we configured the
device to minimize the chance that it would pose a distraction to
the patient—we disabled all unwanted tone and vibration alarms,
disabled visual display of HR, and enabled second-to-second sam-
pling to obtain the most accurate recordings. In our case, a re-
searcher configured the device and then spent 30 min informing
the therapist how to attach the HR strap and check for a signal, and
how to commence and end the recording. During therapy, the
therapist spent 30 min discussing the details of the recording with
the patient—the device was shown to the patient, it was made clear
when the device would need to be attached, what would be
recorded, and how the results would be of benefit. Our data
management procedures were also clearly explained. On the day of
exposure, it took ⬃5 min to both attach and detach the watch and
HR belt. Currently, the device costs 230 Euros (US$335), and the
patient received no payment for her participation.
Potential Research Uses
Tracking movement behavior also holds promise for research-
ers. It may help inform theories of fear extinction and avoidance by
offering detailed insights into the behavioral response domain.
This would be timely given that agoraphobia has recently been
reconceptualized as a standalone disorder in DSM-5 (American
Psychiatric Association, 2013). For instance, various facets of
movement could be classified and related to physiological activa-
tion during exposure: the order in which fear-relevant contexts are
encountered; duration and total distance traveled during exposure;
and speed at which feared situations are confronted. Tracking
movement patterns might also elucidate how overprediction of
anxiety, commonly seen in agoraphobic patients (de Beurs,
Chambless, & Goldstein, 2002), affects the manner in which
fear-evoking situations are confronted. In summary, documenting
movement patterns during exposure could provide useful insights
into the mechanisms underlying exposure, which remain hotly
debated.
Limitations
We acknowledge that the feasibility of our method depends on
user’s familiarity with commercially available sports watches.
Setting up and undertaking recordings using modern devices
should however, be within the grasp of novice users. Subsequent
visualization of GPS paths and accompanying HR is made quite
simple with Web applications that come bundled with most de-
vices. Nonetheless, we anticipate that many full-time therapists
may still hesitate at the time investment required to implement the
simplest strategies outlined here. Most GPS devices have been
developed for use as sports tools, and have not been tailored for
clinical applications. However, we envision that the development
of more tailored applications for smartphones will help to reduce
the burden on therapists and patients alike.
Embedding HR into movement trajectories is more complex and
geared for those with some programming experience. GPS drift
sometimes occurs during overcast weather conditions or in
built-up areas of cities, when GPS signals are occluded—this can
occur on entering, or less frequently, walking near tall buildings.
Drift can be corrected using algorithms such as Kalman filters
(Jun, Guensler, & Ogle, 2006); however, for the purposes of
assessing how long patients have spent in various locations, small
amounts of GPS drift should not overly hinder the clinical or
experimental utility of plots. Because complex signal analysis is
often challenging, becoming familiar with practical issues in-
volved in the collection and processing of GPS data are important
(for a review of these issues, see Kerr, Duncan, & Schipperjin,
2011).
There were also some drawbacks associated with the adminis-
tration of our clinical assessment scales (i.e., the ACQ, BSQ, MI,
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177
MOVEMENT PATTERNS DURING SITUATIONAL EXPOSURE
BDI-II, and BSI). Assessing clinical symptoms directly before and
after exposure sessions would have allowed us to more accurately
gauge the impact of exposure sessions. As they stand, clinical scale
scores only provide a broad impression of how symptoms varied
throughout treatment.
Future Directions
In recent years, the use of movement and position sensors has
become widespread, in part through less restricted access to de-
vices such as mobile phones. With this technology, it is possible to
design studies that help define what constitutes “normal” move-
ment patterns for various groups of individuals. For example,
conducting long-term ambulatory assessment of natural movement
patterns among those with and without agoraphobia would yield
rich data that could be used to determine the average levels of
physiological activation associated with geographic locations
throughout treatment. This, in turn, would enable more detailed
tracking of symptom changes, and offer superior follow-up assess-
ment possibilities that could allow therapists to detect, on the basis
of movement patterns, when their patients are at risk of relapse.
Furthermore, comparing the movement patterns of healthy with
avoidant individuals could spur development of an objective mea-
sure of agoraphobic avoidance. These possibilities are only a
sketch of some of the advantages of collecting and using move-
ment patterns. Ultimately, we hope to inspire creative use of such
devices (standalone or integrated in smart phones) in clinical
practice. In the short term, however, we encourage refinement and
extension of our analytic procedures, and anticipate critical eval-
uation of how this novel data source can be meaningfully used
within the field of psychology.
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Received July 29, 2013
Revision received January 15, 2014
Accepted January 24, 2014 䡲
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