PSYC620 Intervention and Behavior Support

CLINICAL HANDBOOK OF PSYCHOLOGICAL DISORDERS

Also from David H. Barlow

Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic, Second Edition

David H. Barlow

Handbook of Assessment and Treatment Planning for Psychological Disorders, Third Edition

Edited by Martin M. Antony and David H. Barlow

Neuroticism: A New Framework for Emotional Disorders and Their Treatment

Shannon Sauer-Zavala and David H. Barlow

CLINICAL HANDBOOK OF PSYCHOLOGICAL DISORDERS A Step-by-Step Treatment Manual

S I X T H E D I T I O N

edited by

DAVID H. BARLOW

THE GUILFORD PRESS New York London

Copyright © 2021 The Guilford Press A Division of Guilford Publications, Inc. 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the authors, nor the editors and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources.

Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Names: Barlow, David H., editor. Title: Clinical handbook of psychological disorders : a step-by-step treatment manual / edited by David H. Barlow. Description: Sixth edition. | New York : The Guilford Press, [2021] | Includes bibliographical references and index. Identifiers: LCCN 2021014995 | ISBN 9781462547043 (hardcover) Subjects: LCSH: Behavior therapy—Handbooks, manuals, etc. | Medical protocols—Handbooks, manuals, etc. | BISAC: PSYCHOLOGY / Psychopathology / General | PSYCHOLOGY / Clinical Psychology Classification: LCC RC489.B4 C584 2021 | DDC 616.89/142—dc23 LC record available at https://lccn.loc.gov/2021014995

v

David H. Barlow, PhD, ABPP, is Professor Emeritus of Psychology and Psychiatry and Founder and Director Emeritus of the Center for Anxiety and Related Disorders at Boston University. Dr. Barlow has published over 650 articles and chapters and over 90 books and clinical manuals, primarily on the nature and treatment of emotional disorders and clini- cal research methodology. His books and manuals have been translated into more than 20 languages. Dr. Barlow’s numerous awards and citations include psychology’s three highest honors: the Distinguished Scientific Award for the Applications of Psychology from the American Psychological Association, the James McKeen Cattell Fellow Award from the Association for Psychological Science, and the Gold Medal Award for Life Achievement in the Practice of Psychology from the American Psychological Foundation.

About the Editor

vii

Idan M. Aderka, PhD, Department of Psychology, University of Haifa, Haifa, Israel

David H. Barlow, PhD, ABPP, Center for Anxiety and Related Disorders, Boston University, Boston, Massachusetts

Aaron T. Beck, MD, University of Pennsylvania Perelman School of Medicine and Beck Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania

Kate H. Bentley, PhD, Department of Psychiatry, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts

Katherine Berry, PhD, Division of Psychology and Mental Health, University of Manchester, Manchester, United Kingdom

Kathryn L. Bleiberg, PhD, Department of Psychology, Weill Cornell Medicine, New York, New York

Kathleen M. Chard, PhD, Cincinnati VA Medical Center, Cincinnati, Ohio

Andrew Christensen, PhD, Department of Psychology, University of California, Los Angeles, Los Angeles, California

Zafra Cooper, DPhil, Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut

Michelle G. Craske, PhD, Department of Psychology and Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, California

Sona Dimidjian, PhD, Renée Crown Wellness Institute and Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, Colorado

Brian D. Doss, PhD, Department of Psychology, University of Miami, Coral Gables, Florida

Kristen K. Ellard, PhD, Department of Psychiatry, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts

Contributors

viii Contributors

Elizabeth E. Epstein, PhD, Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts

Elizabeth H. Eustis, PhD, Center for Anxiety and Related Disorders, Boston University, Boston, Massachusetts

Todd J. Farchione, PhD, Center for Anxiety and Related Disorders, Boston University, Boston, Massachusetts

Edna B. Foa, PhD, Center for the Treatment and Study of Anxiety, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania

Martin E. Franklin, PhD, Rogers Behavioral Health, Philadelphia, Pennsylvania

Allison G. Harvey, PhD, Department of Psychology, University of California, Berkeley, Berkeley, California

Sarah H. Heil, PhD, Vermont Center on Behavior and Health and Departments of Psychiatry and Psychological Science, University of Vermont, Burlington, Vermont

Ruth Herman‑Dunn, PhD, private practice and Department of Psychology, University of Washington, Seattle, Washington

Stephen T. Higgins, PhD, Vermont Center on Behavior and Health and Departments of Psychiatry and Psychological Science, University of Vermont, Burlington, Vermont

Stefan G. Hofmann, PhD, Center for Anxiety and Related Disorders, Boston University, Boston, Massachusetts

Samuel Hubley, PhD, Renée Crown Wellness Institute and Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, Colorado

Neil S. Jacobson, PhD (deceased), formerly of Department of Psychology, University of Washington, Seattle, Washington

Katherine A. Kaplan, PhD, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Marsha M. Linehan, PhD, ABPP, Department of Psychology, University of Washington, Seattle, Washington

Joseph S. Maimone, BA, Department of Psychology, Massachusetts General Hospital/ Harvard Medical School, Cambridge, Massachusetts

John C. Markowitz, MD, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, New York, New York

Christopher R. Martell, PhD, Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, Massachusetts

Barbara S. McCrady, PhD, Center on Alcohol, Substance Use, and Addictions (CASAA) and Department of Psychology, The University of New Mexico, Albuquerque, Albuquerque, New Mexico

David J. Miklowitz, PhD, Max Gray Child and Adolescent Mood Disorders Program, Division of Child and Adolescent Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, California

Contributors ix

Candice M. Monson, PhD, Department of Psychology, Ryerson University, Toronto, Ontario, Canada

Rebecca Murphy, DClinPsych, Department of Psychiatry, University of Oxford, Oxford, United Kingdom

Andrada D. Neacsiu, PhD, Cognitive Behavioral Research and Therapy Program, Department of Psychiatry and Behavioral Sciences, and Department of Family Medicine, Duke University Medical Center, Durham, North Carolina

Matthew K. Nock, PhD, Department of Psychology, Harvard University, Cambridge, Massachusetts

K. Maria Nylocks, PhD, Emory Healthcare Veterans Program, Emory University School of Medicine, Atlanta, Georgia

Susan M. Orsillo, PhD, Department of Psychology, Suffolk University, Boston, Massachusetts

John D. Otis, PhD, Center for Anxiety and Related Disorders, Boston University, Boston, Massachusetts

Laura A. Payne, PhD, Department of Psychiatry, McLean Hospital/Harvard Medical School, Belmont, Massachusetts

Kelly R. Peck, PhD, Vermont Center on Behavior and Health and Departments of Psychiatry and Psychological Science, University of Vermont, Burlington, Vermont

Lizabeth Roemer, PhD, Department of Psychology, University of Massachusetts Boston, Boston, Massachusetts

Jayne L. Rygh, PhD, private practice, New York, New York

Philippe Shnaider, PhD, Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada

Nicholas Tarrier, PhD, FBPsS, FBA, Emeritus Professor, Department of Psychology, University of Manchester, Manchester, United Kingdom

Erin F. Ward-Ciesielski, PhD, Center for Anxiety and Related Disorders, Boston University, Boston, Massachusetts

Arthur D. Weinberger, PhD, formerly of Cognitive Therapy Center of New York, New York, New York

Jennifer G. Wheeler, PhD, Pacific Evaluation, Consultation, and Treatment Services, PLLC, Seattle, Washington

Kate Wolitzky-Taylor, PhD, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, California

Jeffrey E. Young, PhD, Schema Therapy Institute, New York, New York

Noga Zerubavel, PhD, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina

xi

Evidence-based practice (EBP) is one of those ideas that comes along occasionally and takes the world by storm. Although some of the tenets of EBP have been around for

decades (as has this handbook), it is only in the past 20 years that EBP has been formally identified as a systematic method of delivering clinical care (Institute of Medicine, 2001; Sackett, Strauss, Richardson, Rosenberg, & Haynes, 2000).

Since that time, the “tipping point” (Gladwell, 2000) for EBP has clearly occurred, and health care policymakers and governments, as well as professional societies around the world, have collectively decided that the delivery of health care, including behavioral health care, should be based on evidence (e.g., Silverman et al., 2015; American Psycho- logical Association, 2015; Barlow, 2004; Institute of Medicine, 2015; McHugh & Barlow, 2010). Fulfilling this mandate is the goal of EBP, and has also been the goal of this book since the first edition was published in 1985, and almost all clinical practice guidelines from leading behavioral health care delivery systems worldwide recommend treatment pro- tocols described in this book. This includes the Veterans Health Administration (www. healthquality.va.gov) and the National Institute for Health and Care Excellence within the National Health Service in the United Kingdom (www.nice.org.uk/guidance).

The sixth edition of this handbook continues to represent a distinct departure from any number of similar books reviewing advances in the treatment of psychological disor- ders from the perspective of EBP. Over the past two decades, we have developed a technol- ogy of behavior change that necessarily differs from disorder to disorder (and increasingly for classes of disorders).

This technology comprises a variety of techniques or procedures with more or less proven effectiveness for specific presentations of psychopathology. Naturally, we have more evidence of the effectiveness of these treatments for some disorders than for others. It also has become more apparent since the earlier editions that considerable clinical skill is required to apply this technology most effectively. Therefore, this handbook, in its sixth edition, is not another review of therapeutic procedures for a given problem, with recom- mendations for further research. Rather, it is a detailed description of actual treatment protocols in which experienced clinicians implement the technology of behavior change in the context of the most frequently encountered disorders or classes of disorders.

Preface

xii Preface

In this edition, the originators of some of the best-known treatment protocols have revised and updated the descriptions of their interventions to reflect the latest develop- ments in an increasingly powerful array of psychological therapies. Among these revisions to existing chapters, several deserve comment. Monson, Shnaider, and Chard (Chapter 2) have updated their chapter on posttraumatic stress disorder, describing the tragic case of a soldier fresh from the battlefields of Iraq. Their successful treatment of this individual suffering from the unspeakable (and intolerable) trauma of war is one consequence of today’s headline news stories that seldom makes it into print. Drug abuse continues as a scourge that ruins individual lives, the functioning of families, and the very fabric of soci- ety. Higgins, Heil, and Peck (Chapter 15) present the latest iterations of their approach, with a focus in this edition on the scourge of opiate abuse. Chapters on schizophrenia and other psychotic disorders, borderline personality disorder, bipolar disorder, and a number of anxiety disorders, along with depression, written in almost all cases by the originators of these leading protocols, have been updated considerably to reflect the latest evidence for the most effective approaches to these common but debilitating problems.

In addition, three original treatment protocols make their appearance for the first time in this edition. Chronic pain is the most common and most costly single disorder pre- senting to health care systems, easily outranking cancer, cardiovascular disease, and every other psychological disorder in this book. Brief psychological treatments for chronic pain are the first-line treatment, and the protocol in this book by Otis (Chapter 17), one of the leading investigators and clinicians in this area, reflects decades of research and refinement and is one of the success stories in EBP.

Self-injurious thoughts and behaviors (SITBs) have attracted increasing attention from health care policymakers and delivery systems as a broad area of concern associated with many different disorders, and on occasion occurring independently of additional psy- chopathology. With suicide rates alone climbing since 2010, the application of a transdiag- nostic protocol targeting this class of behaviors originated by Bentley, Maimone, and Nock (Chapter 11), leading investigators from Harvard and Massachusetts General Hospital, is a welcome addition to this book.

Also making a first appearance in this edition are Aderka and Hofmann (Chapter 3), illustrating a newer cognitive-behavioral intervention called “process-based therapy.” This third-wave approach, originated by Hayes and Hofmann (2018), goes beyond the static DSM approach to diagnosis and more standardized treatment protocols by emphasizing a very idiographic or individual approach to assessment and treatment in the specific context of the patient, along with continual processing and feedback. This intervention is nicely illustrated in the assessment and treatment of the case of “Mark,” suffering from social anxiety disorder.

Finally, there is growing consensus that the future of EBP will be to distill principles of effective change that cut across diagnostic conditions, making them more generally applicable. Two of these “unified” or “transdiagnostic” protocols appear in this sixth edi- tion. In Chapter 6 (Payne, Ellard, Farchione, & Barlow), we present our own unified trans- diagnostic approach to emotional disorders. Cooper and Murphy (Chapter 18) describe a transdiagnostic approach to eating disorders that they originated in collaboration with their colleagues.

In all chapters, the nuts and bolts of clinical application are emphasized. As with the previous editions, this book was motivated by countless clinical psychology graduate stu-

Preface xiii

dents, psychiatric residents, and other mental health professionals, either in training or in practice, asking, “But how do I do it?” Realizing that there is no single source in which to find step-by-step treatment protocols for use as a guide to practice, this book attempts to fill the void. To accomplish this purpose, a number of specific topics are common to most chapters. Each chapter begins with a brief review of our knowledge of the specific disorder (or class of disorders), followed by a description of the particular model or mini-theory that guides the technology utilized with the disorder in question. This model, or mini-theory, typically answers the question What particular facets of the disorder should be assessed and treated? While clinical application always dilutes theoretical models, clinicians will recognize cognitive-behavioral and systems approaches, with some psychodynamic contri- butions, as the predominant theoretical context.

This model is followed by a description of the typical setting in which the treatment is carried out. The setting varies from disorder to disorder, ranging from the more usual office setting to the home environment of the patient. Authors provide similar detailed descriptions of the social context of treatment (e.g., the importance of the involvement of family or friends) as well as therapist and client variables that are important within the con- text of the particular problem. For example, therapist variables that may be important in implementing techniques for treatment of agoraphobia or couple distress are described. In addition, authors discuss the implications for treatment of client variables, such as depen- dency and unassertiveness in individuals with panic disorder with agoraphobia.

A detailed description of the actual step-by-step process of assessment and treatment follows, liberally sprinkled in many chapters with transcripts of therapy sessions. Important components of this process are the specifics of the rationale given to the patient before treat- ment, as well as typical problems that arise during the implementation of the technology. Where data exist, authors provide information on clinical predictors of success or failure.

In accomplishing the rather ambitious goals just described, I was very fortunate in this edition of the book, as in previous editions, to have leading clinicians and researchers document in some detail how they actually treat their patients. Once again, these authori- ties reported that the number of details they had to include in order to convey how they actually applied their treatment programs went far beyond their expectations. My hope is that practicing clinicians and clinical students everywhere will benefit from acquaintance with these details.

In closing, I would like to express my deep appreciation to Bethany Harris, my research and administrative assistant during the editing of this book. She worked with me and the authors every step of the way. I am sure this information will come in handy as she is now pursuing her own doctorate in clinical psychology.

REFERENCES

American Psychological Association. (2015). Professional practice guidelines: Guidance for developers and users. American Psychologist, 70(9), 823–831.

Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59(9), 869–878. Gladwell, M. (2000). The tipping point: How little things can make a big difference. Boston: Little,

Brown. Hayes, S. C., & Hofmann, S. G. (Eds.). (2018). Process-based CBT: The science and core clinical compe-

tencies of cognitive behavioral therapy. Oakland, CA: New Harbinger.

xiv Preface

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Wash- ington, DC: National Academies Press.

Institute of Medicine. (2015). Psychosocial interventions for mental and substance use disorders: A frame- work for establishing evidence-based standards. Washington, DC: National Academies Press.

McHugh, R. K., & Barlow, D. H. (2010). Dissemination and implementation of evidence-based psy- chological interventions: A review of current efforts. American Psychologist, 65(2), 73–84.

Sackett, D. L., Strauss, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence- based medicine: How to practice and teach EBM (2nd ed.). London: Churchill Livingstone.

Silverman, J. J., Galanter, M., Jackson-Triche, M., Jacobs, D. G., Lomax, J. W., Riba, M. B., et al. (2015). The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. American Journal of Psychiatry, 172(8), 798–802.

xv

1. Panic Disorder and Agoraphobia 1 Michelle G. Craske, Kate Wolitzky‑Taylor, and David H. Barlow

2. Posttraumatic Stress Disorder 64 Candice M. Monson, Philippe Shnaider, and Kathleen M. Chard

3. Social Anxiety: A Process‑Based Treatment Approach 108 Idan M. Aderka and Stefan G. Hofmann

4. Obsessive–Compulsive Disorder 133 Martin E. Franklin and Edna B. Foa

5. Generalized Anxiety Disorder: An Acceptance‑Based 184 Behavioral Therapy Lizabeth Roemer, Elizabeth H. Eustis, and Susan M. Orsillo

6. Emotional Disorders: A Unified Protocol 217 for Transdiagnostic Treatment Laura A. Payne, Kristen K. Ellard, Todd J. Farchione, and David H. Barlow

Contents

xvi Contents

7. Cognitive Therapy for Depression 257 Jeffrey E. Young, Erin F. Ward‑Ciesielski, Jayne L. Rygh, Arthur D. Weinberger, and Aaron T. Beck

8. Interpersonal Psychotherapy for Depression 317 Kathryn L. Bleiberg and John C. Markowitz

9. Behavioral Activation for Depression 339 Sona Dimidjian, Christopher R. Martell, Ruth Herman‑Dunn, and Samuel Hubley

10. Borderline Personality Disorder 381 Andrada D. Neacsiu, Noga Zerubavel, K. Maria Nylocks, and Marsha M. Linehan

11. Addressing Self‑Injurious Thoughts and Behaviors 443 within the Context of Transdiagnostic Treatment for Emotional Disorders Kate H. Bentley, Joseph S. Maimone, and Matthew K. Nock

12. Bipolar Disorder 480 David J. Miklowitz

13. Schizophrenia and Other Psychotic Disorders 522 Nicholas Tarrier and Katherine Berry

14. Alcohol Use Disorders 555 Barbara S. McCrady and Elizabeth E. Epstein

15. Substance Use Disorders 612 Stephen T. Higgins, Sarah H. Heil, and Kelly R. Peck

16. Treatment of Sleep Disturbance 638 Katherine A. Kaplan and Allison G. Harvey

17. Cognitive‑Behavioral Therapy for Chronic Pain 670 John D. Otis

Contents xvii

18. Eating Disorders: A Transdiagnostic Protocol 705 Zafra Cooper and Rebecca Murphy

19. Couple Distress 742 Andrew Christensen, Jennifer G. Wheeler, Brian D. Doss, and Neil S. Jacobson

Author Index 773

Subject Index 799

1

The treatment protocol described in this chapter represents one of the success stories in the devel- opment of evidence-based psychological treatments. Results from numerous studies indicate that this approach provides substantial advantages over placebo medication or alternative psychosocial approaches containing “common” factors, such as positive expectancies and helpful therapeutic alli- ances. In addition, this treatment forms an important part of every clinical practice guideline in either public health or other sources from countries around the world, describing effective treatments for panic disorder and agoraphobia. Results from numerous studies evaluating this treatment protocol, both individually and in combination with leading pharmacological approaches, suggest that this approach is equally effective as the best pharmacological approaches in the short term and more durable over the long term. But this treatment protocol has not stood still. For example, we have learned a great deal in recent years about neurobiological mechanisms of action in fear reduction, and the best psychological methods for effecting these changes, particularly strategies for optimizing inhibitory learning and retrieval. Newly developed acceptance-based procedures have also proven efficacious. In this chapter we present the latest version of this protocol, incorporating these changes and additions, all as illustrated in a comprehensive account of the treatment of “Julie.” —D. H. B.

Advances continue in the development of biopsycho- social models and cognitive-behavioral treatments

for panic disorder and agoraphobia. The conceptu- alization of panic disorder as an acquired fear of cer- tain bodily sensations, and agoraphobia as a behavioral response to the anticipation of related bodily sensa- tions or their crescendo into a full-blown panic attack, continues to be supported by experimental, clinical, and longitudinal research. Furthermore, the efficacy of cognitive-behavioral treatments that target fear of bodily sensations and associated agoraphobic situations is well established. In addition to presenting an up-to- date review of treatment outcome data, this chapter covers recent theoretical and empirical developments in reference to etiological factors, the role of comorbid diagnoses in treatment, ways to optimize learning dur-

ing exposure therapy, and the effect of medication on cognitive-behavioral treatments. The chapter concludes with a detailed, session-by-session outline of cognitive- behavioral treatment for panic disorder and agorapho- bia. This protocol has been developed in our clinics; the full protocol is detailed in available treatment manuals (Barlow & Craske, 2007; Craske & Barlow, 2007).

NATURE OF PANIC AND AGORAPHOBIA

Panic Attacks

Panic attacks are discrete episodes of intense fear or dis- comfort, accompanied by physical and cognitive symp- toms, as listed in the DSM-5 panic attack checklist (American Psychiatric Association, 2013). Panic attacks

C H A P T E R 1

Panic Disorder and Agoraphobia

Michelle G. Craske Kate Wolitzky‑Taylor David H. Barlow

2 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

are discrete by virtue of their sudden or abrupt onset and brief duration, as opposed to gradually building anxious arousal. Panic attacks in panic disorder often have an unexpected quality, which means that from the patient’s perspective, they appear to happen without an obvious trigger or at unexpected times. Indeed, the diagnosis of panic disorder is defined by recurrent “un- expected” panic attacks, followed by at least 1 month of persistent concern about their recurrence and their consequences, or by a significant change in behavior consequent to the attacks (American Psychiatric Asso- ciation, 2013).

As with all basic emotions (Izard, 1992), panic at- tacks are associated with strong action tendencies: Most often, these are urges to escape, and less often, urges to fight. These fight or flight tendencies usually involve elevated autonomic nervous system arousal needed to support such fight–flight reactivity. Furthermore, per- ceptions of imminent threat or danger, such as death, loss of control, or social ridicule, often accompany such fight–flight reactivity. However, the features of urgency to escape, autonomic arousal, and perception of threat are not present in every self-reported occurrence of panic. For example, despite evidence for elevated heart rate or other indices of sympathetic nervous system acti- vation during panic attacks on average (e.g., Wilkinson et al., 1998), Margraf, Taylor, Ehlers, Roth, and Agras (1987) found that 40% of self-reported panic attacks were not associated with accelerated heart rate. More- over, in general, patients with panic disorder are more likely than nonanxious controls to report arrhythmic heart rate in the absence of actual arrhythmias (Barsky, Cleary, Sarnie, & Ruskin, 1994). Heightened anxiety about signs of autonomic arousal may lead patients to perceive cardiac events when none exist (Barlow, Brown, & Craske, 1994; Craske & Tsao, 1999). We believe that self-reported panic in the absence of heart rate accel- eration or other indices of autonomic activation reflects anticipatory anxiety rather than true panic (Barlow et al., 1994), especially because more severe panic attacks are more consistently associated with accelerated heart rate (Margraf et al., 1987). Sometimes individuals re- port intense abrupt fear in the absence of perceptions of threat or danger. This has been termed noncognitive panic (Rachman, Lopatka, & Levitt, 1988; see Kircan- ski, Craske, Epstein, & Wittchen, 2009). Finally, the urgency to escape is sometimes weakened by situational demands for continued approach and endurance, such as performance expectations or job demands, thus cre-

ating discordance between behavioral responses on the one hand, and verbal or physiological fear responses on the other.

A subset of individuals with panic disorder experi- ence nocturnal panic attacks. Nocturnal panic refers to waking from sleep in a state of panic, with symptoms that are very similar to panic attacks during wakeful states (Craske & Barlow, 1989; Uhde, 1994). Noctur- nal panic does not refer to waking from sleep and pan- icking after a lapse of waking time, or nighttime arous- als induced by nightmares or environmental stimuli (e.g., unexpected noises). Instead, nocturnal panic is an abrupt waking from sleep in a state of panic, without an obvious trigger. Nocturnal panic attacks reportedly most often occur between 1 and 3 hours after sleep onset, and only occasionally more than once per night (Craske & Barlow, 1989). Surveys of select clinical groups suggest that nocturnal panic is relatively com- mon among individuals with panic disorder: 44–71% report having experienced nocturnal panic at least once, and 30–45% report repeated nocturnal pan- ics (Craske & Barlow, 1989; Krystal, Woods, Hill, & Charney, 1991; Mellman & Uhde, 1989; Roy-Byrne, Mellman, & Uhde, 1988; Uhde, 1994). Individuals who suffer frequent nocturnal panic often become fearful of sleep and attempt to delay sleep onset. Avoid- ance of sleep may result in chronic sleep deprivation, which in turn precipitates more nocturnal panic inci- dents (Uhde, 1994).

“Nonclinical” panic attacks occur occasionally in ap- proximately 3–5% of people in the general population who do not otherwise meet criteria for panic disorder (Norton, Cox, & Malan, 1992). Also, panic attacks occur across a variety of anxiety and mood disorders (Barlow et al., 1985), as well as substance use, personal- ity disorders and psychoses (Craske et al., 2010) and are not limited to panic disorder. Indeed, the ubiquity of panic attacks has been emphasized in DSM-5 (Ameri- can Psychiatric Association, 2013), in which panic attacks are designated as a potential specifier for any DSM disorder. As stated earlier, the defining feature of panic disorder is not the presence of panic attacks per se, but involves additional anxiety about the recurrence of panic or its consequences, or a significant behavioral change because of the panic attacks. It is the additional anxiety about panic combined with catastrophic cogni- tions in the face of panic that differentiate between the person with panic disorder and the occasional nonclini- cal panicker (e.g., Telch, Lucas, & Nelson, 1989) or the

Panic Disorder and Agoraphobia 3

person with other anxiety disorders who also happens to panic. The following scenario exemplifies the latter point.

PATIENT: Sometimes I lay awake at night thinking about a million different things. I think about what is going to happen to my daughter if I get sick. Who will look after her, or what would happen if my hus- band died and we didn’t have enough money to give my daughter a good education? Then I think about where we would live and how we would cope. Some- times I can work myself up so much that my heart starts to race, my hands get sweaty, and I feel dizzy and scared. So I have to stop myself from thinking about all those things. I usually get out of bed and turn on the TV—anything to get my mind off the worries.

THERAPIST: Do you worry about the feelings of a rac- ing heart, sweating, and dizziness happening again?

PATIENT: No. They’re unpleasant, but they are the least of my concerns. I am more worried about my daugh- ter and our future.

This scenario illustrates the experience of panic that is not the central focus of the person’s anxiety. More likely, this woman has generalized anxiety disorder, and her uncontrollable worry leads her to panic on occa- sion. The next example is someone with social anxiety disorder, who becomes very concerned about panicking in social situations, because the possibility of a panic attack increases her concerns about being judged nega- tively by others.

PATIENT: I am terrified of having a panic attack in meetings at work. I dread the thought of others no- ticing how anxious I am. They must be able to see my hands shaking, the sweat on my forehead, and worst of all, my face turning red.

THERAPIST: What worries you most about others notic- ing your physical symptoms?

PATIENT: That they will think that I am weird or strange.

THERAPIST: Would you be anxious in the meetings if the panic attacks were gone?

PATIENT: I would still be worried about doing or saying the wrong thing. It is not just the panic attacks that worry me.

THERAPIST: Are you worried about panic attacks in any other situations?

PATIENT: Formal social events and sometimes when I meet someone for the first time.

In this case, even though the patient experiences panic attacks, the real concern is about being judged negatively by others consequent to panic attacks, and the panic attacks do not occur in situations other than social ones. Hence, this presentation is most aptly de- scribed as social anxiety.

Agoraphobia

Agoraphobia refers to avoidance or endurance with dread of situations from which escape might be diffi- cult or when help is unavailable in the event of a panic- like symptoms (including but not limited to panic at- tacks) or other incapacitating symptoms, such as loss of bowel control or vomiting, disorientation (especially in children), or sense of falling (especially in older adults) (American Psychiatric Association, 2013). Typical ago- raphobic situations include shopping malls, waiting in line, movie theaters, traveling by car or bus, crowded restaurants, and being alone. “Mild” agoraphobia is exemplified by the person who hesitates about driving long distances alone but manages to drive to and from work, prefers to sit on the aisle at movie theaters but still goes to movies, and avoids crowded places. “Moderate” agoraphobia is exemplified by the person whose driving is limited to a 10-mile radius from home and only if accompanied, who shops at off-peak times and avoids large supermarkets, and who avoids flying or travel- ing by train. “Severe” agoraphobia refers to very lim- ited mobility, sometimes even to the point of becoming housebound.

Relationship between Panic and Agoraphobia

The relationship between panic and agoraphobia is complex. On the one hand, not all persons who panic develop agoraphobia, and the extent of agoraphobia that emerges is highly variable (Craske & Barlow, 1988). Various factors have been investigated as potential pre- dictors of agoraphobia. Although agoraphobia tends to increase as history of panic lengthens, a significant proportion of individuals panic for many years without developing agoraphobic limitations. Nor is agorapho-

4 CliniCal Handbook of PsyCHologiCal disorders

bia related to age of onset or frequency of panic (Cox, Endler, & Swinson, 1995; Craske & Barlow, 1988; Kikuchi et al., 2005; Rapee & Murrell, 1988). Some studies report more intense physical symptoms during panic attacks when there is more agoraphobia (e.g., de Jong & Bouman, 1995; Goisman et al., 1994; Noyes, Clancy, Garvey, & Anderson, 1987; Telch, Brouillard, Telch, Agras, & Taylor, 1989). Others fail to find such differences (e.g., Cox et al., 1995; Craske, Miller, Ro- tunda, & Barlow, 1990). On the one hand, fears of dying, going crazy, or losing control do not relate to level of agoraphobia (Cox et al., 1995; Craske, Rapee, & Barlow, 1988). On the other hand, concerns about social consequences of panicking may be stronger when there is more agoraphobia (Amering et al., 1997; de Jong & Bouman, 1995; Rapee & Murrell, 1988; Telch, Brouilard, et al., 1989). In addition, Kikuchi and col- leagues (2005) found that individuals who develop agoraphobia within 6 months of the onset of panic dis- order have a higher prevalence of generalized anxiety disorder but not major depression. However, whether social evaluation concerns or comorbidity are precur- sors or are secondary to agoraphobia remains to be de- termined. Occupational status also predicts agorapho- bia, accounting for 18% of the variance in one study (de Jong & Bouman, 1995). Perhaps the strongest predictor of agoraphobia is sex; the ratio of males to females shifts dramatically in the direction of female predominance as level of agoraphobia worsens (e.g., Thyer, Himle, Curtis, Cameron, & Nesse, 1985).

On the other hand, not everyone with agoraphobia has a history of panic attacks or even panic-like symp- toms, although a history of panic is much more com- mon in treatment-seeking samples of individuals with agoraphobia than in epidemiological samples (Witt- chen, Gloster, Beesdo-Baum, Fava, & Craske, 2010). Nonetheless, the prevalence of agoraphobia without a history of panic disorder, panic attacks, or panic-like symptoms was reported to be at least as high as the combined rates of panic disorder with and without agoraphobia across all epidemiological studies (Witt- chen et al., 2010). Approximately 50% of individuals from community samples who endorse agoraphobia do not endorse panic attacks. Furthermore, agoraphobia without panic-like features appears to be as impairing as panic disorder without agoraphobia, although the combination is usually associated with even more im- pairment. In addition, some differences exist between them in terms of incidence, comorbidity, and response to treatment (Wittchen et al., 2010). For these reasons,

panic disorder and agoraphobia are now recognized as two distinct, albeit highly comorbid, disorders in DSM-5 (American Psychiatric Association, 2013).

PRESENTING FEATURES

From the latest epidemiological study in the United States, the National Comorbidity Survey Replication (NCS-R; Kessler, Berglund, Demler, Jin, & Walters, 2005; Kessler, Chiu, Demler, & Walters, 2005), 12- month prevalence estimates for panic disorder are ap- proximately 2% in adults and adolescents. Lower esti- mates have been reported for some Asian, African, and Latin American countries, ranging from 0.1 to 0.8% (Lewis-Fernandez et al., 2010). However, a recent mul- tinational epidemiological study of individuals in 25 countries reported a similar lifetime prevalence esti- mate of 1.7% (de Jonge et al., 2016). The 12-month rates for agoraphobia are approximately 1.7%, and the lifetime morbid risk is 3.7% (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012).

The modal age of onset for panic disorder is late teen- age years and early adulthood (Kessler, Berglund, et al., 2005). In fact, although panic disorder is rare below the age of 14, a substantial proportion of adolescents report panic attacks (e.g., Hayward et al., 1992), and panic disorder in children and adolescents tends to be chronic and comorbid with other anxiety, mood, and disrup- tive disorders (Biederman, Faraone, Marrs, & Moore, 1997). Treatment is usually sought much later, around age 34 (e.g., Noyes et al., 1986). Similarly, agorapho- bia may occur in childhood, but the incidence peaks in late adolescence and early adulthood (Beesdo, Knappe, & Pine, 2007; Bittner et al., 2007); the mean age of onset is 17 years (Kessler et al., 2012), and older in the absence of history of panic disorder or panic attacks. Rates of panic disorder decline in older adults, possi- bly diminishing to subclinical levels (Wolitzky-Taylor, Castriotti, Lenze, Stanley, & Craske, 2010). Similarly, 12-month prevalence rates for agoraphobia reduce to 0.4% in individuals over the age of 65 years (Kessler et al., 2006). The overall ratio of females to males is ap- proximately 2:1 (Kessler et al., 2006) and, as mentioned already, the ratio shifts dramatically in the direction of female predominance as level of agoraphobia worsens (e.g., Thyer et al., 1985).

Rarely do the diagnoses of panic disorder or agoraphobia occur in isolation. Indeed, a multinational epidemiological study found that 80.2% of individu-

Panic Disorder and Agoraphobia 5

als who met lifetime diagnostic criteria for panic dis- order had another lifetime comorbid mental disorder (de Jonge et al., 2016). Commonly co-occurring Axis I conditions included specific phobias, social phobia, dysthymia, generalized anxiety disorder, major depres- sive disorder, and substance abuse (e.g., Brown, Camp- bell, Lehman, Grishman, & Mancill, 2001; Goisman, Goldenberg, Vasile, & Keller, 1995; Kessler, Chiu, et al., 2005). Also, 25–60% of persons with panic disor- der also meet criteria for a personality disorder, mostly avoidant and dependent personality disorders (e.g., Chambless & Renneberg, 1988). However, the nature of the relationship with personality disorders remains unclear. For example, comorbidity rates were highly dependent on the method used to establish Axis II di- agnosis, as well as the co-occurrence of depressed mood (Alneas & Torgersen, 1990; Chambless & Renneberg, 1988). Moreover, the fact that abnormal personal- ity traits improve and some “personality disorders” even remit after successful treatment of panic disorder (Black, Monahan, Wesner, Gabel, & Bowers, 1996; Mavissakalian & Hamman, 1987; Noyes, Reich, Suel- zer, & Christiansen, 1991) raises questions about the validity of Axis II diagnoses. The issue of comorbidity with personality disorders and its effect on treatment for panic disorder and agoraphobia is described in more detail in a later section.

Finally, panic disorder and agoraphobia tend to be chronic conditions, with severe financial and inter- personal costs (Wittchen et al., 2010). Only a minor- ity of untreated individuals remit without subsequent relapse within a few years if not treated (Emmelkamp & Wittchen, 2009; Katschnig & Amering, 1998; Roy- Byrne & Cowley, 1995). Also, individuals with panic disorder overutilize medical resources compared to the general public and individuals with other “psychiatric” disorders (e.g., Katon et al., 1990; Roy-Byrne et al., 1999).

HISTORY OF PSYCHOLOGICAL TREATMENT FOR PANIC DISORDER AND AGORAPHOBIA

It was not until the publication of DSM-III (Ameri- can Psychiatric Association, 1980) that panic disorder with or without agoraphobia was recognized as a dis- tinct anxiety problem. Until that time, panic attacks were viewed primarily as a form of free-floating anxi- ety. Consequently, psychological treatment approaches were relatively nonspecific. They included relaxation

and cognitive restructuring for stressful life events in general (e.g., Barlow, O’Brien, & Last, 1984). Many presumed that pharmacotherapy was necessary for the control of panic. In contrast, the treatment of agora- phobia was quite specific from the 1970s onward, with primarily exposure-based approaches to target fear and avoidance of specific situations. However, relatively little consideration was given to panic attacks in either the conceptualization or treatment of agoraphobia. The development of specific panic control treatments in the middle to late 1980s shifted interest away from agoraphobia. Interest in agoraphobia was subsequently renewed, specifically in terms of whether panic control treatments are sufficient for the management of agora- phobia, and whether their combination with treatments that directly target agoraphobia is superior overall. We address these questions in more detail after describing the conceptualization that underlies cognitive-behav- ioral approaches to the treatment of panic and agora- phobia.

CONCEPTUALIZATION OF ETIOLOGICAL AND MAINTAINING FACTORS FOR PANIC DISORDER AND AGORAPHOBIA

Several independent lines of research (Barlow, 1988; Clark, 1986; Ehlers & Margraf, 1989) converged in the 1980s on the same basic conceptualization of panic disorder as an acquired anxiety focused on bodily sensations, particularly sensations associated with au- tonomic arousal. Psychological and biological predis- positions are believed to enhance the vulnerability to acquire such anxiety. These interacting vulnerabilities have been organized into an etiological conception of anxiety disorders in general, referred to as “triple vul- nerability theory” (Barlow, 1988, 2002; Barlow, Ellard, Sauer-Zavala, Bullis, & Carl, 2014; Suárez, Bennett, Goldstein, & Barlow, 2008). First, genetic contribu- tions to the development of anxiety and negative affect constitute a generalized (heritable) biological vulnera- bility. Second, evidence supports a generalized psycho- logical vulnerability to experience anxiety and related negative affective states, characterized by a diminished sense of control arising from early developmental ex- periences. Although the unfortunate co-occurrence of generalized biological and psychological vulnerabilities may be sufficient to produce anxiety and related states, particularly generalized anxiety disorder and depres- sion, and perhaps, neuroticism itself, a third vulnerabil-

6 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

ity seems necessary to account for the development of at least some specific anxiety disorders, including panic disorder; that is, early learning experiences in some instances seem to focus anxiety on particular areas of concern. In panic disorder, the experience of certain so- matic sensations becomes associated with a heightened sense of threat and danger. This specific psychological vulnerability, when coordinated with the generalized biological and psychological vulnerabilities mentioned earlier, seems to contribute to the development of panic disorder. Fear conditioning, avoidant responding, and information-processing biases are believed to perpetu- ate such fear. It is the perpetuating factors that are tar- geted in the cognitive-behavioral treatment approach. What follows is a very brief review of some contributory factors with practical relevance for panic disorder.

Vulnerability Factors

Genetics and Temperament

The temperament most associated with anxiety disor- ders, including panic disorder, is neuroticism (Eysenck, 1967; Gray, 1982), or proneness to experience negative emotions in response to stressors. A closely linked con- struct, negative affectivity, is the tendency to experience a variety of negative emotions across a variety of situa- tions, even in the absence of objective stressors (Wat- son & Clark, 1984). Structural analyses confirm that negative affect/neuroticism is a higher-order factor that distinguishes individuals with each anxiety disorder (and depression) from controls with no mental disor- der: Lower-order factors discriminate among anxiety disorders, with “fear of fear” (more accurately, anxiety focused on somatic symptoms of the emotion of fear) being the factor that discriminates panic disorder from other anxiety disorders (Brown, Chorpita, & Barlow, 1998; Prenoveau et al., 2010; Zinbarg & Barlow, 1996). The anxiety disorders load differentially on negative af- fectivity, with more pervasive anxiety disorders, such as generalized anxiety disorder, loading more heavily, panic disorder loading at an intermediate level, and social anxiety disorder loading the least (Brown et al., 1998).1 However, these findings derive from cross- sectional datasets.

Longitudinal prospective evidence for the role of neuroticism in predicting the onset of panic disorder is relatively limited. Specifically, neuroticism predicted the onset of panic attacks in adolescents (Hayward, Killen, Kraemer, & Taylor, 2000; Schmidt, Lerew, &

Jackson, 1997, 1999), and “emotional reactivity” at age 3 was a significant variable in the classification of panic disorder in 18- to 21-year-old males (Craske, Poulton, Tsao, & Plotkin, 2001).

Numerous multivariate genetic analyses of human twin samples consistently attribute approximately 30–50% of variance in neuroticism to additive genetic factors (Barlow, Ellard, et al., 2014; Eley, 2001; Lake, Eaves, Maes, Heath, & Martin, 2000). In addition, anxiety and depression appear to be variable expressions of the heritable tendency toward neuroticism (Kendler, Heath, Martin, & Eaves, 1987). Symptoms of panic (i.e., breathlessness, heart pounding) may be addition- ally explained by a unique source of genetic variance that is differentiated from symptoms of depression and anxiety (Kendler et al., 1987) and neuroticism (Martin, Jardine, Andrews, & Heath, 1988).

Analyses of specific genetic markers remain prelimi- nary and inconsistent. For example, panic disorder has been linked to a locus on chromosome 13 (Hamilton et al., 2003; Schumacher et al., 2005) and chromo- some 9 (Thorgeirsson et al., 2003), but the exact genes remain unknown. Findings regarding markers for the cholecystokinin B receptor gene have been inconsistent (cf. Hamilton et al., 2001; van Megen, Westenberg, Den Boer, & Kahn, 1996). Also, association and link- age studies implicate the adenosine receptor gene in panic disorder (Deckert et al., 1998; Hamilton et al., 2004). An allele of the neuropeptide S receptor gene on chromosome 7 was linked in a male-specific manner to panic disorder and not to schizophrenia or atten- tion deficit disorder (Okamura et al., 2011), whereas the same gene was linked in a female-specific man- ner to panic disorder compared to healthy controls ( Domschke et al., 2011). Thus, at this stage, the re- sults are rather piecemeal and sometimes inconsistent, and there is no evidence at this point for a specific link between genetic markers and temperament on the one hand, and panic disorder on the other. Rather, neuro- biological factors seem to comprise a nonspecific bio- logical vulnerability.

Anxiety Sensitivity

As described earlier, neuroticism is viewed as a higher- order factor characteristic of all anxiety disorders, with “fear of fear” being more unique to panic disorder. The construct “fear of fear” overlaps with the construct “anxiety sensitivity,” or the belief that anxiety and its associated symptoms may cause deleterious physical,

Panic Disorder and Agoraphobia 7

social, and psychological consequences that extend beyond any immediate physical discomfort during an episode of anxiety or panic (Reiss, 1980). Anxiety sen- sitivity is elevated across most anxiety disorders, but it is particularly elevated in panic disorder (e.g., Taylor, Koch, & McNally, 1992; Zinbarg & Barlow, 1996; Olatunji & Wolitzky-Taylor, 2009), especially the Phys- ical Concerns subscale of the Anxiety Sensitivity Index (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014; Zinbarg & Barlow, 1996; Zinbarg, Barlow, & Brown, 1997). Therefore, beliefs that physical symptoms of anxiety are harmful seem to be particularly relevant to panic disorder and may comprise a specific psychologi- cal vulnerability.

Anxiety sensitivity is presumed to confer a risk factor for panic disorder, because it primes fear reactivity to bodily sensations. In support, anxiety sensitivity pre- dicts subjective distress and reported symptomatology in response to procedures that induce strong physical sensations, such as CO2 inhalation (Forsyth, Palav, & Duff, 1999), balloon inflation (Messenger & Shean, 1998), and hyperventilation (Sturges, Goetsch, Ridley, & Whittal, 1998) in nonclinical samples, even after re- searchers control for the effects of trait anxiety (Rapee & Medoro, 1994). In addition, several longitudinal studies indicate that high scores on the Anxiety Sensi- tivity Index predict the onset of panic attacks over 1- to 4-year intervals in adolescents (Hayward et al., 2000), college students (Maller & Reiss, 1992), and commu- nity samples with specific phobias or no anxiety disor- ders (Ehlers, 1995). The predictive relationship remains after researchers control for prior depression (Hayward et al., 2000). In addition, Anxiety Sensitivity Index scores predicted spontaneous panic attacks and worry about panic (and anxiety more generally), during an acute military stressor (i.e., 5 weeks of basic training), even after researchers control for history of panic at- tacks and trait anxiety (Schmidt et al., 1997, 1999), and Anxiety Sensitivity Index scores predicted spontaneous panic attacks (and anxiety disorder diagnoses) in a non- clinical adult sample over a 2-year longitudinal period (Schmidt, Zvolensky, & Maner, 2006). Finally, panic attacks themselves elevated anxiety sensitivity over a 5-week period in adults (Schmidt et al., 1999), and over a 1-year period in adolescents, albeit to a lesser extent (Weems, Hayward, Killen, & Taylor, 2002).

However, Bouton, Mineka, and Barlow (2001) have noted that the relationship between anxiety sensitivity and panic attacks in these studies is relatively small, not exclusive to panic, and weaker than the relationship

between panic and neuroticism. Furthermore, these studies have evaluated panic attacks and worry about panic but not the prediction of diagnosed panic disor- der. Thus, the causal significance of anxiety sensitivity for panic disorder remains to be fully understood.

History of Medical Illness and Abuse

Other studies highlight the role of medical illnesses as contributing to a specific psychological vulnerability for panic disorder. For example, using the Dunedin Multidisciplinary Study database, we found that expe- rience with personal respiratory disturbance (and pa- rental poor health) as a youth predicted panic disorder at age 18 or 21 (Craske et al., 2001). This finding is con- sistent with reports of more respiratory disturbance in the history of patients with panic disorder compared to other patients with anxiety disorders (Verburg, Griez, Meijer, & Pols, 1995). Furthermore, first-degree rela- tives of patients with panic disorder had a significantly higher prevalence of chronic obstructive respiratory dis- ease, and asthma in particular, than first-degree rela- tives of patients with other anxiety disorders (van Beek, Schruers, & Friez, 2005). Beyond respiratory disease, other medical illnesses have been shown to contribute to panic disorder onset. A longitudinal study found that the number of physical diseases endorsed on a list of medical problems (e.g., heart problems, asthma, mi- graines) was positively associated with subsequent panic disorder diagnosis (Rudaz, Craske, Becker, Ledermann, & Margraf, 2010).

Childhood experiences of sexual and physical abuse may also prime panic disorder. Retrospective reports of such childhood abuse were associated with panic disor- der onset at ages 16–21 years in a longitudinal analysis of New Zealanders from birth to age 21 (Goodwin, Fer- gusson, & Horwood, 2005). This finding is consistent with multiple cross-sectional studies in both clinical and community samples (e.g., Asselmann, Wittchen, Lieb, & Beesdo-Baum, 2016; Bandelow et al., 2002; Kendler et al., 2000; Kessler, Davis, & Kendler, 1997; Moisan & Engels, 1995; Stein et al., 1996). The association with childhood abuse is stronger for panic disorder than for other anxiety disorders, such as social phobia (Safren, Gershuny, Marzol, Otto, & Pollack, 2002; Stein et al., 1996) and obsessive–compulsive disorder (Stein et al., 1996). In addition, some studies reported an associa- tion between panic disorder and exposure to violence between other family members, generally interparental violence (e.g., Bandelow et al., 2002; Moisan & Engels,

8 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

1995), whereas another study did not (Goodwin et al., 2005). Retrospective reporting of childhood abuse and familial violence in all of these studies, however, limits the findings, and it may be that these early experiences are more strongly related to neuroticism than any one disorder (Barlow, Ellard, et al., 2014)

Interoceptive Awareness

Patients with panic disorder, as well as nonclinical pan- ickers, appear to have heightened awareness of, or abil- ity to detect, bodily sensations of arousal (e.g., Ehlers & Breuer, 1992, 1996; Ehlers, Breuer, Dohn, & Fei- genbaum, 1995; Zoellner & Craske, 1999). Discrepant findings (e.g., Antony et al., 1995; Rapee, 1994) exist but have been attributed to methodological artifact (Ehlers & Breuer, 1996). Ability to perceive heartbeat, in particular, appears to be a relatively stable individu- al-difference variable given that it does not differ be- tween untreated and treated patients with panic dis- order (Ehlers & Breuer, 1992), or from before to after successful treatment (Antony, Meadows, Brown, & Barlow, 1994; Ehlers et al., 1995). Thus, interoceptive accuracy may be a predisposing trait for panic disorder that increases the probability of perceiving sensations that in turn may trigger a panic attack. Whether in- teroceptive awareness is learned, and represents another specific psychological vulnerability, or is more disposi- tional remains to be determined.

Separate from interoception is the issue of propensity for intense autonomic activation. As noted earlier, some evidence points to a unique genetic influence on the reported experience of breathlessness, heart pounding, and a sense of terror (Kendler et al., 1987). Conceiv- ably, cardiovascular reactivity presents a unique physi- ological predisposition for panic disorder. In support of this, cardiac symptoms and shortness of breath predict later development of panic attacks and panic disorder (Keyl & Eaton, 1990). Unfortunately, these data derive from report of symptoms, which is not a good index of actual autonomic state (Pennebaker & Roberts, 1992) and may instead reflect interoception.

Initial Panic Attacks

From an evolutionary standpoint, fear is a natural and adaptive response to threatening stimuli. However, the fear experienced during the first unexpected panic at- tack is often unjustified due to the lack of an identifi- able trigger or antecedent; hence, it represents a “false

alarm” (Barlow, 1988, 2002). The large majority of ini- tial panic attacks are recalled as occurring outside of the home while driving, walking, at work, or at school (Craske et al., 1990), generally in public (Lelliott, Marks, McNamee, & Tobena, 1989), and on a bus, plane, subway, or in social-evaluative situations (Shul- man, Cox, Swinson, Kuch, & Reichman, 1994). Barlow (1988) and Craske and Rowe (1997) believe situations that set the scene for initial panic attacks are ones in which bodily sensations are perceived as posing the most threat because of impairment of functioning (e.g., driving), entrapment (e.g., air travel, elevators), negative social evaluation (e.g., job, formal social events), or dis- tance from safety (e.g., unfamiliar locales). Entrapment concerns may be particularly salient for the subsequent development of agoraphobia (Faravelli, Pallanti, Bion- di, Paterniti, & Scarpato, 1992).

Maintenance Factors

Acute “fear of fear” (or, more accurately, anxiety fo- cused on somatic sensations) that develops after initial panic attacks in vulnerable individuals refers to anxiety about certain bodily sensations associated with panic attacks (e.g., racing heart, dizziness, paresthesias) (Bar- low, 1988; Goldstein & Chambless, 1978), and is attrib- uted to two factors. The first is interoceptive condition- ing, or conditional fear of internal cues, such as elevated heart rate, because of their association with intense fear, pain, or distress (Razran, 1961). Specifically, interocep- tive conditioning refers to low-level somatic sensations of arousal or anxiety becoming conditional stimuli, so that early somatic components of the anxiety response come to elicit significant bursts of anxiety or panic (Bouton et al., 2001). An extensive body of experimen- tal literature attests to the robustness of interoceptive conditioning (e.g., Dworkin & Dworkin, 1999), par- ticularly with regard to early interoceptive drug-onset cues becoming conditional stimuli for larger drug ef- fects (e.g., Sokolowska, Siegel, & Kim, 2002). In addi- tion, interoceptive conditional responses are not depen- dent on conscious awareness of triggering cues (Razran, 1961); thus, they have been observed in patients under anesthesia (e.g., Block, Ghoneim, Fowles, Kumar, & Pathak, 1987). Within this model, then, slight changes in relevant bodily functions that are not consciously recognized may elicit conditional anxiety or fear and panic due to previous pairings with panic (Barlow, 1988; Bouton et al., 2001); the result would be an unex- pected panic attack. Further support for a conditioning

Panic Disorder and Agoraphobia 9

model comes from evidence that individuals with panic disorder, as well as other anxiety disorders, show ele- vated fear conditioning and weakened fear extinction in laboratory paradigms (Lissek et al., 2005), suggest- ing that they are more prone to developing fear through negative associations, and once acquired, their fear is less likely to diminish with time. This pattern seems to be compounded for individuals with panic disorder who additionally show impaired safety learning (Lissek et al., 2009) and greater fear generalization (Lissek et al., 2010) in laboratory paradigms. In other words, once fear of specific bodily sensations is acquired, individu- als with panic disorder may have difficulty perceiving other sensations as being harmless and may be more likely to generalize their fear to various bodily states.

The second factor, offered by Clark (1986) to explain acute fear of panic-related body sensations, is cata- strophic misappraisals of bodily sensations (misinter- pretation of sensations as signs of imminent death, loss of control, etc.). We have taken issue with the purely cognitive model of panic disorder by stating that it cannot account for panic attacks devoid of conscious cognitive appraisal without turning to constructs such as “automatic appraisals,” which prove to be untestable (Bouton et al., 2001). Catastrophic misappraisals may accompany panic attacks because they are a natural part of the constellation of responses that go with panic, or because they have been encouraged and reinforced much like sick role behaviors during childhood. In ad- dition, such thoughts may become conditioned stimuli that trigger anxiety and panic, as demonstrated via panic induction through presentation of pairs of words involving sensations and catastrophic outcomes (Clark et al., 1988). In this case, catastrophic cognitions may well be sufficient to elicit conditioned panic attacks, but not necessary.

Whether cognitively or noncognitively based, ex- cessive anxiety over panic-related bodily sensations in panic disorder is well supported. Persons with panic disorder endorse strong beliefs that bodily sensations associated with panic attacks cause physical or men- tal harm (e.g., Chambless, Caputo, Bright, & Galla- gher, 1984; McNally & Lorenz, 1987). They are more likely to interpret bodily sensations in a catastrophic fashion (Clark et al., 1988) and to allocate more at- tentional resources to words that represent physical threat, such as disease and fatality (e.g., Ehlers, Mar- graf, Davies, & Roth, 1988; Hope, Rapee, Heimberg, & Dombeck, 1990); catastrophe words, such as death and insane (e.g., Maidenberg, Chen, Craske, Bohn, &

Bystritsky, 1996; McNally, Riemann, Louro, Lukach, & Kim, 1992); and heartbeat stimuli (Kroeze & van den Hout, 2000); however, attentional bias is not al- ways found (e.g., DeCort, Hermans, Spruyt, Griez, & Schruers, 2008). Also, individuals with panic disorder show enhanced brain potentials in response to panic- related words (Pauli, Amrhein, Muhlberger, Dengler, & Wiedemann, 2005). In addition, they are more likely to become anxious in procedures that elicit bodily sen- sations similar to the ones experienced during panic attacks, including benign cardiovascular, respiratory, and audiovestibular exercises (Antony, Ledley, Liss, & Swinson, 2006; Jacob, Furman, Clark, & Durrant, 1992), as well as more invasive procedures, such as CO2 inhalations, compared to patients with other anxiety disorders (e.g., Perna, Bertani, Arancio, Ronchi, & Bellodi, 1995; Rapee, 1986; Rapee, Brown, Antony, & Barlow, 1992) or healthy controls (e.g., Gorman et al., 1994). The findings are not fully consistent, however, because patients with panic disorder did not differ from patients with social phobia in response to an epineph- rine challenge (Veltman, van Zijderveld, Tilders, & van Dyck, 1996). Nonetheless, individuals with panic disorder also fear signals that ostensibly reflect height- ened arousal and false physiological feedback (Craske & Freed, 1995; Craske, Lang, et al., 2002; Ehlers, Mar- graf, Roth, Taylor, & Birnbaumer, 1988).

Distress over bodily sensations is likely to generate ongoing distress for a number of reasons. First, in the immediate sense, autonomic arousal generated by fear in turn intensifies the feared sensations, thus creating a reciprocating cycle of fear and sensations that is sus- tained until autonomic arousal abates or the individual perceives safety. Second, because bodily sensations that trigger panic attacks are not always immediately obvi- ous, they may generate the perception of unexpected or “out of the blue” panic attacks (Barlow, 1988) that causes even further distress (Craske, Glover, & De- Cola, 1995). Third, the perceived uncontrollability, or inability to escape or terminate bodily sensations, again, is likely to generate heightened anxiety (e.g., Maier, Laudenslager, & Ryan, 1985; Mineka, Cook, & Miller, 1984). Unpredictability and uncontrollability, then, are seen as enhancing general levels of anxiety about “When is it going to happen again?” and “What do I do when it happens?” which thereby contributes to high levels of chronic anxious apprehension (Bar- low, 1988, 2002). In turn, anxious apprehension in- creases the likelihood of panic by directly increasing the availability of sensations that have become condi-

10 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

tioned cues for panic and/or attentional vigilance for these bodily cues. Thus, a maintaining cycle of panic and anxious apprehension develops. Also, subtle avoid- ance behaviors are believed to maintain negative beliefs about feared bodily sensations (Clark & Ehlers, 1993). Examples include holding onto objects or persons for fear of fainting, sitting and remaining still for fear of a heart attack, and moving slowly or searching for an escape route because one fears acting foolish (Salkov- skis, Clark, & Gelder, 1996). Such avoidance includes experiential avoidance, or being unwilling to remain in contact with particular private experiences, in this case bodily sensations and catastrophic cognitions. Experi- ential avoidance is believed to contribute to overall dis- tress and dysfunction in general (Hayes, Wilson, Gif- ford, & Follette, 1996), and appears to correlate with panic-related worries and disability in individuals with panic disorder (Kampfe et al., 2012). Further support for the role of experiential avoidance comes from evi- dence for instructions to accept symptoms of panic to result in less fear and avoidance in patients with panic disorder (Campbell-Sills, Barlow, Brown, & Hofmann, 2006; Eifert & Heffner, 2003), including CO2 inha- lation challenges (Levitt, Brown, Orsillo, & Barlow, 2004). Finally, anxiety may develop over specific con- texts in which the occurrence of panic would be par- ticularly troubling (i.e., situations associated with im- pairment, entrapment, negative social evaluation, and distance from safety). These anxieties may contribute to agoraphobia, which in turn maintains distress by preventing disconfirmation of catastrophic misapprais- als and extinction of conditioned responding. Clearly, this model targets panic disorder and agoraphobia, and is not as relevant to agoraphobia in the absence of panic attacks or panic-like symptoms.

TREATMENT VARIABLES

Setting

There are several different settings for conducting cog- nitive-behavioral therapy for panic disorder and agora- phobia. The first, the outpatient clinic–office setting, is suited to psychoeducation, cognitive restructuring, assignment, and feedback regarding homework assign- ments and role-play rehearsals. In addition, certain exposures can be conducted in the office setting, such as interoceptive exposure to feared bodily sensations we describe later. Outpatient settings have extended from mental health settings to primary care suites (e.g.,

Craske, Roy-Byrne, et al., 2002; Craske et al., 2011; Roy-Byrne, Craske, et al., 2005; Roy-Byrne et al., 2010; Sharp, Power, Simpson, Swanson, & Anstee, 1997). This extension is particularly important because of the higher prevalence of panic disorder in primary care set- tings (e.g., Shear & Schulberg, 1995; Tiemens, Ormel, & Simon, 1996). However, whether a mental health or a primary care office is being used, the built-in safety signals of such an office may limit the generalizability of learning that takes place in that setting. For example, learning to be less afraid in the presence of the therapist, or in an office located near a medical center, may not necessarily generalize to conditions in which the thera- pist is not present, or when the perceived safety of a medical center is not close by. For this reason, home- work assignments to practice cognitive-behavioral skills in a variety of different settings are particularly impor- tant.

In the second setting, the natural environment, cog- nitive restructuring and other anxiety management skills are put into practice as the patient faces feared situations. The latter is called in vivo exposure and can be conducted with the aid of the therapist or alone. Therapist-directed exposure is particularly useful for patients who lack a social network to support in vivo ex- posure assignments, and more valuable than self-direct- ed exposure for patients with more severe agoraphobia (Holden, O’Brien, Barlow, Stetson, & Infantino, 1983). Therapist-directed exposure is essential to “guided mas- tery exposure,” in which the therapist gives corrective feedback about the way the patient faces feared situ- ations to minimize unnecessary defensive behaviors. For example, patients are taught to drive in a relaxed position and to walk across a bridge without holding the rail. On the one hand, guided mastery exposure has been shown to be more effective than “stimulus expo- sure” when patients attempt simply to endure the situ- ation alone until fear subsides, without the benefit of ongoing therapist feedback (Williams & Zane, 1989). On the other hand, self-directed exposure is very valu- able also, especially to the degree that it encourages in- dependence and generalization of the skills learned in treatment to conditions in which the therapist is not present. Thus, the most beneficial approach in the nat- ural environment is to proceed from therapist-directed to self-directed exposure.

In telephone-guided treatment, an interesting varia- tion that combines the office and the natural envi- ronment, therapists direct patients with agoraphobia by phone to conduct in vivo exposure to feared situa-

Panic Disorder and Agoraphobia 11

tions (NcNamee, O’Sullivan, Lelliott, & Marks, 1989; Swinson, Fergus, Cox, & Wickwire, 1995) or provide instruction in panic control skills (Côté, Gauthier, La- berge, Cormier, & Plamondon, 1994). In addition, one small study showed that cognitive-behavioral therapy was as effective when delivered by videoconference as in person (Bouchard et al., 2004).

Self-directed treatments, with minimal direct thera- pist contact, take place in the natural environment and are beneficial for highly motivated and educated pa- tients (e.g., Ghosh & Marks, 1987; Gould & Clum, 1995; Gould, Clum, & Shapiro, 1993; Lidren et al., 1994; Schneider, Mataix-Cols, Marks, & Bachofen, 2005; Mitsopoulou et al., 2020). On the other hand, self-directed treatments are less effective for more se- verely affected patients (Holden et al., 1983); for those with more comorbidity (Hecker, Losee, Roberson-Nay, & Maki, 2004), less motivation, and less education; or for patients who are referred as opposed to recruited through advertisement (Hecker, Losee, Fritzler, & Fink, 1996). Self-directed treatments have expanded beyond workbooks and manuals to computerized and Internet versions (e.g., Carlbring, Ekselius, & Anders- son, 2003; Richards, Klein, & Austin, 2006; Richards, Klein, & Carlbring, 2003). In general, these treat- ments yield very positive results with strong effect sizes (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010), and at least two studies indicate that they are as ef- fective as therapist-led cognitive-behavioral therapy for panic disorder (Carlbring et al., 2005; Kiropoulos et al., 2008). However, attrition rates may be higher with self-directed computer/Internet programs in the absence of any therapist contact (e.g., Carlbring et al., 2003; Nordgreen et al., 2016). Recent models of Internet-based cognitive-behavioral therapy for panic disorder that include online support by a clinician have demonstrated effectiveness in reducing panic disorder symptoms severity yet still experience high attrition (Hedman et al., 2013).

The third setting, the inpatient facility, is most ap- propriate when conducting very intensive cognitive- behavioral therapy (e.g., daily therapist contact) or treating severely disabled persons who can no longer function at home. In addition, certain medical or drug complications may warrant inpatient treatment. The greatest drawback to the inpatient setting is poor gener- alization to the home environment. Transition sessions and follow-up booster sessions in an outpatient clinic– office or in the patient’s own home facilitate generaliza- tion.

Format

Cognitive-behavioral therapy for panic disorder and agoraphobia may be conducted in individual or group formats. Several clinical outcome studies have used group treatments (e.g., Bohni, Spindler, Arendt, Hou- gaaard, & Rosenberg, 2009; Craske, DeCola, Sachs, & Pontillo, 2003; Craske et al., 2007; Evans, Holt, & Oei, 1991; Feigenbaum, 1988; Hoffart, 1995; Telch et al., 1993). The fact that their outcomes are generally consistent with the summary statistics obtained from individually formatted treatment suggests that group treatment is as effective as individual therapy. In direct comparisons, albeit few in number, a slight advantage is shown for individual formats. Specifically, Néron, La- croix, and Chaput (1995) compared 12–14 weekly ses- sions of individual or group cognitive-behavioral thera- py (N = 20), although the group condition received two additional 1-hour individual sessions. The two condi- tions were equally effective for measures of panic and agoraphobia at posttreatment and 6-month follow-up. However, the individual format was more successful in terms of generalized anxiety and depressive symptoms by the follow-up point. In addition, individual treat- ments resulted in more clinically significant outcomes than group formats in primary care (Sharp, Power, & Swanson, 2004). Furthermore, 95% of individuals assigned to the wait-list condition in the latter study stated a clear preference for individual treatment when given the choice at the end of the wait list.

Most studies of cognitive-behavioral therapy for panic and agoraphobia involve 10–20 weekly treatment sessions. Several studies show that briefer treatments may be effective as well. Evans and colleagues (1991) compared a 2-day group cognitive-behavioral treatment to a waiting-list condition, although without random assignment. The 2-day program comprised lectures (3 hours); teaching skills, such as breathing, relaxation, and cognitive challenge (3 hours); in vivo exposure (9 hours); and group discussion plus a 2-hour support group for significant others. Eighty-five percent of treated patients were reported to be either symptom- free or symptomatically improved, and these results were maintained 1 year later. In contrast, the waiting- list group did not demonstrate significant changes. A pilot study similarly indicated effectiveness with inten- sive cognitive-behavioral therapy over 2 days (Deacon & Abramowitz, 2006). Other studies have evaluated the effectiveness of cognitive-behavioral therapy when delivered over fewer sessions. A five-session cognitive

12 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

behavioral therapy protocol for panic disorder that fo- cuses largely on interoceptive exposure demonstrated large effect sizes in two studies (Otto et al., 2010; Na- tions et al., 2012). In a randomized study, patients with panic disorder with agoraphobia who awaited phar- macotherapy treatment were assigned to four weekly sessions of either cognitive-behavioral therapy or sup- portive nondirective therapy (Craske, Maidenberg, & Bystritsky, 1995). Cognitive-behavioral therapy was more effective than supportive therapy, particularly with less severely affected patients, although the results were not as positive as those typically seen with more sessions. Also, we found that up to six sessions (aver- age of three sessions) of cognitive-behavioral therapy combined with medication recommendations yielded significantly greater improvements on an array of mea- sures, including quality of life, compared to treatment as usual for individuals with panic disorder in primary care settings (Roy-Byrne, Craske, et al., 2005). Notably, however, the treatment effects substantially increased as the number of cognitive-behavioral therapy sessions (up to six) and follow-up booster phone call sessions (up to six) increased (Craske et al., 2006). In our subsequent primary care study, an average of seven sessions of cognitive-behavioral therapy and/or medication recom- mendations was superior to usual care, and in this case, usual care often involved several active treatment ele- ments (Craske et al., 2011). Finally, in a direct compari- son, results were equally effective whether cognitive- behavioral therapy was delivered across the standard 12 sessions or across approximately six sessions (Clark et al., 1999).

Interpersonal Context

Interpersonal context variables have been researched in terms of the development, maintenance, and treatment of agoraphobia. The reason for this research interest is apparent from the following vignette:

“My husband really doesn’t understand. He thinks it’s all in my head. He gets angry at me for not being able to cope. He says I’m weak and irresponsible. He resents having to drive me around, and doing things for the kids that I used to do. We argue a lot because he comes home tired and frustrated from work only to be frustrated more by the problems I’m having. But I can’t do anything without him. I’m so afraid that I’ll collapse into a helpless wreck without him, or that I’ll be alone for the rest of my life. As cruel as

he can be, I feel safe around him because he always has everything under control. He always knows what to do.”

This first vignette illustrates dependence on the significant other for a sense of safety despite a non- sympathetic response that may only serve to increase background stress for the patient. The second vignette illustrates inadvertent reinforcement of fear and avoid- ance through attention from the significant other:

“My boyfriend really tries hard to help me. He’s al- ways cautious of my feelings and doesn’t push me to do things that I can’t do. He phones me from work to check on me. He stays with me and holds my hand when I feel really scared. He never hesitates to leave work to help me if I’m having a bad time. Only last week we visited some of his friends, and we had to leave. I feel guilty because we don’t do the things we used to enjoy doing together. We don’t go to the mov- ies anymore. We used to love going to ball games, but now it’s too much for me. I am so thankful for him. I don’t know what I would do without him.”

Perhaps some forms of agoraphobia represent a con- flict between desire for autonomy and dependence in interpersonal relationships (Fry, 1962; Goldstein & Chambless, 1978). In other words, the “preagorapho- bic” individual is trapped in a domineering relationship without the skills needed to activate change. However, the concept of a distinct marital system that predispos- es toward agoraphobia lacks empirical evidence. This is not to say that marital or interpersonal systems are unimportant to agoraphobia. For example, interperson- al discord/dissatisfaction may represent one of several possible stressors that precipitate panic attacks. Also, interpersonal relations may be negatively impacted by the development of agoraphobia (Buglass, Clarke, Hen- derson, & Presley, 1977) and in turn contribute to its maintenance. Not unlike one of the earlier vignettes, consider the woman who has developed agoraphobia and now relies on her husband to do the shopping and other errands. These new demands on the husband lead to resentment and marital discord. The marital distress adds to background stress, making progress and recov- ery even more difficult for the patient.

Aside from whether interpersonal dysregulation con- tributes to the onset or maintenance of panic disorder or agoraphobia, some studies suggest that poor marital relations adversely impact exposure-based treatments

Panic Disorder and Agoraphobia 13

(Bland & Hallam, 1981; Dewey & Hunsley, 1990; Milton & Hafner, 1979). However, other studies show no relationship between marital distress and outcome from cognitive-behavioral therapy (Arrindell & Em- melkamp, 1987; Emmelkamp, 1980; Himadi, Cerny, Barlow, Cohen, & O’Brien, 1986). Another line of re- search suggests that involving significant others in every aspect of treatment may override potential negative im- pacts of poor marital relations on phobic improvement (Barlow et al., 1984; Cerny, Barlow, Craske, & Himadi, 1987). Furthermore, involvement of significant others resulted in better long-term outcomes from cognitive- behavioral therapy for agoraphobia (Cerny et al., 1987). Similarly, communications training with significant others, compared to relaxation training, after 4 weeks of in vivo exposure therapy, resulted in significantly greater reductions on measures of agoraphobia by post- treatment (Arnow, Taylor, Agras, & Telch, 1985), an effect that was maintained over an 8-month follow-up. Together, these studies suggest the value of including significant others in the treatment for agoraphobia. On the other hand, treatment focused specifically on interpersonal relationships, via interpersonal therapy, was not as effective as cognitive-behavioral therapy for panic disorder and agoraphobia (Vos, Huibers, Diels, & Arntz, 2012).

Yet another question is the degree to which treatment for panic disorder and agoraphobia influences marital/ interpersonal relations. Some have noted that successful treatment can have deleterious effects (Hafner, 1984; Hand & Lamontagne, 1976). Others note that it has no effect or a positive effect on marital functioning (Barlow et al., 1984; Himadi et al., 1986) and interper- sonal functioning in general (Hoffart, 1997). Barlow, O’Brien, Last, and Holden (1983) suggested that when negative effects do occur, it may be because exposure therapy is conducted intensively, without the significant other’s involvement, which causes major role changes that the significant other perceives as being beyond his/ her control. This again speaks to the value of involving significant others in the treatment process.

Therapist Variables

Only a few studies have evaluated therapist variables in relation to cognitive-behavioral treatments for anxiety disorders, let alone panic disorder or agoraphobia. Wil- liams and Chambless (1990) found that patients with agoraphobia who rated their therapists as caring/in- volved, and as modeling self-confidence, achieved bet-

ter outcomes on behavioral approach tests. However, an important confound in this study was that patient ratings of therapist qualities may have depended on patient responses to treatment. Keijsers, Schaap, Hoog- duin, and Lammers (1995) reviewed findings on thera- pist relationship factors and behavioral outcome. They concluded that empathy, warmth, positive regard, and genuineness assessed early in treatment predict positive outcome; patients who view their therapists as under- standing and respectful improve the most, and patient perceptions of therapist expertness, self-confidence, and directiveness relate positively to outcome, although not consistently. In their own study of junior thera- pists who provided cognitive-behavioral treatment for panic disorder with or without agoraphobia, Keijsers and colleagues found that more empathic statements and questioning occurred in Session 1 than in later ses- sions. In Session 3, therapists became more active and offered more instructions and explanations. In Session 10, therapists employed more interpretations and con- frontations than previously. Most importantly, direc- tive statements and explanations in Session 1 predicted poorer outcome. Empathic listening in Session 1 related to better behavioral outcome, whereas empathic listen- ing in Session 3 related to poorer behavioral outcome. Thus, they demonstrated the advantages of different in- teractional styles at different points in therapy. Interest- ingly, one study found that the therapist contribution to the therapy alliance predicted attrition (with greater al- liance factors as reported by the patient associated with less dropout), but did not predict treatment outcomes (Huppert et al., 2014). A study using independent raters of therapeutic alliance, which overcomes some of the methodological limitations described earlier, found that ratings of therapeutic alliance were positively associated with improvement in patients’ agoraphobic avoidance (Weck et al., 2016).

Most clinicians assume that therapist training and experience improve the chances of successful outcome. Some believe this to be the case particularly with respect to the cognitive aspects of cognitive-behavioral therapy (e.g., Michelson et al., 1990), and some indirect evi- dence for this supposition exists. Specifically, cognitive- behavioral therapy conducted by “novice” therapists in a medical setting (Welkowitz et al., 1991) was some- what less effective in comparison to the same therapy conducted by inexperienced but highly trained thera- pists in a psychological setting (Barlow, Craske, Czerny, & Klosko, 1989), or by experienced and highly trained therapists in a community mental health setting (Wade,

14 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Treat, & Stuart, 1998). Huppert and colleagues (2001), who directly evaluated the role of therapist experience, found that, in general, therapist experience positively related to outcome, seemingly because these therapists were more flexible in administering the treatment and better able to adapt it to the individual being treated. In contrast, there is some evidence that adherence (i.e., fol- lowing the protocol) but not competence (i.e., degree to which the treatment is delivered skillfully) is predictive of treatment outcome in cognitive-behavioral therapy for panic disorder (Weck et al., 2016). Obviously, there is a need for more evaluation of the role of therapist ex- perience and training in cognitive-behavioral therapy.

In our primary care work, we developed a computer guide to assist novice clinicians in implementing a cog- nitive-behavioral program for panic disorder (plus other anxiety disorders and depression) (Craske et al., 2001), called Calm Tools for Living (CALM). The clinician and patient sit side by side as both view the program on- screen. Throughout, the program prompts clinicians to engage in specific tasks, such as helping patients to es- tablish a fear hierarchy, demonstrating breathing skills, practicing cognitive skills, conducting interoceptive ex- posure, or designing in vivo exposure assignments. The program also provides learning tools for patients, such as didactic information, interactive exercises, video vi- gnettes, and quizzes. The goal of the computerized pro- gram is to enhance the integrity of cognitive-behavioral therapy in the hands of novice and relatively untrained clinicians.

Patient Variables

There has been interest in the effect of comorbidity on the outcomes of cognitive-behavioral therapy for panic disorder and agoraphobia. Brown, Antony, and Barlow (1995) found that comorbidity with other anxiety dis- orders did not predict response to cognitive-behavioral therapy overall, although social phobia was unexpected- ly associated with superior outcome for panic disorder and agoraphobia. In contrast, Tsao, Lewin, and Craske (1998) found a trend for comorbidity that comprised mostly other anxiety disorders to be associated with slightly lower rates of overall success. In a subsequent study, however, we replicated the finding by Brown and colleagues (1995) of no relationship between baseline comorbidity comprising mostly other anxiety disorders, and either immediate or 6-month outcome for panic disorder and agoraphobia (Tsao, Mystkowski, Zucker, & Craske, 2002).

Research on how comorbid depression affects the course and outcome of panic disorder treatment has yielded mixed results. Studies focused on cognitive- behavioral therapy for all anxiety disorders and treat- ment participation have found that comorbidity with depression is associated with increased rates of refusal to enter treatment (Issakidis & Andrews, 2004); however, once patients have entered treatment, the comorbidity has no effect on rates of attrition (Allen et al., 2010; Brown et al., 1995). Preliminary research investigating the effects of comorbidity on engagement with treat- ment has revealed that comorbid depression has no ef- fect on compliance with cognitive-behavioral therapy homework (McLean, Woody, Taylor, & Koch, 1998) or compliance with cognitive-behavioral treatment as a whole (Murphy, Michelson, Marchione, Marchione, & Testa, 1998), though it does increase levels of dis- tress associated with treatment (Murphy et al., 1998). Interestingly, comorbid depression has no effect on the response to cognitive-behavioral therapy for panic disorder at posttreatment or follow-up and in both referred and primary care settings (Allen et al., 2010; McLean et al., 1998; Roy-Byrne, Craske, et al., 2005). It seems contradictory that comorbid depression would have significant impact on the severity and persistence of panic disorder (Baldwin, 1998) but would not affect the outcomes of panic disorder treatment. This may be a product of limitations to the current treatment litera- ture. For example, studies have recruited patients for the treatment of panic disorder and have often excluded patients who are very extremely depressed or suicidal. Thus, the majority of patients are mildly to moderately depressed. Many of these studies also exclude patients with bipolar disorder, and therefore exclude an entire group of individuals who experience major depressive episodes. However, it may also be that the effects of cognitive-behavioral therapy for panic disorder are suf- ficiently potent to impact depressive symptoms either directly or indirectly.

A relatively high co-occurrence exists between panic disorder and agoraphobia, and avoidant, dependent, and histrionic personality disorders (e.g., Reich et al., 1994). Questions of diagnostic reliability and validity aside, comorbid personality disorders are sometimes as- sociated with poorer response than usual to cognitive- behavioral therapy for panic disorder or agoraphobia (e.g., Hoffart & Hedley, 1997; Marchand, Goyer, Du- puis, & Mainguy, 1998). However, closer examina- tion reveals that although individuals with comorbid personality disorders have greater severity of panic

Panic Disorder and Agoraphobia 15

or agoraphobia pre- and post–cognitive-behavioral therapy, the rate of decrease in panic or agoraphobia symptoms usually is not affected by the comorbid per- sonality disorder. Thus, Dreessen, Arntz, Luttels, and Sallaerts (1994) and van den Hout, Brouwers, and Oomen (2006) found that comorbid personality dis- orders did not affect response to cognitive-behavioral therapy for panic or agoraphobia. Moreover, Hofmann and colleagues (1988) found that scores on question- naire subscales reflecting Axis II personality disorders did not predict panic disorder treatment response to either cognitive-behavioral therapy or to medication. In fact, some personality traits may associate positively with outcome, as was reported by Rathus, Sanderson, Miller, and Wetzler (1995) with respect to compulsive personality features.

Substance use disorders also commonly co-occur with panic disorder and agoraphobia, but very few treat- ment studies have addressed this important comorbid- ity. In a series of single cases (N = 3), Lehman, Brown, and Barlow (1998) demonstrated successful control of panic attacks in individuals who were abusing alcohol. Also, the addition of anxiety treatment to a relapse pre- vention program for abstinent individuals with a pri- mary diagnosis of alcohol dependence and a comorbid diagnosis of panic disorder or social phobia decreased anxiety symptoms relative to a relapse prevention pro- gram alone (Schade et al., 2005). However, adding the anxiety treatment did not affect rates of alcohol relapse in that study. More recent work has attempted to fully integrate the cognitive-behavioral therapy for panic disorder into substance use disorder treatment more seamlessly, with more promising effects on both panic disorder symptoms and substance use symptoms (Kushner et al., 2006, 2013). Our own work adapting Calm Tools for Living (Craske et al., 2009) for clients with comorbid substance use disorders and anxiety dis- orders (including panic disorder and agoraphobia) has shown that a computer-assisted but therapist-directed integrated cognitive-behavioral treatment for comorbid anxiety and substance use disorders showed greater im- provement in anxiety and substance use outcomes than a substance use disorder treatment alone (Wolitzky- Taylor et al., 2018). More work is needed in this area, though recent data suggest that panic disorder can improve when substance use disorders are present, and that treating both simultaneously can improve panic/ anxiety symptoms and substance use severity.

Another source of comorbidity is medical conditions, such as cardiac arrhythmias or asthma, that may slow

improvement rates given the additional complications involved in discriminating between anxiety and disease symptomatology, increases in actual medical risk, and the stress of physical diseases. We found that medically ill patients with panic disorder, although more severely affected than their nonmedically ill counterparts at baseline, responded just as favorably to cognitive- behavioral therapy with psychotropic medication rec- ommendations (Roy-Byrne, Stein, et al., 2005). Also, cognitive-behavioral therapy for panic disorder has been shown to alleviate self-reported physical health symptoms (Schmidt et al., 2003). Similarly, we found that cognitive-behavioral therapy and/or psychotropic medication recommendations for anxiety disorders (in- cluding panic disorder) significantly improve physical health functioning (Niles et al., 2013).

Other patient variables include socioeconomic status and general living conditions. We evaluated perceived barriers to receiving mental health treatment in our pri- mary care study of panic disorder (Craske, Golinelli, et al., 2005). Commonly reported barriers included in- ability to find out where to go for help (43%), worry about cost (40%), lack of coverage by one’s health plan (35%), and inability to get an appointment soon enough (35%). Also, in our multicenter trial, attrition from cognitive-behavioral and/or medication treatment for panic disorder with minimal agoraphobia was pre- dicted by lower education, which in turn was dependent on lower income (Grilo et al., 1998). Similarly, levels of education and motivation were associated with dropout rates in another sample, although the effects were small (Keijsers, Kampman, & Hoogduin, 2001). Low educa- tion–income may reflect less discretionary time to en- gage in activities such as weekly treatment. Consider a woman who is the mother of two, a full-time clerk, whose husband is on disability due to a back injury, or the full-time student who works an extra 25 hours a week to pay his way through school. Under these con- ditions, treatment assignments of daily in vivo exposure exercises are much less likely to be completed. Frustra- tion with lack of treatment progress is likely to result. Therapeutic success requires either a change in lifestyle that allows the cognitive-behavioral treatment to be- come a priority or termination of therapy until a later time, when life circumstances are less demanding. In fact, these kinds of life circumstance issues may explain the trend for African Americans to show less treatment benefit in terms of mobility, anxiety, and panic attacks than European Americans (Friedman & Paradis, 1991; Williams & Chambless, 1994). Although, in contrast

16 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

to these two studies, Friedman, Paradis, and Hatch (1994) found equivalent outcomes across the two ra- cial groups, and the results from another study yielded outcomes from a female African American sample that were judged to be comparable to those of European Americans (Carter, Sbrocco, Gore, Marin, & Lewis, 2003). The influence of ethnic and cultural differences on treatment outcome and delivery clearly needs more evaluation.

Finally, patients’ understanding of the nature of their problem may be important to the success of cognitive- behavioral treatments. Given the somatic nature of panic disorder, many patients seek medical help first. Beyond that, however, differences in the way the prob- lem is conceptualized could lead to the perception that pharmacological or analytical treatment approaches are more credible than cognitive-behavioral treatment ap- proaches. For example, individuals who strongly believe their condition is due to “a neurochemical imbalance” may be more likely to seek medication and to refute psychological treatments. Similarly, individuals who at- tribute their condition to “something about my past—it must be unconscious influences” may resist cognitive- behavioral interpretations. Also, Grilo and colleagues (1998) found that patients with panic disorder or agoraphobia who attributed their disorder to specific stressors in their lives were more likely to drop out of cognitive-behavioral or medication treatment, perhaps because they saw the offered treatment as irrelevant.

Concurrent Pharmacological Treatment

Many more patients receive medications than cogni- tive-behavioral therapy for panic disorder and agora- phobia, partly because primary care physicians are usu- ally the first line of treatment. Thus, one-half or more of patients with panic disorder who attend psychology research clinics already are taking anxiolytic medica- tions. The obvious questions, therefore, are the extent to which cognitive-behavioral therapy and medications have a synergistic effect, and how medications impact cognitive-behavioral therapy.

Results from large clinical trials, including our own multisite trial (Barlow, Gorman, Shear, & Woods, 2000), suggest no advantage during or immediately after treatment of combining cognitive-behavioral and pharmacological approaches. Specifically, both indi- vidual cognitive-behavioral and drug treatment, and a combination treatment were immediately effective fol- lowing treatment. Furthermore, following medication

discontinuation, the combination of medication and cognitive-behavioral therapy fared worse than cogni- tive-behavioral therapy alone, suggesting the possibility that state- (or context-) dependent learning in the pres- ence of medication may have attenuated the new learn- ing that occurs during cognitive-behavioral therapy. In contrast, in the primary care setting, we found that the addition of even just one component of cognitive- behavioral therapy to medications for panic disorder re- sulted in statistically and clinically significant improve- ments at posttreatment and 12 months later (Craske, Golinelli, et al., 2005).

More recently, our multisite collaborative team has been investigating long-term strategies in the treatment of panic disorder. We examined sequential combina- tion strategies to determine whether this approach is more advantageous than simultaneously combining treatments. In the initial phase, 256 patients with panic disorder and all levels of agoraphobia completed 3 months of initial treatment with cognitive-behavioral therapy (Aaronson et al., 2008; White et al., 2010). Patients were then triaged into two clinical trials. Re- sponders were randomized to 9 months of monthly booster sessions (N = 79) or no booster sessions (N = 78), then followed for an additional 12 months with- out treatment (White et al., 2013). Booster sessions produced significantly lower relapse rates (5.2%) and reduced work and social impairment compared to the assessment-only condition without booster sessions (18.4%) at 21-month follow-up. Multivariate Cox pro- portional hazards models showed that residual symp- toms of agoraphobia at the end of acute-phase treat- ment were independently predictive of time to relapse during 21-month follow-up (hazard rate = 1.15, p < .01). Thus, booster sessions aimed at reinforcing acute treatment gains to prevent relapse and offset disorder recurrence improved long-term outcome for panic dis- order with and without agoraphobia. Fifty-eight of the original patients did not reach an optimal level of functioning (high end-state functioning) and entered a trial in which they received either continued cogni- tive-behavioral therapy for 3 months or paroxetine for 3 months. Patients doing well with one treatment or the other continued with the respective treatment for an additional 9 months. Results indicated significantly lower panic disorder symptoms for individuals in the paroxetine condition compared to those in continued cognitive-behavioral therapy at 3 months. However, group differences had disappeared 9 months later. Re- sults were maintained when excluding individuals with

Panic Disorder and Agoraphobia 17

comorbid major depression. These data suggest a more rapid treatment response when switching to paroxetine after not responding optimally to cognitive-behavioral therapy; however, both treatments ultimately achieved similar outcomes.

In another study with similar results, patients who did not respond to cognitive-behavioral therapy also benefited more from the addition of a serotonergic drug (paroxetine) to continued cognitive-behavioral therapy than from the addition of a drug placebo, with substan- tially different effect sizes (Kampman, Keijsers, Hoog- duin, & Hendriks, 2002). Conversely, individuals who are resistant to pharmacotherapy may respond positive- ly to cognitive-behavioral therapy, although these find- ings were part of an open trial without randomization (Heldt et al., 2006).

Findings from the combination of fast-acting anx- iolytics, specifically, the high-potency benzodiazepines, and behavioral treatments for agoraphobia are contra- dictory (e.g., Marks et al., 1993; Wardle et al., 1994). Nevertheless, several studies have reliably demonstrated the detrimental effects of chronic use of high-potency benzodiazepines on short-term and long-term out- come in cognitive-behavioral treatments for panic or agoraphobia (e.g., Otto, Pollack, & Sabatino, 1996; van Balkom, de Beurs, Koele, Lange, & van Dyck, 1996; Wardle et al., 1994). Specifically, there is evidence for more attrition, poorer outcome, and more relapse with chronic use of high-potency benzodiazepines. In addi- tion, use of benzodiazepines as needed was associated with poorer outcome than regular use or no use in one small naturalistic study (Westra, Stewart, & Conrad, 2002).

Finally, the cost-effectiveness of cognitive-behavioral and medication treatments alone rather than in com- bination requires further evaluation; currently, cogni- tive-behavioral therapy is considered to be more cost- effective (e.g., disability costs, work days missed, health care use) than pharmacotherapy (Heuzenroeder et al., 2004).

Understanding the ways in which psychotropic medications influence cognitive-behavioral therapy may prove useful for developing methods that optimize the combination of these two approaches to treatment. First, medications, particularly fast-acting, potent medications that cause a noticeable shift in state and are used on an as-needed basis (e.g., benzodiazepines, beta-blockers), may contribute to relapse, because ther- apeutic success is attributed to them rather than to cog- nitive-behavioral therapy. Patients’ resultant lack of per-

ceived self-control may increase relapse potential when medication is withdrawn or contribute to maintenance of a medication regimen under the assumption that it is necessary to functioning. In support, attribution of therapeutic gains to alprazolam, and lack of confidence in coping without alprazolam, even when given in con- junction with behavioral therapy, predicted relapse (Ba- soglu, Marks, Kilic, Brewin, & Swinson, 1994). Sec- ond, medications may assume the role of safety signals, or objects to which persons erroneously attribute their safety from painful, aversive outcomes. Safety signals may contribute to maintenance of fear and avoidance in the long term (Hermans, Craske, Mineka, & Lovibond, 2006) and may interfere with corrections of misapprais- als of bodily symptoms (see below for further discussion of this issue). Third, medications may reduce the mo- tivation to engage in practices of cognitive-behavioral skills, yet completion of between-session assignments is a positive predictor of outcome from cognitive-behav- ioral therapy (e.g., Glenn et al., 2013). Finally, learning that takes place under the influence of medications may not necessarily generalize to the time when medications are removed, thus contributing to relapse (Bouton & Swartzentruber, 1991). Some of these points are illus- trated in the following vignettes:

“I had been through a program of cognitive-behav- ioral therapy, but it was really the Paxil that helped. Because I was feeling so much better, I considered tapering off the medication. At first, I was very con- cerned about the idea. I had heard horror stories about what people go through when withdrawing. However, I thought it would be OK as long as I ta- pered slowly. So, I gradually weaned myself off. It re- ally wasn’t that bad. Well, I had been completely off the medication for about a month when the problem started all over again. I remember sitting in a res- taurant, feeling really good because I was thinking about how much of a problem restaurants used to be for me before, and how easy it seemed now. Then, whammo. I became very dizzy and I immediately thought, ‘Oh no, here it comes.’ I had a really bad panic attack. All I could think of was why didn’t I stay on the medication?”

“I started to lower my dose of Xanax. I was OK for the first couple of days. . . . I felt really good. Then, when I woke up on Friday morning, I felt strange. My head felt really tight and I worried about having the same old feelings all over again. The last thing

18 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

I want to do is to go through that again. So I took my usual dose of Xanax and, within a few minutes, I felt pretty good again. I need the medication. I can’t manage without it right now.”

In what ways might such negative effects of medi- cations be offset? One possibility is that continuation of exposure after medication is withdrawn may offset relapse, because it enhances attributions of personal mastery and reduces the safety signal function of medi- cations. In addition, opportunities to practice exposure and cognitive and behavioral strategies without the aid of medication overcome state dependency and enhance generalization of therapeutic gains once treatment is over.

CASE STUDY

Julie, a 33-year-old mother of two, lives with Larry, her husband of 8 years. For the past 3 years, she has been chronically anxious and panic stricken. She de- scribes her panic attacks as unbearable and increasing in frequency. The first time she felt panicky was just over 3 years ago, when she was rushing to be by her grandmother’s side in the last moments before she died. Julie was driving alone on the freeway. She remembers feeling as if everything were moving in slow motion, as if the cars were standing still, and things around her seemed unreal. She recalled feeling short of breath and detached. However, it was so important to reach her destination that she did not dwell on how she felt until later. After the day was over, she reflected on how lucky she was not to have had an accident. A few weeks later, she experienced the same feeling again when driving on the freeway. This time it occurred without the pressure of getting to her dying grandmother. It scared Julie, be- cause she was unable to explain the feelings. She pulled to the side of the road and called her husband, who came to meet her. She followed him home, feeling anx- ious the entire way.

Now, Julie has these feelings in many situations. She describes her panic attacks as feelings of unreality, detachment, shortness of breath, a racing heart, and a general fear of the unknown. It is the unreality that scares her the most. Consequently, Julie is sensitive to anything that produces “unreal” types of feelings, such as the semiconsciousness that occurs just before fall- ing asleep, the period when daylight changes to night, bright lights, concentrating on the same thing for long

periods of time, alcohol or drugs, and being anxious in general. Even though she has a prescription for Klono- pin (a high-potency benzodiazepine), she rarely, if ever, uses it because of her general fear of being under the influence of a drug, or of feeling an altered state of consciousness. She wants to be as alert as possible at all times, but she keeps the Klonopin with her in the event that she has no other way of managing her panic. She does not leave home without the Klonopin. Julie is very sensitive to her body in general; she becomes scared of anything that feels a little different than usual. Even coffee, which she used to enjoy, is distressing to her now because of its agitating and racy effects. She was never a big exerciser, but to think of exerting herself now is also scary. Julie reports that she is constantly waiting for the next panic attack to occur. She avoids freeways, driving on familiar surface streets only. She limits her- self to a 10-mile radius from home. She avoids crowds and large groups as well, partly because of the feeling of too much stimulation and partly because she is afraid to panic in front of others. In general, she prefers to be with her husband or her mother. However, she can do most things as long as she is within her “safety” region.

Julie describes how she differs from the way she used to be: how weak and scared she is now. The only other incident that is similar to her current panic attacks oc- curred in her early 20s, when she had a negative reac- tion to smoking marijuana. Julie became very scared of the feeling of losing control and feared that she would never return to reality. She has not taken drugs since then. Otherwise, there is no history of serious medi- cal conditions or any previous psychological treatment. Julie had some separation anxiety and was shy as a young child and throughout her teens. However, her social anxiety improved throughout her 20s, to the point that until the onset of her panic attacks, she was mostly very comfortable around people. Since the onset of her panic attacks, Julie has become concerned that others will notice that she appears anxious. However, her social anxiety is limited to panic attacks and does not reflect a broader social phobia.

In general, Julie’s appetite is good, but her sleep is restless. At least once a week she wakes abruptly in the middle of the night, feeling short of breath and scared, and she has great difficulty going to sleep when her husband travels. In addition to worrying about her panic attacks, Julie worries about her husband and her children, although these latter worries are secondary to her worry about panicking and not excessive. She has some difficulty concentrating but is generally able to

Panic Disorder and Agoraphobia 19

function at home and at work because of the familiar- ity of her environment and the safety she feels in the presence of her husband. Julie works part-time as the manager of a business that she and her husband own. She sometimes becomes depressed about her panic and the limitations on how far she can travel. Occasionally she feels hopeless about the future, doubting whether she will ever be able to escape the anxiety. Although the feelings of hopelessness and the teariness never last than more than a few days, Julie has generally had a low- grade depressed mood since her life became restricted by the panic attacks.

Julie’s mother and her uncle both had panic attacks when they were younger. Julie is now worried that her oldest child is showing signs of being overly anxious, because he is hesitant about trying new things or spend- ing time away from home.

ASSESSMENT

A functional behavioral analysis depends on several dif- ferent modes of assessment, which we describe next.

Interviews

An in-depth interview is the first step in establishing diagnostic features and the profile of symptomatic and behavioral responses. Several semistructured and fully structured interviews exist. The Anxiety Disorders In- terview Schedule for DSM-IV (ADIS-IV; Di Nardo, Brown, & Barlow, 1994) and for DSM-5 (ADIS-5; Brown & Barlow, 2014) primarily assesses anxiety dis- orders, as well as mood and somatoform disorders. Psy- chotic and drug conditions are screened by this instru- ment also. The ADIS facilitates gathering the necessary information to make a differential diagnosis among anxiety disorders and offers a means to distinguish between clinical and subclinical presentations of a dis- order. Data on the frequency, intensity, and duration of panic attacks, as well as details on avoidance behav- ior, are embedded within the ADIS; this information is necessary for tailoring treatment to each individual’s presentation. The value of structured interviews is their contribution to a differential diagnosis and interrater reliability. Interrater agreement ranges from satisfactory to excellent for the various anxiety disorders using the ADIS-IV (Brown, Di Nardo, Lehman, & Campbell, 2001). Similar analyses for the ADIS-5 are underway (Brown & Tung, 2018).

Similarly, the Schizophrenia and Affective Disor- ders Schedule—Lifetime Version (modified for the study of anxiety) produces reliable diagnoses for most of the anxiety disorders (generalized anxiety disorder and simple phobia are the exceptions) (Manuzza, Fyer, Liebowitz, & Klein, 1990), as does the Structured Clin- ical Interview for DSM (SCID), now in its fifth edition (American Psychiatric Association, 2013).

Differential diagnosis is sometimes difficult because, as described earlier, panic is a ubiquitous phenomenon (Barlow, 1988) that occurs across a wide variety of emo- tional disorders. It is not uncommon for persons with specific phobias, social phobia, generalized anxiety dis- order, obsessive–compulsive disorder, and posttraumat- ic stress disorder to report panic attacks. For Julie, there was a diagnostic question regarding differentiation be- tween social anxiety disorder versus panic disorder and/ or agoraphobia. Shown in Figure 1.1 are the ADIS-5 questions that address this differentiation (Julie’s an- swers are in italics).

As demonstrated in Figure 1.1, Julie experiences panic attacks in social situations and is concerned about being negatively evaluated by others if her anxiety be- comes visibly apparent. However, despite her history of shyness, Julie’s current social discomfort is based primarily on the possibility of panicking. Because of this, and because she meets the other criteria for panic disorder (i.e., unexpected/nonsocial panic attacks and pervasive apprehension about future panic attacks), the social distress is best subsumed under the domain of panic disorder and agoraphobia. If Julie reported that she experiences panic attacks in social situations only, or that she worries about panic attacks in social situa- tions only, then a diagnosis of social anxiety disorder would be more probable. A report of unexpected panic attacks, as well as self-consciousness about things that she might do or say in social situations regardless of the occurrence of panic, would be consistent with a dual diagnosis of panic disorder–agoraphobia and social anxiety disorder. In general, an individual with panic disorder may continue to feel anxious even when play- ing a passive role in a social setting, whereas a patient with social phobia is more likely to feel relaxed when he/she is not the center of attention and does not an- ticipate being evaluated or judged (Dattilio & Salas- Auvert, 2000).

The same types of diagnostic questioning are useful for distinguishing between panic disorder–agoraphobia and claustrophobia. Other differential diagnostic is- sues can arise with respect to somatoform disorders, real

20 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

FIGURE 1.1. Julie’s responses (in italics) to ADIS-5 questions.

Parts of ADIS-5 Panic Disorder Section

Do you currently have times when you feel a sudden rush of intense fear or discomfort? Yes.

In what kinds of situations do you have those feelings? Driving, especially on freeways . . . alone at home . . . at parties or in crowds of people.

Do you ever have those feelings come “from out of the blue,” for no apparent reason, or in situations where you did not expect them to occur? Yes.

How long [does/did] it usually take for the rush of fear/discomfort to reach its peak level? It varies, sometimes a couple of seconds and at other times it seems to build more slowly.

How long [does/did] the fear or discomfort usually last at its peak level? Depends on where I am at the time. If it happens when I’m alone, sometimes it is over within a few minutes or even seconds. If I’m in a crowd, then it seems to last until I leave.

In the last month, how much have you been worried or concerned about having another panic attack or about the potential consequences of having another attack (circle rating)?

0 1 2 3 4 5 6 7 8

No worry/ no fear

Rarely worried/ mild fear

Occasionally worried/

moderate fear

Frequently worried/

severe fear

Constantly worried/

extreme fear

Parts of ADIS-5 Social Phobia Section

In social situations, where you might be observed or evaluated by others, or when meeting new people, do you feel fearful, anxious, or nervous? Yes.

Are you overly concerned that you might do and/or say something that might embarrass or humiliate yourself in front of others, or that others may think badly of you? Yes.

What are you concerned will happen in these situations? That others will notice that I am anxious. My face turns white and my eyes look strange when I panic. I am worried that I’ll flip out in front of them, and they won’t know what to do.

Are you anxious about these situations because you are afraid that you will have a panic attack? Yes (either a panic or that I’ll feel unreal).

Other than when you are exposed to (specify social situations), have you experienced an unexpected rush of fear/anxiety? Yes.

Panic Disorder and Agoraphobia 21

medical conditions, and avoidant or dependent person- ality disorders.

Following completion of a diagnostic assessment, a dimensional assessment specifically designed for panic disorder, such as the Panic Disorder Severity Scale (PDSS; Shear et al., 1997), may be helpful. This cli- nician-completed scale rates seven areas of responding using a 0- to 4-point severity rating scale: panic attack frequency; distress; anticipatory anxiety; agoraphobic and interoceptive-related fears; avoidant behavior; and work and social impairment. A cutoff score of 8 on the PDSS identifies patients with panic disorder with high sensitivity and acceptable specificity (Shear et al., 2001).

Medical Evaluation

A medical evaluation is generally recommended, be- cause several medical conditions should be ruled out before assigning the diagnosis of panic disorder. These include thyroid conditions, caffeine or amphetamine intoxication, drug withdrawal, or pheochromocytoma (a rare adrenal gland tumor). Furthermore, certain medical conditions can exacerbate panic disorder, al- though panic disorder is likely to continue even when the symptoms are under medical control. Mitral valve prolapse, asthma, allergies, and hypoglycemia fall into this latter category. According to the model described earlier, these medical conditions exacerbate panic disor- der to the extent that they elicit the feared physical sen- sations. For example, mitral valve prolapse sometimes produces the sensation of a heart flutter, asthma pro- duces shortness of breath, and hypoglycemia produces dizziness and weakness, all of which overlap with symp- toms of panic and may therefore become conditional cues for panic.

Self‑Monitoring

Self-monitoring is a very important part of assessment and treatment for panic disorder and agoraphobia. Retrospective recall of past episodes of panic and anxi- ety, especially when made under anxious conditions, may inflate estimates of panic frequency and intensity (Margraf et al., 1987; Rapee, Craske, & Barlow, 1990). Moreover, such inflation may contribute to apprehen- sion about future panic. In contrast, ongoing self-mon- itoring generally yields more accurate, less inflated es- timates (for a comprehensive review of self-monitoring for panic and anxiety, see Craske & Tsao, 1999). Also, ongoing self-monitoring is believed to contribute to an

objective self-awareness. Objective self-monitoring re- places negative, affect-laden self-statements such as “I feel horrible. This is the worst it has ever been—my whole body is out of control” with “My anxiety level is 6. My symptoms include tremulousness, dizziness, un- real feelings, and shortness of breath—and this episode lasted 10 minutes.” Objective self-awareness usually re- duces negative affect. Finally, self-monitoring provides feedback for judging progress and useful material for in-session discussions.

Panic attacks are recorded in the Panic Attack Re- cord, a version of which is shown in Figure 1.2. This re- cord, which is to be completed as soon as possible after a panic attack occurs, is therefore carried on-person (wal- let size). Daily levels of anxiety, depression, and worry about panic are monitored with the Daily Mood Re- cord shown in Figure 1.3. This record is completed at the end of each day. Finally, activities may be recorded by logging daily excursions in a diary, or by checking off activities completed from an agoraphobia checklist.

A common problem with self-monitoring is noncom- pliance. Sometimes noncompliance is due to misunder- standing or lack of perceived credibility in self-moni- toring. Most often, however, noncompliance is due to anticipation of more anxiety as a result of monitoring. This is particularly true for individuals whose pre- ferred style of coping is to distract themselves as much as possible because thoughts of panic might otherwise become overwhelming: “Why should I make myself worse by asking myself how bad I feel?” In Julie’s case, the self-monitoring task was particularly difficult, be- cause explicit reminders of her anxiety elicited strong concerns about losing touch with reality. Prompting, reassurance that anxiety would subside with persever- ance at self-monitoring, and emphasis on objective versus subjective self-monitoring were helpful for Julie. In addition, therapist attention to the self-monitored information and corrective feedback about the method of self-monitoring at the start of each treatment session reinforced Julie’s self-monitoring.

Standardized Inventories

Several standardized self-report inventories provide use- ful information for treatment planning and are sensitive markers of therapeutic change. The Anxiety Sensitiv- ity Index (Reiss, Peterson, Gursky, & McNally, 1986) and the multidimensional Anxiety Sensitivity Index–3 (Taylor et al., 2007) have received wide acceptance as a trait measure of threatening beliefs about bodily sensa-

22 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

0——1——2——3——4——5——6——7——8——9——10

None Mild Moderate Strong Extreme

Date Average anxiety

Average depression

Average worry about panic

7572/16

5452/17

5442/18

4342/19

1122/21

2222/22

5442/29

FIGURE 1.3. Julie’s Daily Mood Record.

Date Time began

Triggers

Expected Unexpected

Maximum Fear 0——1——2——3——4——5——6——7——8——9——10

None Mild Moderate Strong Extreme

Check all symptoms present to at least a mild degree:

Chest pain or discomfort Sweating

Heart racing/palpitations/pounding Nausea/upset stomach

Short of breath Dizzy/unsteady/lightheaded/faint

Shaking/trembling Chills/hot flushes

Numbness/tingling Feelings of unreality

Feelings of choking Fear of dying

Fear of losing control/going crazy

Thoughts:

Behaviors:

2/16/06 Home alone and shortness of breath x

x x x x

x

x

I am going crazy, I will lose control Called my mother

5:20 P.M.

FIGURE 1.2. Julie’s Panic Attack Record.

Panic Disorder and Agoraphobia 23

tions. Both display good psychometric properties and tend to discriminate panic disorder and agoraphobia from other anxiety disorders (e.g., Taylor et al., 1992; Telch, Sherman, & Lucas, 1989), especially the Physical Concerns subscale (Zinbarg et al., 1997). More specific information about which particular bodily sensations are feared most and what specific misappraisals occur most often may be obtained from the Body Sensations Questionnaire and the Agoraphobia Cognitions Ques- tionnaire, respectively (Chambless et al., 1984). Both scales have strong to excellent psychometric proper- ties and are sensitive to change following treatment (see Keller & Craske, 2008). The Mobility Inventory (Chambless, Caputo, Gracely, Jasin, & Williams, 1985) lists agoraphobic situations, which are rated in terms of degree of avoidance when alone and when accompa- nied. This instrument is very useful for establishing in vivo exposure hierarchies and, again, is well supported psychometrically. As described earlier, the PDSS (Shear et al., 2001) is a commonly used, brief dimensional measure of panic disorder symptom severity with good psychometric properties. Finally, the Panic Appraisal Inventory assesses cognitive maintaining factors of panic disorder and includes three 15-item subscales in- cluding anticipated panic, perceived consequences of panic, and perceived self-efficacy to cope with panic (Telch et al., 1989).

In addition, we have developed two standardized self- report inventories that are useful for panic disorder and agoraphobia. The first, the Albany Panic and Phobia Questionnaire (Rapee, Craske, & Barlow, 1995), as- sesses fear and avoidance of activities that produce feared bodily sensations (e.g., exercise, caffeine), as well as more typical agoraphobia and social situations. Factor analy- ses confirmed three distinct factors labeled Agoraphobia, Social Phobia, and Interoceptive Fears. The question- naire has adequate psychometric properties and is useful in profiling agoraphobic versus interoceptive avoidance. The second, the Anxiety Control Questionnaire, assess- es perceived lack of control over anxiety- related events and occurrences, such as internal emotional reactions or externally threatening cues (Rapee, Craske, Brown, & Barlow, 1996). This scale is designed to assess locus of control, but in a more specific and targeted manner rel- evant to anxiety and anxiety disorders compared to more general locus-of-control scales. A revised, 15-item version yields three factors—Emotion Control, Threat Control, and Stress Control—with a higher-order dimension of perceived control (Brown, White, Forsyth, & Barlow, 2004). Changes in this scale from pre- to posttreatment

predicted reductions in comorbidity at follow-up in one study (Craske et al., 2007). A more detailed review of each questionnaire listed herein and the complete assess- ment for panic disorder and agoraphobia is provided by Keller and Craske (2008).

Behavioral Tests

The behavioral test is a useful measure of degree of avoidance of specific interoceptive cues and external sit- uations. Behavioral approach tests can be standardized or individually tailored. The standardized behavioral test for agoraphobic avoidance usually involves walk- ing or driving a particular route, such as a 1-mile loop around the clinic setting. Standardized behavioral tests for anxiety about physical sensations involve exercises that induce panic-like symptoms, such as spinning in a circle, running in place, hyperventilating, and breath- ing through a straw (Barlow & Craske, 2006). Anxiety levels are rated at regular intervals throughout the be- havioral tests, and actual distance or length of time is measured. The disadvantage of standardized behavioral tests is that the specific task may not be relevant to all patients (e.g., a 1-mile walk or running in place may be only mildly anxiety provoking to some but highly dis- tressing to others); hence, the value of individually tai- lored tasks. In the case of agoraphobia, this usually en- tails attempts at three to five individualized situations that the patient has identified as ranging from Some- what difficult to Extremely difficult, such as driving two exits on freeway, waiting in a bank line, or shopping in a local supermarket for 15 minutes. For anxiety about physical sensations, individually tailored behavioral tests entail exercises designed specifically to induce the sensations feared most by a given patient (e.g., nose plugs to induce sensations of difficulty breathing). As with standardized tests, ongoing levels of anxiety and degree of approach behavior are measured in relation to individually tailored behavioral tests.

Individually tailored behavioral tests are more in- formative for clinical practice, although they confound between-subject comparisons for research purposes. Behavioral tests are an important supplement to self- report of agoraphobic avoidance, because patients tend to underestimate what they can actually achieve (Craske et al., 1988). In addition, behavioral tests often reveal important information for treatment planning of which the individual is not yet fully aware. For ex- ample, the tendency to remain close to supports, such as railings or walls, may not be apparent until one ob-

24 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

serves the patient walking through a shopping mall. In Julie’s case, the importance of change from daylight to night was not apparent until she was asked to drive on a section of road as a behavioral test. Her response was that it was too late in the day to drive, because dusk made her feel as if things were unreal. Similarly, it was not until Julie completed a behavioral test that we rec- ognized the importance of air-conditioning when she was driving. Julie believed that the cool air blowing on her face helped her to remain “in touch with reality.” Fi- nally, we noticed that her physical posture while driving was a factor that contributed to anxiety: Julie’s shoul- ders were hunched, and she leaned toward the steering wheel and held it very tightly. All of these were targeted in the treatment: Driving at dusk was included in her hierarchy; air-conditioning was regarded as a safety sig- nal from which she should be weaned; and driving in a more relaxed position was part of mastery exposure.

Psychophysiology

Ongoing physiological measures are not very practi- cal tools for clinicians, but they can provide important information. In particular, the discrepancy described earlier between reports of symptoms and actual physi- ological arousal (i.e., report of heart rate acceleration in absence of actual heart rate acceleration) may serve as a therapeutic demonstration of the role of attention and cognition in symptom production. Similarly, actual re- cordings provide data to disconfirm misappraisals such as “My heart feels like it’s going so fast that it will ex- plode” or “I’m sure my blood pressure is so high that I could have a stroke at any minute.” Finally, resting lev- els of physiological functioning, which are sometimes dysregulated in anxious individuals, may be sensitive measures of treatment outcome (e.g., Craske, Lang, Ai- kins, & Mystkowski, 2005).

Functional Analysis

The various methods of assessment provide the mate- rial for a full functional analysis for Julie. Specifically, the topography of her panic attack is as follows: The most common symptoms include a feeling of unreal- ity, shortness of breath, and racing heart; average fre- quency of panic attacks is three per week; each panic attack on average lasts from a few seconds to 5 minutes, if Julie is not in a crowd, where the panicky feelings last until she exits the crowd; in terms of apprehension, Julie worries about panic 75% of the day; and most of

her panic attacks are expected, but she has some unex- pected ones as well. Julie has both situational and in- ternal antecedents to her panic attacks. The situational antecedents include driving on freeways; crowds of peo- ple; being alone, especially at night; restaurants; dusk; reading and concentrating for long periods of time; and aerobic activity. The internal antecedents include heart rate fluctuations, lightheaded feelings, hunger feelings, weakness due to lack of food, thoughts of the “big one” happening, thoughts of not being able to cope with this for much longer, and anger. Her misappraisals about panic attack symptoms include beliefs that she will never return to normality, that she will go crazy or lose control, and that others will think she is weird. Her behavioral reactions to panic attacks include escape behaviors such as pulling off to the side of the road, leaving restaurants and other crowded places, calling her husband or mother, and checking for her Klonopin. Her behavioral reactions to the anticipation of panic at- tacks include avoidance of driving long distances alone, driving on unfamiliar roads and freeways or at dusk, crowded areas, exercise, quiet time with nothing to do, and doing one thing for a long period of time. In addition, she tries not to think about anxiety or feel- ings of unreality. Her safety signals and safety-seeking behaviors include having her Klonopin on hand at all times, always knowing the location of her husband, and having the air-conditioning on. The consequences of her panic disorder with agoraphobia affect her fam- ily: Julie’s husband is concerned and supportive, but her mother thinks she should pull herself together because “it’s all in her head.” In addition, Julie works but has cut back the number of hours, and she travels and socializes much less. Her general mood includes some difficulty concentrating and sleeping, restlessness, headaches, and muscular pains and aches. In addition, she is occasion- ally tearful, sad, and hopeless, and generally feels down.

COMPONENTS OF COGNITIVE‑BEHAVIORAL THERAPY

The components of the cognitive-behavioral treatment described in this section are integrated into a session- by-session treatment program in the next section.

Education

The treatment begins with education about the nature of panic disorder, the causes of panic and anxiety, and

Panic Disorder and Agoraphobia 25

the ways panic and anxiety are perpetuated by feed- back loops among physical, cognitive, and behavioral response systems. In addition, specific descriptions of the psychophysiology of the fight–flight response are provided, as well as an explanation of the adaptive value of the various physiological changes that occur during panic and anxiety. The purpose of this education is to correct the common myths and misconceptions about panic symptoms (i.e., beliefs about going crazy, dying, or losing control) that contribute to panic and anxiety. The survival value of alarm reactions (i.e., panic at- tacks) is emphasized throughout.

Education also distinguishes between the state of anxiety and the emotion of fear/panic, both conceptu- ally and in terms of its three response modes (subjective, physiological, and behavioral). This distinction is cen- tral to the model of panic disorder and to the remainder of the treatment. Anxiety is viewed as a state of prepara- tion for future threat, whereas panic is the fight–flight emotion elicited by imminent threat. Panic/fear is characterized by perceptions of imminent threat, sud- den autonomic discharge, and fight–flight behavior. In contrast, anxiety is characterized by perceptions of future threat and chronic tension, cautiousness, avoid- ance, and disruption of performance.

Self‑Monitoring

Self-monitoring is essential to the personal scientist model of cognitive-behavioral therapy. Self-monitoring is introduced as a way to enhance objective self-aware- ness and increase accuracy in self-observation. As noted earlier, patients are asked to keep at least two types of records. The first, the Panic Attack Record, is com- pleted as soon after each panic attack as possible; this record provides a description of cues, maximal distress, symptoms, thoughts, and behaviors. The second, the Daily Mood Record, is completed at the end of each day to record overall or average levels of anxiety, de- pression, and whatever else is considered important to record. Additionally, patients may keep a daily record of activities or situations completed or avoided.

Breathing Retraining and Capnometry‑Assisted Respiratory Training

Breathing retraining is a central component early on in the development of panic control treatments, because many patients with panic describe symptoms of hyper- ventilation as being very similar to their panic attack

symptoms. It is noteworthy, however, that a hyperven- tilation symptom report does not always accurately rep- resent hyperventilation physiology: Only 50% or fewer patients show actual reductions in end-tidal CO2 values during panic attacks (Hibbert & Pilsbury, 1989; Holt & Andrews, 1989; Hornsveld, Garssen, Fiedelij Dop, & van Spiegel, 1990).

In early conceptualizations, panic attacks were related to stress-induced respiratory changes that provoke fear either because they are perceived as threatening or they augment fear already elicited by other phobic stimuli (Clark, Salkovskis, & Chalkley, 1985). Several studies illustrated a positive effect of breathing retraining, in- volving slow abdominal breathing exercises (e.g., Kraft & Hoogduin, 1984). The value of breathing retrain- ing was subsequently questioned. For example, several studies suggested that the addition of breathing retrain- ing alone did not improve on in vivo exposure (e.g., de Beurs, van Balkom, Lange, Koele, & van Dyck, 1995). We found breathing retraining to be slightly less effec- tive than interoceptive exposure when each was added to cognitive restructuring and in vivo exposure (Craske, Rowe, Lewin, & Noriega-Dimitri, 1997), and in anoth- er study, the inclusion of breathing retraining resulted in poorer outcomes than cognitive-behavioral therapy without breathing retraining, although the findings were not robust (Schmidt et al., 2000). From their re- view of efficacy and mechanisms of action, Garssen, de Ruiter, and van Dyck (1992) concluded that breathing retraining probably effects change not through breath- ing per se but through distraction and/or a sense of con- trol. Thus, breathing retraining is no longer considered a central component of cognitive-behavioral therapy for panic disorder. Furthermore, to the extent that it might become misused as a means for avoiding physical symp- toms, it may even be countertherapeutic. That being said, there may be occasions when breathing retrain- ing is a useful tool, such as for the individual showing obvious signs of irregular breathing (e.g., rapid, shallow breathing, frequent deep breaths), as long as breathing retraining does not become a method of avoidance or safety seeking.

In contrast to traditional breathing retraining, cap- nometry-assisted respiratory training (CART) targets respiratory dysregulation, in particular hypocapnia (Meuret, Rosenfield, Seidel, Bhaskara, & Hofmann, 2010; Meuret, Wilhelm, Ritz, & Roth, 2008). CART is a brief, 4-week training that uses immediate feedback of end-tidal partial pressure CO2 (pCO2) to teach patients how to raise their subnormal levels of pCO2 (hyperven-

26 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

tilation) and thereby gain control over dysfunctional re- spiratory patterns and associated panic symptoms (e.g., shortness of breath, dizziness). The device, a portable capnometer, offers breath-by-breath feedback of expired CO2 and rate of breathing (both measured via a nasal canula). Due to the novelty of CART, randomized controlled trials are limited but promising. In a first randomized controlled study, Meuret and colleagues (2008) tested the efficacy of 4 weeks of CART (N = 20) compared to a delayed wait-list control group (WL, N = 17). CART, but not WL, led to sustained increases in pCO2 levels and reduced panic severity and frequency. Reductions in panic symptom severity (PDSS; Shear et al., 1997) were comparable to standard cognitive- behavioral therapy, and improvements were maintained at 12-month follow-up. In a second study, patients with panic disorder were randomly assigned to receive either 4 weeks of CART (N = 21) or cognitive therapy (N = 20). An initial 4 weeks of skills training was followed by three sessions of in vivo exposure and a fourth session at a 2-month follow-up. Respective skills acquisition trainings led to significant and comparable reductions in panic symptom severity and panic-related cogni- tions, irrespective of modality. However, only CART, not cognitive therapy, led to a correction of hypocapnic levels of pCO2 (Meuret et al., 2010; Seidel, Rosenfield, Bhaskara, Hofmann, & Meuret, 2009). However, an evaluation of the degree to which CART augments exposure therapy (relative to exposure therapy alone) awaits testing.

Applied Relaxation

A form of relaxation known as applied relaxation has shown good results as a treatment for panic at- tacks. Two studies by Öst (Öst & Westling, 1995; Öst, Westling, & Hellström, 1993) indicate that ap- plied relaxation is as effective as in vivo exposure and cognitive therapy. In contrast, Barlow and colleagues (1989) found that applied progressive muscle relaxation (PMR) is relatively ineffective for panic attacks, al- though we excluded all forms of interoceptive exposure from the hierarchy of tasks to which PMR was applied, which was not necessarily the case in the studies by Öst (Öst, 1988; Öst & Westling, 1995; Öst, Westling, & Hellström, 1993). Clark and colleagues (1994) found cognitive therapy to be superior to applied PMR when conducted with equal amounts of in vivo exposure, whereas Beck, Stanley, Baldwin, Deagle, and Averill (1994) found very few differences between cognitive

therapy and PMR when each was administered without exposure procedures.

Cognitive Restructuring

Cognitive restructuring is a skills set in which patients learn to recognize cognitive errors and generate alter- native, noncatastrophic explanations for the sensations that are feared during panic attacks. Cognitive therapy begins with a treatment rationale and discussion of the role of thoughts in generating emotions. Next, thoughts are recognized as hypotheses rather than as fact, and are therefore open to being questioned and challenged. De- tailed self-monitoring of emotions and associated cogni- tions is instituted to identify specific beliefs, appraisals, and assumptions. Once identified, relevant cognitions are categorized into types of typical errors that occur during heightened emotion, such as overestimations of risk of negative events or catastrophization of mean- ing of events. The process of categorization, or label- ing of thoughts, is consistent with a personal scientist model and facilitates an objective perspective by which the validity of the thoughts can be evaluated. Thus, in labeling the type of cognitive distortion, the patient is encouraged to use an empirical approach to examine the validity of his/her thoughts by considering all of the available evidence. Therapists use Socratic questioning to help patients make guided discoveries and question their anxious thoughts. Next, more evidence-based alternative hypotheses are generated. In addition to surface-level appraisals (e.g., “That person is frowning at me because I look foolish”), core-level beliefs or sche- mas (e.g., “I am not strong enough to withstand fur- ther distress” or “I am unlikable”) are questioned in the same way. Importantly, cognitive restructuring is not intended as a direct means of minimizing fear, anxiety, or unpleasant symptoms. Instead, cognitive restructur- ing is intended to correct distorted thinking; eventually fear and anxiety are expected to subside, but their dimi- nution is not the first goal of cognitive therapy.

Cognitive therapy is often intermingled with behav- ioral techniques (e.g., “behavioral experiments,” “hy- pothesis testing,” “instructions” involving exposure) that complicate direct testing of the efficacy of cogni- tive therapy in its “pure” form (e.g., Hoffart, Sexton, Hedley, & Martinsen, 2008; Hofmann et al., 2007; Öst et al., 1993; Teachman, Marker, & Smith-Janik, 2008). Nonetheless, there is some evidence that training in cognitive procedures in full isolation from exposure and behavioral procedures is efficacious in reducing aspects

Panic Disorder and Agoraphobia 27

of panic (Beck et al., 1994; Meuret et al., 2010; Salkov- skis, Clark, & Hackmann, 1991; van den Hout, Arntz, & Hoekstra, 1994). Similarly, in a study by Bouchard and colleagues (1996), cognitive restructuring was as effective as exposure therapy in reducing panic symp- toms. However, the effects of cognitive therapy alone on agoraphobia are unclear. One study found that cog- nitive therapy was less effective than exposure therapy for agoraphobia (Williams & Falbo, 1996). In another study, Hoffart (1995) found that cognitive therapy was as effective as guided mastery exposure delivered inten- sively over 6 weeks for individuals with moderate to se- vere agoraphobia, although some elements of exposure (e.g., hyperventilation tests to elicit sensations) were in- cluded in the cognitive therapy condition.

A few studies have evaluated the effects of cogni- tive therapy combined with exposure in comparison to exposure alone or in combination with other coping skills. Most often, cognitive therapy combined with ex- posure does not yield an additional benefit over in vivo exposure alone (Öst, Thulin, & Ramnero, 2004; van den Hout et al., 1994; see Murphy et al., 1998, for an exception).

Exposure

Exposure is a critical phase of treatment and, once begun, is a major focus of treatment sessions as well as between-treatment session homework, since limited exposure practice is of small benefit and may even be detrimental. The exposure is designed to disconfirm misappraisals and extinguish conditional emotional re- sponses to external situations and contexts, through in vivo exposure, as well as to bodily sensations, through interoceptive exposure. Growing evidence suggests that exposure represents the most powerful component of cognitive-behavioral therapy for panic disorder and agoraphobia, including meta-analyses that fail to show any additional benefit of either cognitive restructuring or somatic coping skills beyond exposure therapy alone (Norton & Price, 2007). A large trial reported a dose– response relationship between exposure and improve- ment in agoraphobia (Gloster et al., 2011).

In Vivo Exposure

In vivo exposure refers to repeated and systematic, real- life exposure, in this case, to agoraphobic situations. A long history of research has established the efficacy of in vivo exposure for agoraphobia.

Most often, in vivo exposure is conducted in a grad- uated manner, proceeding from the least to the most anxiety-provoking situations on an avoidance hierar- chy. However, there is some evidence to suggest that intensive or ungraduated exposure may be effective. In a study by Feigenbaum (1988), treatment sessions were conducted in a massed format over the course of 6–10 consecutive days. One group received ungraded expo- sure (N = 25), beginning with the most feared items from avoidance hierarchies. Another group received graded exposure (N = 23), beginning with the least feared hierarchy items. Approximately one-third of this severely agoraphobic sample was housebound at initial assessment. At posttreatment and 8 months later, the conditions proved to be equally effective (although, in- triguingly, the graded group reported the treatment to be more distressing). However, ungraded exposure was clearly superior at the 5-year follow-up assessment: 76% of the intensive group versus 35% of the graded group reported themselves to be completely free of symptoms. When 104 subjects were added to the intensive expo- sure format, the same results were obtained. Of 129 subjects, 78% were reportedly completely symptom-free 5 years later. This dramatic set of results suggests that an intensive approach, which is likely to produce higher levels of arousal than a graduated approach, can be very beneficial (at least when conducted in a massed format). Unfortunately, the validity of the outcome measures in this study is somewhat questionable, and replication by independent investigators has yet to be reported.

The amount of time devoted to in vivo exposure is very dependent on the patient’s agoraphobia profile. Obviously, more time is needed for patients with more severe agoraphobia.

Interoceptive Exposure

In interoceptive exposure, the goal is deliberately to in- duce feared physical sensations a sufficient number of times, and long enough each time, so that misappraisals about the sensations are disconfirmed and conditional anxiety responses are extinguished. A standard list of exercises, such as hyperventilating and spinning, is used to establish a hierarchy of interoceptive exposures. With a graduated approach, exposure begins with the less dis- tressing physical exercises and continues with the more distressing exercises. It is essential that the patient en- dure the sensations beyond the point at which they are first noticed, for at least 30 seconds to 1 minute, be- cause early termination of the task may eliminate the

28 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

opportunity to learn that the sensations are not harm- ful and that the anxiety can be tolerated. The exercise is followed by a discussion of what the patient learned about the physical sensations. These interoceptive exer- cises are practiced daily outside of the therapy session to consolidate the process of learning. Interoceptive ex- posure extends to naturalistic activities that induce so- matic sensations (e.g., caffeine consumption, exercise).

A series of studies reported on the effects of intero- ceptive exposure independent of other therapeutic strategies. Early on, Bonn, Harrison, and Rees (1971) and Haslam (1974) observed successful reduction in reactivity with repeated infusions of sodium lactate (a drug that produces panic-type bodily sensations). However, panic was not monitored in these investiga- tions. Griez and van den Hout (1986) compared six sessions of graduated CO2 inhalations to a treatment regimen of propranolol (a beta-blocker chosen because it suppresses symptoms induced by CO2 inhalations), both conducted over the course of 2 weeks. CO2 inha- lation treatment resulted in a mean reduction from 12 to four panic attacks, which was superior to the results from propranolol. In addition, inhalation treatment resulted in significantly greater reductions in reported fear of sensations. A 6-month follow-up assessment suggested maintenance of treatment gains, although panic frequency was not reported. Beck and Shipherd (1997) similarly found a positive effect from repeated CO2 inhalations, although it had little effect on agora- phobia (Beck, Shipherd, & Zebb, 1997). Broocks and colleagues (1998) tested the effects of exercise (with once-weekly supportive contact from a therapist) in comparison to clomipramine or drug placebo over 10 weeks. The exercise group was trained to run 4 miles, three times per week. Despite high attrition from ex- ercise (31%), exercise was more effective than the drug placebo condition. However, clomipramine was supe- rior to exercise.

In the first comparison to other cognitive and be- havioral treatments, Barlow and colleagues (1989) compared applied PMR, interoceptive exposure plus breathing retraining and cognitive restructuring, their combination with applied PMR, and a wait-list con- trol in a sample with panic disorder with limited ago- raphobia. The two conditions involving interoceptive exposure, breathing retraining and cognitive restruc- turing, were significantly superior to applied PMR and wait-list conditions. The results were maintained 24 months following treatment completion for the group receiving interoceptive exposure, breathing retraining,

and cognitive restructuring without PMR, whereas the combined group tended to deteriorate over follow-up (Craske, Brown, & Barlow, 1991). As already men- tioned, we compared interoceptive exposure, cognitive therapy, and in vivo exposure to breathing retraining, cognitive therapy, and in vivo exposure for individuals with varying levels of agoraphobia. The condition that included interoceptive exposure was slightly superior to breathing retraining at posttreatment and 6 months later (Craske et al., 1997). Similarly, Ito, Noshirvani, Basoglu, and Marks (1996) found a trend for those who added interoceptive exposure to their self-directed in vivo exposure and breathing retraining to be more like- ly to achieve at least a 50% improvement in phobic fear and avoidance. However, the combination of breathing education, breathing retraining, and repeated intero- ceptive exposure to hyperventilation did not increase the effectiveness of in vivo exposure for agoraphobia (de Beurs, Lange, van Dyck, & Koele, 1995).

Interoceptive exposure is now a standard compo- nent of cognitive-behavioral therapy for panic disorder (e.g., Barlow et al., 2000; Craske, Lange, et al., 2005), although different groups give different emphases to interoceptive exposure, with some emphasizing it as a means for extinguishing fear responses (Barlow & Craske, 2006) and others, as a vehicle for disconfirm- ing misappraisals (Clark, 1996). Indeed, dismantling studies indicate that interoceptive exposure may be a particularly active ingredient of cognitive-behavioral therapy for panic disorder. One analogue study with in- dividuals high in anxiety sensitivity compared one ses- sion of interoceptive exposure to interoceptive exposure plus cognitive restructuring to interoceptive exposure plus cognitive restructuring and breathing retraining (Deacon et al., 2012). All three groups showed greater improvement in anxiety symptoms compared to a con- trol condition, with no differences between the three active treatment groups, suggesting that there was no benefit to adding cognitive restructuring or breathing retraining. However, the benefits of cognitive restruc- turing and breathing retraining may not be observed in a single session.

Optimizing Learning during Exposure

Our understanding of the mechanisms of exposure therapy has evolved over time. One of the most influen- tial theories, emotional processing theory, emphasized habituation of fear responding within an exposure trial as a necessary precursor to habituation across treatment

Panic Disorder and Agoraphobia 29

sessions that in turn leads to long-term corrective learn- ing (Foa & Kozak, 1986; Foa & McNally, 1996). Most recently, we have emphasized optimizing inhibitory learning and its retrieval in ways that are not necessar- ily dependent on reductions in fear throughout trials of exposure (Craske et al., 2008); we discuss this approach below.

Emotional processing theory emphasizes mecha- nisms of habituation as precursors to cognitive correc- tion. Specifically, emotional processing theory purports that the effects of exposure therapy derive from activa- tion of a “fear structure” and integration of information that is incompatible with it, resulting in the develop- ment of a non-fear structure that replaces or competes with the original one. Incompatible information derives first from within-session habituation, or reduction in fear responding with prolonged exposure to the fear stimulus. Within-session habituation is seen as a pre- requisite for the second piece of incompatible informa- tion, which derives from between-session habituation over repeated occasions of exposure. Between-session habituation is purported to form the basis for long-term learning and to be mediated by changes in “meaning,” or lowered probability of harm (i.e., risk) and lessened negativity (i.e., valence) of the stimulus. Emotional processing theory guides clinicians to focus on the ini- tial elevation of fear followed by within- and between- session reductions in fear as signs of treatment success. Although enticing in its face validity, support for the theory has been inconsistent at best (Craske et al., 2008; Craske, Liao, Brown, & Vervliet, 2012). Rather, the evidence suggests that the amount by which fear ha- bituates from the beginning to the end of an exposure practice is not a good predictor of overall outcomes, and that evidence for between-session habituation is mixed (Craske et al., 2008, 2012).

A return to the science of fear learning and extinction may help to explain the effects of exposure therapy and thereby optimize its implementation. It is now thought that inhibitory learning is central to extinction (Bou- ton, 1993). Inhibitory pathways are also recognized in the neurobiology of fear extinction (see Sotres-Bayon, Cain, & LeDoux, 2006). Within a Pavlovian condi- tioning approach, inhibitory learning means that the original conditioned stimulus–unconditioned stimulus (CS-US) association learned during fear conditioning is not erased during extinction, but rather is left intact as a new, secondary learning about the CS-US devel- ops (Bouton, 1993). The degree to which inhibitory as- sociations shape fear responding at retest (the index of

strength and stability of new “learning”) is independent of fear levels expressed throughout extinction and in- stead is dependent on factors such as context and time.

Based on the inhibitory retrieval model of extinction, outcomes may be enhanced by strategies that do not rely on fear reduction within a trial of exposure (Craske et al., 2008, 2012). Indeed, fear reduction may become a safety behavior for persons with panic disorder (since fear reduction eradicates the very thing that is feared), such that a more appropriate goal may be to maintain high levels of fear and anxiety in order to disconfirm the expectancy of negative consequences. One trans- lational possibility is “deepened extinction” (Rescorla, 2006), in which multiple fear conditional stimuli are first extinguished separately before being combined during extinction, and in animal studies, decrease spon- taneous recovery and reinstatement of fear. Indeed, this is what is essentially done when interoceptive exposure is conducted in feared agoraphobic situations (Barlow & Craske, 1994), and recent experimental data support the beneficial effects of deepened extinction in human conditioning studies (Culver, Vervliet, & Craske, 2015).

In addition, the effects of exposure therapy may be enhanced by the prevention or removal of “safety sig- nals” or “safety behaviors.” Common safety signals and behaviors for clients with panic disorder are the pres- ence of another person, therapists, medications, or food or drink. In the experimental literature, safety signals alleviate distress in the short term, but when they are no longer present, the fear returns (Lovibond, Davis, & O’Flaherty, 2000), an effect that may derive in part from interference with the development of inhibitory associations. In phobic samples, the availability and use of safety signals and behaviors has been shown to be detrimental to exposure therapy (Sloan & Telch, 2002), whereas instructions to refrain from using safe- ty behaviors improved outcomes (Salkovskis, 1991). Similarly, the use of safety signals was associated with poorer outcomes for panic (Helbig-Lang & Petermann, 2010). However, recent data have presented contradic- tory findings (Rachman, Shafran, Radomsky, & Zysk, 2011).

Further options include stimulus variability throughout exposure, since variability has been shown to enhance the storage capacity of newly learned in- formation. Two studies with clinical analogues have demonstrated positive benefits in terms of spontane- ous recovery (Lang & Craske, 2000; Rowe & Craske, 1998), while a third showed trends only (Kircanski et al., 2011). In the treatment for panic disorder with ago-

30 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

raphobia, this implies conducting exposure for varying durations, at varying levels of intensity, rather than continuing exposure in one situation until fear declines before moving to the next situation. Notably, such vari- ability typically elicits higher levels of anxiety during exposure but without detrimental effects and some- times with beneficial effects in the long term.

Based on evidence of the weakening of fear extinc- tion by antagonists of the glutamate receptors in the amygdala, Walker and Davis (2002) tested and dem- onstrated that drug agonists of the same receptors, and in particular, D-cycloserine, enhance extinction in animal studies. In a meta-analysis of the efficacy of D-cycloserine for anxiety disorders, Norberg, Krystal, and Tolin (2008) reported effect sizes of d = 0.60 at posttreatment and 0.47 at follow-up in clinical anxiety samples. D-Cycloserine in combination with interocep- tive exposure for panic clients has resulted in a greater reduction in symptom severity, and a greater likelihood of achieving a change in clinical status at posttreatment and 1-month follow-up compared to exposure plus pla- cebo (Otto et al., 2010). Notably, D-cycloserine has been shown to have positive effects without influencing the level of fear during exposure per se.

A number of options for enhancing retrieval of the extinction memory have been tested. One option dur- ing extinction training is to include retrieval cues to be used in other contexts once extinction is over. This has been shown to be effective in animal studies and human conditioning studies (see Craske et al., 2012, for a review). In clinical analogue samples, the effects of a retrieval cue upon context renewal were very weak in one study (Culver, Stoyanova, & Craske, 2012), although instructions to reinstate what was learned mentally during exposure had more robust effects in re- ducing context renewal in another study (Mystkowski, Craske, Echiverri, & Labus, 2006). In the treatment of panic disorder, this approach simply suggests that cli- ents carry with them cues (e.g., a wristband) to remind them what they learned during exposure therapy (as long as the cues do not become safety signals), or are prompted to remind themselves of what they learned in exposure therapy each time they experience previously feared sensations or situations.

Another option is to provide multiple contexts in which extinction takes place. This approach has been shown to offset context renewal in rodent samples, and in a clinical analogue study of exposure therapy (Vansteenwegen et al., 2007), although the results are not always consistent (Neumann, Lipp, & Cory, 2007).

In the treatment of panic disorder and agoraphobia, this would mean asking clients to conduct their interocep- tive and in vivo exposures in multiple different contexts, such as when alone, in unfamiliar places, or at varying times of day or varying days of the week.

A recent (re)discovery is that retrieving already stored memories induces a process of reconsolidation (Nader, Schafe, & LeDoux, 2000), since the memory is writ- ten into long-term memory again, requiring de novo neurochemical processes. Thus, it may be possible to change memories during the reconsolidation time frame upon retrieval. Propranolol, a beta-blocker, has been shown to block the reconsolidation of memories, and Debiec and LeDoux (2004) found that infusions of propranolol blocked the reconsolidation of a previously formed CS-US memory, and led to erasure of the fear response and resistance to reinstatement effects. This suggests that propranolol upon retrieval may be a useful clinical tool, and indeed, two fear conditioning studies in healthy humans (Kindt, Soeter, & Vervliet, 2009; Soeter & Kindt, 2010) have replicated the effects. How- ever, the effects have not been tested in the context of exposure therapy for panic disorder.

Role of Acceptance during Exposure

Cognitive and somatic coping skills are central to cognitive-behavioral therapy and are taught to facili- tate and improve exposure therapy. Newer approaches that explore acceptance and cognitive defusion (e.g., acceptance and commitment therapy; Hayes, Strosahl, & Wilson, 1999) have been gaining interest, especially given evidence that experiential avoidance is a correlate of anxious psychopathology and acceptance increases willingness to experience and lessens emotional distress over induced anxiety symptoms in individuals with panic disorder (e.g., Campbell-Sills et al., 2006; Eifert & Heffner, 2003), including CO2 inhalation challeng- es (Levitt et al., 2004). Interestingly, the acceptance approach is entirely consistent with our formulation of interoceptive exposure, in which patients are encour- aged to experience the feared physical sensations with- out any attempt to lessen them or to think differently about them in the moment of exposure. We recently extended this model of acceptance during interoceptive exposure to acceptance during in vivo exposure in an open trial of 11 patients with panic disorder (Meuret, Twohig, Rosenfield, Hayes, & Craske, 2012). In gen- eral, the exposures were an opportunity for patients to behave with their panic-related thoughts, feelings, and

Panic Disorder and Agoraphobia 31

bodily sensations; in other words, patients were encour- aged to realize that they can drive for and reach life goals, even in the presence of unpleasant inner experi- ences. To that end, it was explicitly stated that the level of anxiety or fear was not the determining factor. Rath- er, it was explained that “willingness can do surprising things to one’s inner experiences. If one is willing to experience anxiety it may or may not show up. Thus, we are not going to judge the success of these exposures on how high the anxiety gets, but instead in how open you are to what might show up.” To plan effectively for interoceptive (i.e., eliciting panic sensations such as a racing heart or shortness of breath) and in vivo expo- sures (i.e., seeking places and situations that one previ- ously avoided because of the fear of panic sensations), a hierarchy of least to most anxiety-provoking items was created. Movement up the hierarchy was not based on reductions in anxiety at the preceding step but on high willingness to experience panic-related inner experienc- es. During the exposures, patients were encouraged to maintain an open, nonjudgmental stance toward what- ever thoughts, feelings, and bodily sensations arose in a given moment, experiencing them for what they were, and moving toward them while anxious. Treatment was associated with clinically significant improvements in panic symptom severity, willingness to allow inner experiences to occur, and reductions in avoidant be- havior. In another study of a mixed anxiety disorder sample, we found very few differences in outcome be- tween acceptance and commitment therapy (Hayes et al., 1999) and cognitive-behavioral therapy, although the treatments were matched on amount of time spent on exposure therapy, albeit framed differently within for each condition (Arch et al., 2012). Thus, the data to date suggest that both a cognitive therapy coping approach and an acceptance-based exposure approach are effective.

OVERALL EFFICACY OF COGNITIVE‑BEHAVIORAL THERAPY

An extensive body of research has evaluated the efficacy of cognitive-behavioral therapy for panic disorder and agoraphobia. Cognitive-behavioral therapy, involving most or all of the components just listed, yields panic- free rates in the range of 70–80% and high end-state rates (i.e., within normative ranges of functioning) in the range of 50–70% for panic disorder with mini- mal agoraphobia (e.g., Barlow et al., 1989; Clark et al.,

1994). Although agoraphobic avoidance is sometimes associated with less positive response (e.g., Dow et al., 2007), the overall within-group effect size for change in panic disorder and agoraphobia from pre- to post- treatment is very large (e.g., effect size = 1.53; Norton & Price, 2007). Moreover, the between-group effect size is substantial in comparison to wait-list conditions (e.g., effect size = 0.64; Haby, Donnelly, Corry, & Vos, 2006). However, more research is needed comparing cognitive-behavioral therapy to alternative active treat- ment conditions.

The effectiveness extends to clients who experience nocturnal panic attacks (Craske, Lang, et al., 2005). Furthermore, cognitive-behavioral therapy results in improvements in rates of comorbid anxiety and mood disorders (e.g., Craske et al., 2007; Tsao, Mystkowksi, Zucker, & Craske, 2005), although one study sug- gested that the benefits for comorbid conditions may lessen over time, when assessed 2 years later (Brown et al., 1995). Finally, applications of cognitive-behav- ioral therapy lower relapse rates upon discontinuation of high-potency benzodiazepines (e.g., Spiegel, Bruce, Gregg, & Nuzzarello, 1994). The effects of cognitive- behavioral therapy are sustained over time, as meta- analyses show little change (i.e., maintenance of treat- ment effects) from posttreatment to follow-up (effect size = 0.12; Norton & Price, 2007).

With regard to long-term maintenance of gains after cognitive-behavioral therapy, in a review of meta-analy- ses for cognitive-behavioral therapy across all disorders, Butler, Chapman, Forman, and Beck (2006) concluded that evidence for maintenance of treatment gains was particularly strong for panic disorder, where the rate of relapse was almost half the rate of relapse following pharmacotherapy. Continuing improvement after acute treatment is facilitated by involvement of significant others in every aspect of treatment for agoraphobia (e.g., Cerny et al., 1987). Also, booster sessions enhance long-term outcomes and prevent return of symptoms and relapse (Craske et al., 2006; White et al., 2013). There is some evidence to suggest that although long- term maintenance is observed over a 24-month period for individuals who received cognitive-behavioral ther- apy for panic disorder and agoraphobia, improvement in agoraphobic avoidance is maintained to a greater ex- tent for those who receive in-person therapy compared to those who receive self-help therapy (Gloster et al., 2013), indicating that treatment effects may be more stable over the long term when treatment is provided by a therapist.

32 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Efficacy data from research settings are now being complemented by effectiveness data from real-world, primary care settings. In a randomized controlled trial in primary care settings with novice therapists, cognitive-behavioral therapy combined with expert recommendations for medication regimens was more effective than treatment as usual (Roy-Byrne, Craske, et al., 2005). The effects appeared primarily to be due to cognitive-behavioral therapy rather than medication (Craske, Golinelli, et al., 2005). In the more recent CALM study (Craske et al., 2011), the effectiveness of cognitive-behavioral therapy for panic disorder in pri- mary care settings was demonstrated in the hands of nonexperienced therapists with the aid of a computer- ized guide, combined with expert recommendations for medication, relative to treatment as usual.

Even though cognitive-behavioral therapy for panic disorder and agoraphobia is efficacious and effective, there is room for improvement. In one study, Brown and Barlow (1995) estimated that 30% of clients con- tinue to function poorly at follow-up, and only 48% reached high end-state status. In a landmark study (Barlow et al., 2000), only 32% of clients with panic disorder assigned to cognitive-behavioral therapy alone demonstrated strong treatment response 12 months after acute treatment. Finally, of those who do start treatment, the mean dropout rate is 19%, with a range of 0–54% (Haby et al., 2006).

TREATMENT DESCRIPTION: PROTOCOL

What follows is a description of a 12-session cognitive- behavioral therapy for panic disorder and agoraphobia tailored to Julie’s presentation. Of course, the degree to which the various components of treatment are empha- sized vary by the functional assessment conducted for each patient.

Overview

The basic aim of the treatment protocol is to influence directly the catastrophic misappraisals and avoidance of bodily sensations and agoraphobic situations. This is done first through the provision of accurate informa- tion as to the nature of the fight–flight response. By provision of such information, patients are taught that they experience sensations that are normal and harm- less. Second, treatment aims to teach a set of skills for

developing evidence-based appraisals regarding bodily sensations and agoraphobic situations. At the same time, specific information concerning the effects of hyperventilation and its role in panic attacks is pro- vided, with practice of breathing retraining, if deemed appropriate. Then, the crux of the treatment involves repeated exposure to feared internal cues and agorapho- bic situations.

Session 1

The goals of Session 1 are to describe fear and anxi- ety; to help patients understand the cyclical influ- ences among behavioral, physiological, and cognitive responses; to understand that panic attack symptoms are not harmful; and to begin self-monitoring, if it was not already begun with the initial assessment. Therapy begins with identifying anxiety patterns and the situ- ations in which anxiety and panic attacks are likely to occur. Many patients have difficulty identifying specif- ic antecedents, reporting that panic can occur at almost any time. Therapists help patients to identify internal triggers, specifically, negative verbal cognitions, cata- strophic imagery, and physical sensations. The follow- ing interchange took place for Julie:

THERAPIST: In what situations are you most likely to panic?

JULIE: Crowded restaurants and when I’m driving on the freeway. But sometimes I am driving along, feel- ing OK, when all of a sudden it hits. And other times I can be sitting at home feeling quite relaxed and it just hits. That’s when I really get scared because I can’t explain it.

THERAPIST: So, when you are driving on the freeway, what is the very first thing you notice that tells you you’re about to panic?

JULIE: Well, the other cars on the road look as if they are moving really slowly . . . it’s as if I am in a dream.

THERAPIST: And what is the first thing you notice when you’re at home?

JULIE: An unreal feeling, like I’m floating. THERAPIST: So, what does that tell you? What is the

common factor that started these two panic attacks? JULIE: The feeling as if things are unreal? Wow, I al-

ways thought the physical feelings were the panic at- tack, but maybe they start the panic attack.

Panic Disorder and Agoraphobia 33

Next, the three-response system model for describ- ing and understanding anxiety and panic is introduced. This model contributes to an objective self-awareness— to becoming a personal scientist—and provides the groundwork for an alternative conceptual framework for explaining panic and anxiety that replaces the pa- tient’s own misassumptions. Patients are asked to de- scribe cognitive, physiological, and behavioral aspects to their responding: to identify the things that they feel, think, and do when they are anxious and panicky. As described earlier, differences between the response profiles of anxiety and panic are highlighted. After grasping the notion of three responses that are partially independent, interactions among the response systems are described. The patient is asked to describe the three- response system components in a recent panic attack and to identify ways in which they interacted to pro- duce heightened distress, as in the following example:

THERAPIST: How would you describe the three parts to the panic attack you had at home last week?

JULIE: Well, physically, my head felt really light, and my hands were clammy. I thought that I would ei- ther pass out or that I would somehow dissolve into nothingness. My behavior was to lie down and phone my husband.

THERAPIST: Ok that’s a great description of your thoughts, physical feelings, and behaviors. Now let’s look at the sequence of events. What was the very first thing you noticed?

JULIE: When I stood up, my head started to feel really weird, as if it was spinning inside.

THERAPIST: What was your very next reaction to that feeling?

JULIE: I held onto the chair. I thought something was wrong. I thought it could get worse and that I’d col- lapse.

THERAPIST: So it began with a physical sensation, and then you had some very specific thoughts about those sensations. What happened next?

JULIE: I felt very anxious. THERAPIST: And what happened next? JULIE: Well, the dizziness seemed to be getting worse

and worse. I became really concerned that it was dif- ferent from any other experience I had ever had. I was convinced that this was “it.”

THERAPIST: So, as you became more anxious, the physi- cal feelings and the thoughts that something bad was going to happen intensified. What did you do next?

JULIE: I called my husband and lay on the bed until he came home. It was horrible.

THERAPIST: Can you see how one thing fed off another, creating a cycle? That it began with a sensation, then some anxious thoughts, then feeling anxious, then more sensations and more thoughts, and more fear, and so on?

Next, the reasons why panic attacks first began are addressed briefly. Patients are informed that it is not necessary to understand the reasons why they began to panic to benefit from the treatment, because factors involved in onset are not necessarily the same as the factors involved in the maintenance of a problem. Nev- ertheless, the initial panic attack is described as a mani- festation of anxiety/stress. The stressors surrounding the time of the first panic attack are explored with the patient, particularly in terms of how stressors may have increased levels of physical arousal and primed certain danger-laden cognitive schemas.

Also, the therapist briefly describes the physiology un- derlying anxiety and panic, and the myths about what the physical sensations might mean. The main concepts covered in this educational phase are (1) the survival value or protective function of anxiety and panic; (2) the physiological basis to the various sensations experienced during panic and anxiety, and the survival function of the underlying physiology; and (3) the role of specific learned and cognitively mediated fears of certain bodily sensations. The model of panic we described earlier in this chapter is explained. In particular, the concepts of misappraisals and interoceptive conditioning are ex- plained as accounting for panic attacks that seem to occur from out of the blue—that are triggered by very subtle internal cues or physical sensations that may occur at any time. Not only does this information reduce anxi- ety by decreasing uncertainty about panic attacks but it also enhances the credibility of the subsequent treatment procedures. This information is detailed in a handout given to the patient to read over the next week (for the handout, see Barlow & Craske, 2006).

This information was very important for Julie, be- cause the inability to explain her panic attacks was a major source of distress. Here are some of the questions she asked in her attempt to understand more fully:

34 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

JULIE: So, if I understand you correctly, you’re saying that my panic attacks are the same as the fear I expe- rienced the time we found a burglar in our house. It doesn’t feel the same at all.

THERAPIST: Yes, those two emotional states—an unex- pected panic attack and fear when confronted with a burglar—are essentially the same. However, in the case of the burglar, where were you focusing your attention—on the burglar or on the way you were feeling?

JULIE: The burglar, of course, although I did notice my heart was going a mile a minute.

THERAPIST: And when you have a panic attack, where are you focusing your attention—on the people around you or on the way you are feeling?

JULIE: Well, mostly on the way I’m feeling, although it depends on where I am at the time.

THERAPIST: Being most concerned about what’s going on inside can lead to a very different type of experi- ence than being concerned about the burglar, even though basically the same physiological response is occurring. For example, remember our description of the way fear of sensations can intensify the sensa- tions.

JULIE: I get that. But what about the feelings of unreal- ity? How can they be protective or how can feeling unreal help me deal with a dangerous situation?

THERAPIST: OK, remember that it’s the physiological events that are protective—not the sensations. The sensations are just the end result of those events. Now, feelings of unreality can be caused by changes in your blood flow to your brain (although not dan- gerously so), or from overbreathing, or from concen- trating too intensely on what’s going on inside you. So the unreality sensation may not be protective, but the changes in blood flow and overbreathing are.

JULIE: I understand how I can create a panic attack by being afraid of my physical feelings, like my heart racing or feeling unreal. But sometimes it happens so quickly that I don’t have time to think.

THERAPIST: Yes, these reactions can occur very quickly, at times automatically. But remember, we are tuned to react instantaneously to things that we believe to be dangerous. Imagine yourself walking through a dark alley, and you have reason to believe that some- where in the darkness lurks a killer. Under those con- ditions, you would be extremely attentive to any sign,

any sound, or any sight of another person. If you were walking through the same alley and were sure there were no killers, you might not hear or detect the same signals you picked up on in the first case. Now let’s translate this to panic; the killer in the dark alley is the panic attack, and the signs, sounds, and smells are the physical sensations you think signal the possibility of a panic attack. Given the acute de- gree of sensitivity to physical symptoms that signal a panic attack, it is likely that you are noticing normal “noises” in your body that you would otherwise not notice, and on occasion, immediately become fearful because of those “noises.” In other words, the sen- sations are often noticeable because you attend to them.

Next, the method of self-monitoring was described and demonstrated with in-session practice of complet- ing a Panic Attack Record. Julie was concerned that self-monitoring would only elevate her distress, by re- minding her of the very thing she was afraid of (panic and unreality). The therapist clarified the difference between objective and subjective self-monitoring, and explained that distress would subside as Julie persevered with self-monitoring.

The homework for this session was to self-monitor panic attacks, daily anxiety, and mood, and to read the handout. In fact, we encourage patients to reread the handout several times and to actively engage in the material by circling or marking the most personally relevant sections or areas in need of clarification, be- cause effort enhances long-term retention of the mate- rial learned. Of course, for some patients, reading the material draws their attention to things they fear (just as with self-monitoring). In this case, therapists can dis- cuss the role of avoidance, and how, with repeated read- ings, distress levels will most likely subside.

At the end of the session, Julie suddenly became highly anxious. She felt unable to tolerate either the treatment procedures or her anticipation of them. She became very agitated in the office and reported feel- ings of unreality. She opened the office door to find her husband, who was waiting outside. The therapist helped Julie understand how the cycle of panic had emerged just at that moment: (1) The trigger was the treatment description—having to face eventually feared sensations and situations; (2) this was anxiety produc- ing, because Julie believed that she could not cope with the treatment demands, that the treatment would cause her so much anxiety that she would “flip out” and lose

Panic Disorder and Agoraphobia 35

touch with reality permanently, or that she would never improve because she could not tolerate the treatment; (3) the current anxiety in the office elicited sensations of unreality and a racing heart; (4) Julie began to worry that she might panic and lose touch with reality per- manently within the next few minutes; (5) the more anxious Julie felt, and the stronger her attempts to es- cape and find safety, the stronger the physical sensa- tions became; and (6) she felt some relief upon finding her husband, because his presence reassured her that she would be safe. Julie was reassured that treatment would progress at a pace with which she was comfortable, but at the same time she was helped to understand that her acute distress about the feeling of unreality would be the precise target of this type of treatment, therefore attesting to the relevance of this treatment for her. She was also calmed by preliminary cognitive restructur- ing of the probability of permanently losing touch with reality. After a lengthy discussion, Julie became more receptive to treatment. A team approach to treatment planning and progress was agreed upon, so that Julie did not feel that she would be forced to do things she did not think she could do.

Session 2

The goals of this session are to begin the development of a hierarchy of agoraphobic situations and coping skills of breathing retraining and cognitive restructur- ing. The individualized hierarchy comprises situations that range from mild to moderate anxiety, all the way up to extreme anxiety. These situations become the basis of graduated in vivo exposure. Although in vivo exposure exercises are not scheduled to take place until Session 4, the hierarchy is introduced now, so that cog- nitive restructuring skills can be practiced in relation to each situation on the hierarchy before in vivo exposure begins. Moreover, the hierarchy will be refined as a re- sult of the cognitive restructuring practice, because the latter highlights specific features of agoraphobic situa- tions that are most anxiety provoking.

Julie was asked to develop a hierarchy over the fol- lowing week. She expressed some doubt that she would ever be able to accomplish any, let alone all, of the items on her hierarchy. The therapist helped Julie by asking her to think of any situation in her lifetime that used to be difficult but became easier with practice. Julie remembered how anxious she used to be when she first started working with customers at her husband’s office—and how that discomfort subsided over time.

This was used to help Julie realize that the same might happen with the situations listed on her hierarchy. Ju- lie’s final hierarchy comprised the following situations: driving home from work alone; sitting in a crowded movie theater; spending 2 hours alone at home during the day; being alone at home as day turned to night; driving on surface streets to her brother’s house (10 miles) alone; driving two exits on Freeway 444, with her husband following in the car behind; driving two exits on Freeway 444, alone; driving four exits on Free- way 444; and driving on the freeway to her brother’s house alone. Then, Julie was to repeat all of these tasks without taking Klonopin, and without knowing the lo- cation of her husband.

Breathing retraining also is begun in this session. Pa- tients are asked to hyperventilate voluntarily by stand- ing and breathing fast and deep, as if blowing up a balloon, for 1½ minutes. With prompting and encour- agement from the therapist, patients can often complete the full 1½ minutes, after which time they are asked to sit, close their eyes, and breathe very slowly, paus- ing at the end of each breath, until the symptoms have abated. The experience is then discussed in terms of the degree to which it produced symptoms similar to those that occur naturally during anxiety or panic. Approxi- mately 50–60% of patients report that the symptoms of hyperventilation are very similar to their panic attack symptoms. Often, however, similarity of the symptoms is confused with similarity of the anxiety. Because the exercise is conducted in a safe environment and the symptoms have an obvious cause, most patients rate the experience as less anxiety provoking than if the same symptoms had occurred naturally. This distinction is important to make, because it demonstrates the signifi- cance of perceived safety for the degree of anxiety expe- rienced. Julie rated the hyperventilation exercise as very anxiety provoking (8 on a 0- to 10-point scale), and rated the symptoms as being quite similar to her panic symptoms (6 on a 0- to 10-point scale). She terminated the task after approximately 40 seconds in anticipation of experiencing a full-blown panic attack. The therapist and Julie discussed this experience in terms of the three response systems, and the role of misappraisals and in- teroceptive conditioning described during the previous session.

Then, Julie was briefly educated about the physio- logical basis to hyperventilation (see Barlow & Craske, 2006). As before, the goal of the didactic presentation was to allay misinterpretations of the dangers of over- breathing, and to provide a factual information base

36 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

on which to draw when actively challenging misinter- pretations. The educational content is tailored to the patient’s own educational level and covered only to the degree that it is relevant to the patient.

In the next step, the therapist teaches breathing re- training, which begins by teaching patients to rely more on the diaphragm (abdomen) than on chest muscles. In addition, patients are instructed to concentrate on their breathing by counting on their inhalations and think- ing the word “relax” on exhalations. (Slow breathing is introduced in Session 3.) Therapists model the sug- gested breathing patterns, then provide corrective feed- back to patients while they practice in the office setting. (Note that CART uses a different method of breathing retraining that is based on raising levels of CO2 in the blood through biofeedback.)

Initial reactions to the breathing exercise may be negative for patients who are afraid of respiratory sen- sations, because the exercise directs their attention to breathing. It also can be difficult for patients who are chronic overbreathers, and patients for whom any inter- ruption of habitual breathing patterns initially increases respiratory symptomatology. In both cases, continued practice is advisable, with reassurance that sensations such as shortness of breath are not harmful. The goal is to use breathing skills training to encourage continued approach toward anxiety and anxiety-producing situa- tions. On occasion, patients mistakenly view breathing retraining as a way of relieving themselves of terrifying symptoms, thus falling into the trap of fearing dire con- sequences should they not succeed in correcting their breathing. This is what happened for Julie:

JULIE: So, all I have to do is to slow down my breathing, then everything will be OK?

THERAPIST: Certainly, slowing down your breathing will help to decrease the physical symptoms that you feel, but I am not sure what you mean when you ask whether everything will be OK.

JULIE: That proper breathing will prevent me from los- ing touch with reality—that I won’t disappear.

THERAPIST: Breathing retraining will help you to regu- late your breathing, which may lessen your physical symptoms, including the sense of unreality. Your question, though, is the reason for our next treat- ment skill of changing your thinking, so you can learn that the sense of unreality is not a sign of actual loss of touch with reality and disappearance.

The homework is to practice diaphragmatic breath- ing for at least 10 minutes, two times a day in relaxing environments.

Therapists introduce cognitive restructuring in this session, by explaining that everyone has errors in think- ing when anxious, thus helping the patient to expect his/her thinking to be distorted. Patients are informed that these distortions have an adaptive function: Chances of survival are greater if we perceive danger as probable and worthy of attention rather than mini- mize it. Therefore, anxiety leads us to judge threatening events as being more likely and more threatening than they really are. However, the cognitive distortions are unnecessary, because there is no real threat in the case of panic disorder.

Then, patients are taught to treat their thoughts as hypotheses or guesses rather than as facts. The notions of automatic thinking and discrete predictions are also explained, to emphasize the need to become an astute observer of one’s own habitual self-statements in each situation. This leads to a “downward arrow technique” to identify specific predictions made at any given mo- ment, as shown with Julie.

THERAPIST: What is it that scared you about feeling detached in the movie theater last night?

JULIE: It is just such a horrible feeling. THERAPIST: What makes it so horrible? JULIE: I can’t tolerate it. THERAPIST: What makes you think you cannot tolerate

it? What is the feeling of detachment going to do to you that makes you think it is horrible and intoler- able?

JULIE: It might become so intense that it overwhelms me.

THERAPIST: And if it overwhelms you, what would happen?

JULIE: I could become so distressed that I lose touch with reality.

THERAPIST: What would it mean if you lost touch with reality?

JULIE: That I would be in a different mind state forev- er—I would never come back to reality. That I would be so crazy that I would have to be carted out of the movie theater to a mental hospital and locked away forever.

Panic Disorder and Agoraphobia 37

Overly general self-statements, such as “I feel ter- rible—something bad could happen,” are insufficient, nontherapeutic, and may serve to intensify anxiety by virtue of their global and nondirective nature. Instead, detail in thought content, such as “I am afraid that if I get too anxious while driving, then I’ll lose control of the wheel and drive off the side of the road and die,” permits subsequent cognitive restructuring.

Analysis of anxious thought content yields two broad factors that are labeled as risk and valence. These two main types of cognitive errors are described to patients. Risk translates to overestimation, or jumping to con- clusions by viewing negative events as being probable events, when in fact they are unlikely to occur. The pa- tient is asked to identify overestimations from the anxi- ety and panic incidents over the past couple of weeks: “Can you think of events that you felt sure were going to happen when you panicked, only to find out in the end that they did not happen at all?” Usually, patients can identify such events easily, but with protestations, as in the following example:

JULIE: Well, several times I thought that I really was going to lose it this time . . . that I would flip out and never return to reality. It never actually happened, but it could still happen.

THERAPIST: Why do you think “it” could still happen? JULIE: Part of me feels like I’ve always managed to es-

cape it just in time, by either removing myself from the situation or by having my husband help me, or by holding on long enough for the feeling to pass. But what if I can’t hold on the next time?

THERAPIST: Knowing what we know about our thoughts when we are anxious, can you classify any of the ideas you just expressed, of “just holding on” or “just escaping in time,” as overestimations?

JULIE: I suppose you’re saying that I can hold on or I can always escape in time.

THERAPIST: More that you feel the need to hold on and the need to escape because you are overestimating the likelihood of flipping out and never returning to reality.

JULIE: But it really feels like I will. THERAPIST: The confusion between what you think

will happen and what actually happens is the very problem that we are addressing in this session.

The reasons why overestimations persist despite re- peated disconfirmation are explored. Typically, patients misattribute the absence of danger to external safety signals or safety behaviors (e.g., “I only made it because I managed to find help in time,” “If I had not taken Xanax last week when I panicked in the store, I’m sure I would have passed out,” or “I wouldn’t have made it if I hadn’t pulled off the road in time”), or to “luck,” instead of realizing the inaccuracy of the original pre- diction. Similarly, patients may assume that the only reason they are still alive, sane, and safe is because the “big one” has not happened. In this case, patients err by assuming that intensity of panic attacks increases the risk of catastrophic outcomes.

The method for countering overestimation errors is to question the evidence for probability judgments. The general format is to treat thoughts as hypotheses or guesses rather than as facts, and to examine the evi- dence and generate alternative, more realistic predic- tions. This is best done by the therapist using a Socratic style, so that patients learn the skill of examining the content of their statements and arrive at alternative statements or predictions after they have considered all of the evidence. Questioning of the logic (e.g., “How does a racing heart lead to heart attack?”), or the bases from which judgments are made (e.g., misinformation from others, unusual sensations) is useful in this regard. Continuing with the previous example from Julie, the questioning took the following course:

THERAPIST: One of the specific thoughts you have identified is that you will flip out and never return to reality. What specifically leads you to think that that is likely to happen?

JULIE: Well, I guess it really feels like that. THERAPIST: Describe the feelings? JULIE: Well, I feel spacey and unreal, like things around

me are different and that I’m not connected. THERAPIST: And why do you think those feelings mean

that you have actually lost touch with reality? JULIE: I don’t know—it feels as if I have. THERAPIST: So, let’s examine that assumption. What is

your behavior like when you feel unreal? For exam- ple, do you respond if someone asks you a question during those episodes?

JULIE: Well, I respond to you even though I feel that way sometimes in here.

38 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: OK, and can you walk or write or drive when you feel that way?

JULIE: Yes, but it feels different. THERAPIST: But you do perform those functions de-

spite feeling detached. So, what does that tell you? JULIE: Well, maybe I haven’t lost complete touch with

reality. But what if I do? THERAPIST: How many times have you felt detached? JULIE: Hundreds and hundreds of times. THERAPIST: And how many times have you lost touch

with reality permanently? JULIE: Never. But what if the feelings don’t go away?

Maybe I’ll lose it then? THERAPIST: So what else tells you that this is a pos-

sibility? JULIE: Well, what about my second cousin? He lost it

when he was about 25, and now he’s just a mess. He can hardly function at all, and he is constantly in and out of psychiatric hospitals. They have him on a bunch of heavy-duty drugs. I’ll never forget the time I saw him totally out of it. He was talking to himself in jibberish.

THERAPIST: So, do you make a connection between him and yourself?

JULIE: Yes. THERAPIST: What are the similarities between the two

of you? JULIE: There are none really. It’s just that he is what I

think I will become. THERAPIST: Did he ever feel the way you feel now? JULIE: I don’t know. THERAPIST: And if another one of your cousins had

severe back problems, would you be concerned that you would end up with severe back problems?

JULIE: No. THERAPIST: Why not? JULIE: Because it never crosses my mind. It is not some-

thing that I worry about. THERAPIST: So, it sounds like you think you will end

up like your cousin because you are afraid of ending up like him.

JULIE: I suppose so. THERAPIST: So, let’s look at all of the evidence and

consider some alternatives. You have felt unreal hun-

dreds of times, and you’ve never lost touch with real- ity because you’ve continued to function in the midst of those feelings, and they have never lasted. You are afraid of becoming like your cousin, but there are no data to show that you and he have the same problem. In fact, the data suggest otherwise, because you func- tion and he does not. So what is the realistic prob- ability that you will lose touch with reality perma- nently? Use a scale of 0 to 100, where 0 = No chance at all and 100 = Definitely will happen.

JULIE: Well, maybe it is lower than I thought. Maybe 20%.

THERAPIST: So that would mean that you have actually lost touch with reality in a permanent way once every five times you have felt unreal.

JULIE: When it’s put like that, I guess not. Maybe it’s a very small possibility.

THERAPIST: Yes, so what is an alternative explanation? JULIE: Perhaps the feelings of unreality are caused by

feeling anxious or overbreathing, and having those feelings does not mean that I am actually losing touch with reality, and that I am not like my cousin at all.

For homework, in addition to continuation of self- monitoring and practice of diaphragmatic breathing, Julie was asked to identify her anxious thoughts in rela- tion to every item on her agoraphobia hierarchy, and to use the in-session steps of examining the evidence and generating alternative evidence-based interpretations for errors of overestimating the risk. She was to do the same for every panic attack that occurred over the next week.

Session 3

The goals of this session are to develop breathing re- training and to continue active cognitive restructuring. The therapist reviews the patient’s week of diaphrag- matic breathing practice. Julie was disappointed with her attempts to practice.

JULIE: I just didn’t seem to be able to do it the right way. Sometimes I would start off OK and then the more I tried, the more it felt like I was running out of air, and I’d have to take a big gulp between breaths. At other times, I felt dizzy and the unreal feelings would start, at which point I would stop and do “busy work” to keep my mind occupied.

Panic Disorder and Agoraphobia 39

THERAPIST: It sounds like quite a few things were going on. First of all, remember that this is a skill, just like learning to ride a bike, and you cannot expect it to be easy from the get-go. Second, it sounds like you experienced some uncomfortable physical symptoms that worried you. You said it felt like you were run- ning out of air. Based on what we talked about last week, what do you think might have caused that feel- ing?

JULIE: Well, maybe I wasn’t getting enough air into my lungs because it’s really hard for me to use my dia- phragm muscle. I felt like I was suffocating myself.

THERAPIST: Possibly it’s just a matter of learning to use the diaphragm muscle, but were you really suffocat- ing or was it an interpretation that you might be suf- focating?

JULIE: I don’t know. I’ve had the feeling of suffocat- ing before, especially when I’m trapped in a crowded room.

THERAPIST: So, how do you know you were suffocat- ing?

JULIE: I don’t know. It just felt that way. THERAPIST: So, let’s put the evidence together. You’ve

had the feelings before and never suffocated. As we discussed last time, anxiety can sometimes create a sensation of shortness of breath even though you are getting plenty of air. Can you think of an alternative explanation?

JULIE: Well, maybe I wasn’t suffocating. Maybe it just felt like that.

Julie’s complaints represent typical concerns that should be addressed. The next step is to slow the rate of breathing until the patient can comfortably span a full inhalation and exhalation cycle of 6 seconds. Again, the therapist models slowed breathing, then provides cor- rective feedback on practice in the session. The patient is instructed to continue to practice slow breathing in “safe” or relaxing environments, and is discouraged from applying slow breathing when anxious or panick- ing, until fully skilled in its application.

Also, cognitive restructuring is continued by ad- dressing the second cognitive error, which involves viewing an event as “dangerous,” “insufferable,” or “catastrophic.” Typical examples of catastrophic errors are “If I faint, people will think that I’m weak, and that would be unbearable” or “Panic attacks are the worst thing I can imagine,” and “The whole evening is ruined

if I start to feel anxious.” Decatastrophizing means to face the worst, to realize that the occurrences are not as “catastrophic” as stated, and to think about actual ways to cope with negative events rather than how “bad” they are. A key principle underlying decatastrophiz- ing is that events can be endured even though they are uncomfortable. Recognition of the time-limited na- ture of discomfort contributes to the development of a sense of being able to cope. The critical distinction here is that although patients might prefer that these events not occur, they can tolerate the discomfort, if necessary. Thus, for the person who states that negative judgments from others are unbearable, it is important to discuss what he/she would do to cope should some- one else make a direct negative judgment. Similarly, for the person who states that the physical symptoms of panic are intolerably embarrassing, the following type of questioning is helpful:

JULIE: I am really worried that I might lose control and do something crazy, like yell and scream.

THERAPIST: Let’s face the worst and find out what is so bad about it. What would be so horrible about yell- ing and screaming?

JULIE: I could never live it down. THERAPIST: Well, let’s think it through. What are the

various things you could do in the situation? You have just yelled and screamed—now what?

JULIE: Well, I guess the yelling and screaming would eventually stop.

THERAPIST: That’s right—at the very least you would eventually exhaust yourself. What else?

JULIE: Well, maybe I would explain to the people around me that I was having a really bad day but that I would be OK. In other words, reassure them.

THERAPIST: Good. What else? JULIE: Maybe I would just get away—find someplace to

calm down and reassure myself that the worst is over. THERAPIST: Good. JULIE: But what if the police came and took me away,

locked me up in a mental ward? THERAPIST: Again, let’s face the worst. What if the po-

lice did come when you were yelling and screaming, and what if the police did take you away? As scary as that may sound to you, let’s consider what actually would happen.

40 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

JULIE: I have this image of myself not being able to tell them what is really going on—that I am so out of it I don’t have the ability to let them know I am just anxious.

THERAPIST: If you were so distraught that you could not clearly communicate, how long would that last?

JULIE: You’re right. I would eventually exhaust myself and then I could speak more clearly. But what if they didn’t believe me?

THERAPIST: What if they did not believe you at first? How long would it take before they would realize that you were not crazy?

JULIE: I guess that after a while they would see that I was OK, and maybe I could call a friend or my doc- tor to explain what was going on.

The homework for this session, in addition to contin- ued self-monitoring, is to practice slow and diaphrag- matic breathing in relaxing environments, and to iden- tify errors of catastrophizing in relation to each item on the agoraphobia hierarchy, followed by practice of decatastrophizing and generation of ways to cope. In addition, Julie was to use the skill of decatastrophizing for panic attacks that occurred over the following week.

Session 4

The main goal of this session is to use breathing retrain- ing skills as a coping tool, to review cognitive restruc- turing skills, and to begin in vivo exposure to the first item on the agoraphobia hierarchy.

Now that patients have practiced slow and diaphrag- matic breathing sufficiently in relaxing environments, they are ready to use these methods in distracting en- vironments and in anxious situations. Patients are en- couraged to use breathing skills as a coping technique as they face fear, anxiety, and anxiety-provoking situ- ations. Some patients use breathing skills as a safety signal or a safety behavior; in other words, they believe that they will be at risk for some mental, physical, or social calamity if they do not breathe correctly. This issue came up with Julie:

JULIE: When I panicked during the week, I tried to use the breathing. It didn’t work. It made me feel worse.

THERAPIST: It sounds as if you might have attempted to use the breathing exercise as a desperate attempt to control the feelings you were experiencing.

JULIE: Yes, that’s right. THERAPIST: What did you think would have happened

if you had not been able to control the feelings? JULIE: I was really worried that I might not be able to

handle the feelings. THERAPIST: And if you weren’t able to handle the feel-

ings, what would happen? JULIE: It just feels like I will lose it, permanently. THERAPIST: So this is one of those thoughts that we

were talking about last time. What does your evi- dence tell you about the likelihood of losing touch with reality permanently?

JULIE: So you mean even if I don’t control my breath- ing, then I will be OK?

THERAPIST: Well, you had not lost touch with reality permanently before you learned the breathing exer- cise. So what does that tell you?

JULIE: OK, I get it. THERAPIST: The breathing exercise is best thought of as

a tool to help you face whatever is provoking anxiety. So, as you face situations and your anxiety increases, use the breathing exercise to help you to face rather than run away from anxiety. The breathing exercise can be helpful for helping you approach or stay in these situations, but you don’t actually need it to face these situations and tolerate your anxiety.

Patients who consistently use the breathing skills as a safety behavior might be discouraged from using the breathing skills, because they learn that what they are most worried about either does not happen or it can be managed without using the breathing skills.

In terms of the cognitive restructuring, therapists give corrective feedback to patients on the methods of questioning the evidence to generate realistic prob- abilities, facing the worst, and generating ways to cope with each item on the agoraphobia hierarchy and any panic attacks that occurred over the past week. Partic- ular “corrective” feedback is given when patients lack specificity in their cognitive restructuring (e.g., patients who record that they are most worried about panicking should be encouraged to detail what it is about pan- icking that worries them) or rely on blanket reassur- ance (e.g., patients who record that “Everything will be OK” as their evidence and/or ways of coping should be encouraged to list the evidence and/or generate actual coping steps).

Panic Disorder and Agoraphobia 41

Next, attention is given to how to practice the first item on the agoraphobia hierarchy. If appropriate, rea- sons why previous attempts at in vivo exposure may have failed are reviewed. Typical reasons for patients’ past failures at in vivo exposure include attempts that are too haphazard and/or brief or spaced too far apart, and attempts conducted without a sense of mastery, or while maintaining beliefs that catastrophe is very pos- sible. Julie had tried to face agoraphobic situations in the past, but each time she had escaped, feeling over- whelmed by panic and terrified of losing touch with reality permanently. The therapist helped Julie realize how to approach the agoraphobic situations differently to benefit from the exposure. Julie’s typical safety sig- nals were the presence of her husband, or at least know- ing his whereabouts, and Klonopin (which she carried but rarely used). The therapist discussed the impor- tance of eventual weaning from those safety signals.

As mentioned earlier, the goal of exposure therapy is not immediate reduction in fear and anxiety; rather, the goal is for the patient to learn something new as a result of exposure. Clarification of what patients are most worried about as they face their feared situations and the conditions that best help them to learn that what worries them most never or rarely happens, and/ or that they can cope with the situation and tolerate anxiety, is essential for effective exposure. If a patient is most worried that fear and anxiety will remain elevated for the duration of the practice, then corrective learn- ing involves toleration of sustained anxiety. For Julie, the first situation on her hierarchy was to drive home from work, alone. She stated that what most worried her in that situation was that she would panic and lose touch with reality, and as a result, lose control of the car and die in an accident. She also stated that to drive at dusk was the condition under which she was most convinced of these eventualities. Thus, the task that the therapist considered most effective in teaching Julie that she would not lose touch with reality, or that she could cope with the sensations of unreality and panic, was to drive home from work at dusk.

Delineate the exposure task as concretely as possible, so that patients clearly understand exactly what the practice entails (e.g., “Walk around inside of mall for 10 minutes by myself”). Importantly, the practice should not be ended because of anxiety (e.g., “Continue driving on the freeway until I feel anxious”), because the expo- sure practice would then reinforce avoidance of anxiety.

Julie was reminded that she could use her coping skills should she panic as she practiced the task; that is,

in moments of fear, patients are encouraged to use their breathing and thinking skills to complete the assigned task, if needed to stay in engaged in the task; the coping skills are not intended as means to reduce fear and anxi- ety, but to tolerate it. Acceptance and nonjudgmental observation of physical sensations and thoughts can be another strategy to use in the midst of exposure therapy.

Patients are encouraged to maintain a regular sched- ule of repeated in vivo exposure practices at least three times per week and to conduct these practices regard- less of internal (e.g., having a “bad day,” feeling ill) or external (e.g., inclement weather, busy schedules) fac- tors that may prompt postponement of practices. Julie expressed some concerns about being able to practice at least three times over the following week:

JULIE: I don’t know if I can practice three times, be- cause more days than not I feel pretty worn down; maybe I can practice on just Monday and Tuesday, because they are the days I typically feel better.

THERAPIST: What is it you are worried about happen- ing if you practice on a day when you already feel worn down?

JULIE: I feel more fragile on those days. THERAPIST: And if you feel more fragile, what might

happen? JULIE: I just don’t think I could do it. It would be too

hard. I might really freak out and lose touch with reality for ever.

THERAPIST: OK, so let’s think about that thought. What does your experience tell you? How many times have you permanently lost touch with reality, including days when you were worn down?

JULIE: Well, never. THERAPIST: So, what does that tell you? JULIE: OK, but it still feels difficult to drive on those

days. THERAPIST: How about you start with Monday or

Tuesday, but quickly move to the other days of the week when you are feeling worn down, so that you get a really good opportunity to learn whether you permanently lose touch with reality or not?

Julie’s homework for this session involves continued self-monitoring, continued use of cognitive restructur- ing and breathing retraining in the event of elevated anxiety or panic, and practicing the first item on the

42 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

agoraphobia hierarchy at least three times, with at least one of those times being without her husband Larry.

Session 5

The goals of this session are to review the practice of in vivo exposure, to design another exposure task to be practiced over the next week, and to begin interoceptive exposure. Note that in vivo and interoceptive exposure can be done simultaneously or sequentially. For Julie, in vivo exposure was begun in Session 4, whereas in- teroceptive exposure was begun in this session, but they could easily have been done in the opposite order.

It is essential to review the week’s practice of in vivo exposure. An objective evaluation of performance is considered necessary to offset subjective and damag- ing self-evaluations. As demonstrated in experimental literature on learning and conditioning, appraisals of aversive events after they have occurred can influence anxiety about future encounters with the same types of aversive events. Any practice that is terminated prema- turely is to be reviewed carefully for contributing fac- tors that can then be incorporated into subsequent trials of in vivo exposure. Recognition of the precipitant to escape is very important, because the urge to escape is usually based on the prediction that continued endur- ance would result in some kind of danger. For example, patients may predict that the sensations will become intense and lead to an out-of-control reaction. This pre- diction can be discussed in terms of jumping to con- clusions and blowing things out of proportion. At the same time, escape itself need not be viewed catastrophi- cally (i.e., as embarrassing, or as a sign of failure). In addition, therapists reinforce the use of breathing and cognitive skills (or acceptance skills), if needed, to help patients remain in the situation until the specified dura- tion or task has been completed, despite uncomfortable sensations. However, if patients are able to remain in the situation without explicit use of coping skills, that is perfectly fine. In fact, this approach may aid patients in learning that they can tolerate anxiety without at- tempting to manage it, or even that it may go away on its own as corrective learning takes place, without the use of coping skills.

Again, it is important for patients to recognize that the goal is repeatedly to face situations despite anxiety, not to achieve a total absence of anxiety. Toleration of fear rather than immediate fear reduction is the goal for each exposure practice; this approach leads to an eventual fear reduction over time. Anxiety that does

not decline over repeated days of in vivo exposure may result from too much emphasis on immediate fear and anxiety reduction; that is, trying too hard or wishing too much for anxiety to decline typically maintains anxiety.

Julie had success with her first in vivo exposure prac- tice; she managed to drive home from work at dusk, alone, four different times. She noted that the first time was easier than she had expected; the second was harder, and one time she pulled off to the side of the road. The therapist helped Julie identify the thoughts and sensa- tions that led her to “escape” from the situation: the sensations of unreality and fears of losing touch with re- ality. Julie had waited for a few minutes, then continued driving home—an action that was highly reinforced by the therapist. The third and fourth times were easier.

Julie’s husband, Larry, attended Session 5, so that he could learn how to help Julie overcome her panic and agoraphobia. He was supportive and eager to help in any way possible, expressing frustration at having had no idea how to help in the past.

There are general principles for involvement of sig- nificant others in treatment. First, a treatment concep- tualization is provided to the significant other to reduce his/her frustration and/or negative attributions about the patient’s emotional functioning (e.g., “Oh, she’s just making it up. There’s nothing really wrong with her” or “He has been like this since before we were mar- ried, and he’ll never change”). The way in which the agoraphobic problem has disrupted daily routines and distribution of home responsibilities is also explored and discussed. Examples might include social activities, leisure activities, and household chores. The therapist explains that family activities may be structured around the agoraphobic fear and avoidance to help the patient function without intense anxiety. At the same time, reassignment of the patient’s tasks to the significant other may actually reinforce the agoraphobic pattern of behavior. Consequently, the importance of comply- ing with in vivo exposure homework instructions, even though the patient may experience some distress ini- tially, is emphasized.

The significant other is encouraged to become an active participant by providing his/her perception of the patient’s behavior and fearfulness, and the impact on the home environment. Sometimes the significant other provides information of which the patient is not fully aware, or did not report, particularly in relation to how the patient’s behavior affects his/her own daily functioning. Larry, for example, described how he felt

Panic Disorder and Agoraphobia 43

restricted at home in the evenings; whereas, before, he occasionally played basketball with his friends at the local gym, he now stays at home, because he feels guilty if he leaves Julie alone.

The next step is to describe the role of the significant other regarding in vivo exposure tasks. The significant other is viewed as a coach, and the couple is encouraged to approach the tasks as a problem-solving team. This includes deciding exactly where and when to practice in vivo exposure. In preparation for practices, the patient identifies his/her misappraisals about the task and gen- erates cognitive alternatives. The significant other is en- couraged to help the patient question his/her own “anx- ious” thoughts. Role plays of this type of questioning of the patient by the significant other may be conducted in the session, so that the therapist can provide corrective feedback to each partner. Throughout in vivo exposure, the significant other reminds the patient to apply cop- ing skills, whether it be cognitive challenges, breath- ing skills, or acceptance skills. Because the significant other is usually a safety signal, tasks are less anxiety provoking. However, the patient must be weaned from the safety signal eventually. Therefore, initial attempts at facing agoraphobic situations are conducted with the significant other, and later trials are conducted alone. Weaning from the significant other may be graduated, as in the case of Julie (1) driving first with Larry in the car, (2) with him in a car behind, (3) meeting him at a destination point, and (4) driving alone.

Very important to the success of this collaboration is style of communication. On the one hand, the signifi- cant other is discouraged from magnifying the experi- ence of panic and encouraged to help the patient apply coping statements when anxious. On the other hand, the significant other is encouraged to be patient given the fact that progress for the patient may be erratic. The patient and the significant other are instructed to use a 0- to 10-point rating scale to communicate with each other about the patient’s current level of anxiety or distress, as a way of diminishing the awkwardness associated with discussion of anxiety, especially in public situations. The patient is warned about the po- tential motivation to avoid discussing his/her feelings with the significant other, due to embarrassment or an attempt to avoid the anxiety for fear that such discus- sion and concentration on anxiety may intensify his/ her distress level. Avoidance of feelings is discouraged, because distraction is viewed as less beneficial in the long term than objectively facing whatever is distressing and learning that predicted catastrophes do not occur.

The patient is reassured that the initial discomfort and embarrassment will most likely diminish as the part- ners become more familiar with discussing anxiety lev- els and their management. Furthermore, the patient’s concerns about the significant other being insensitive or too pushy are addressed. For example, a significant other may presume to know the patient’s level of anxi- ety and anxious thoughts without confirmation from the patient, or the significant other may become angry at the patient for avoiding or escaping from situations, or being fearful. All of these issues are described as rela- tively common and understandable patterns of commu- nication that are nevertheless in need of correction. In- session role playing of more adaptive communication styles during episodes of heightened anxiety is a useful learning technique. On occasion, more specific com- munications training may be beneficial, especially if the partners frequently argue in their attempts to generate items or methods for conducting in vivo exposure.

The next in vivo exposure task for Julie was to sit in a crowded movie theater, gradually moving away from the aisle, toward the middle of the row, because that was the condition in which she was most concerned that she would lose control and draw attention to herself. Julie and Larry rehearsed their approach to the in vivo expo- sure task in session, while the therapist provided cor- rective feedback using the principles of communication and coping described earlier. They were instructed to practice this task at least three times over the next week. On at least one occasion, Julie was to practice the task alone.

Next, interoceptive exposure was introduced. As with in vivo exposure, through repeated exposures to feared sensations, patients learn that they are not harmed by the sensations, and they achieve increased confidence in their ability to tolerate symptoms of anxiety. The procedure begins with assessment of the patient’s response to a series of standardized exercises. The therapist models each exercise first. Then, after the patient has completed the exercise, the therapist records the sensations, anxiety level (0–10), sensation intensity (0–10), and similarity to naturally occurring panic sensations (0–10). The exercises include shaking the head from side to side for 30 seconds; placing the head between the legs for 30 seconds and lifting the head to an upright position quickly; running in place or using steps for l minute; holding one’s breath for as long as possible; complete body muscle tension for 1 minute or holding a push-up position for as long as pos- sible; spinning in a swivel chair for 1 minute; hyper-

44 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

ventilating for 1 minute; breathing through a narrow straw (with closed nasal passages) or breathing as slowly as possible for 2 minutes; and staring at a spot on the wall or at one’s mirror image for 90 seconds. If none of these exercises produce sensations at least moderately similar to those that occur naturally, other, individually tailored exercises are generated. For example, tightness around the chest may be induced by a deep breath be- fore hyperventilating; heat may be induced by wearing heavy clothing in a heated room; choking sensations may be induced by a tongue depressor, a high-collared sweater, or a necktie; and startle may be induced by an abrupt, loud noise in the midst of relaxation. For Julie, the sensations produced by hyperventilating, spinning, and staring at a spot on the wall were most anxiety pro- voking.

Patients who report little or no fear because they feel safe in the presence of the therapist are asked to attempt each exercise alone, either at home or with the thera- pist out of the office. At the same time, discussing the influence of perceived safety as a moderating factor in the amount of fear experienced reinforces the value of cognitive restructuring. For a minority of patients, the known cause and course of the sensations override the fear response; that is, because the sensations are predict- ably related to a clear cause (the interoceptive exercise), and because the sensations can be relatively easily con- trolled by simply terminating the interoceptive exercise, fear is minimal. Under these conditions, discussion can productively center on the misassumptions that render naturally occurring sensations more frightening than the ones produced by the interoceptive exercises. Typi- cally, these misassumptions are that naturally occurring sensations are unpredictable; that unpredictable sensa- tions are more harmful; and that if naturally occurring sensations are not controlled, then they pose a potential threat. The majority of patients fear at least several of the interoceptive exercises despite knowing the cause of the sensations and their controllability.

Interoceptive exercises rated as producing at least somewhat similar sensations to naturally occurring panic (at least 3 on the 0- to 10-point scale) are selected for repeated exposure. A graduated approach is used for interoceptive exposure, beginning with the lowest item on the hierarchy established in Session 4. For each trial of exposure, the patient is asked to begin the induction, to indicate when the sensations are first experienced (e.g., by raising a hand), and to continue the induction for at least 30 seconds longer to permit corrective learn- ing. After terminating the induction, anxiety is rated,

and the patient is given time to apply cognitive and breathing coping skills, if needed, to keep the patient engaged. Although some cognitive restructuring may naturally occur as patients see that their predictions are not coming true during interoceptive exposure, ex- plicit use of cognitive restructuring or diaphragmatic breathing skills in between interoceptive exposure tri- als is not necessary. Allowing patients to experience and tolerate anxiety during the exercise, take a short break, and begin a new trial without efforts to manage anxiety is appropriate. Finally, the therapist reviews the induction experience. During this review, the therapist emphasizes the importance of experiencing the sensa- tions fully during the induction, of concentrating ob- jectively on the sensations versus distracting from them, and of identifying specific cognitions and challenging them by considering all of the evidence. In addition, the therapist asks key questions to help the patient real- ize his/her safety (e.g., “What would have happened if you had continued spinning for another 60 seconds?”), and to generalize to naturally occurring experiences (e.g., “How is this different from when you feel dizzy at work?”). In other words, cognitive restructuring ex- tends the cognitive reprocessing already taking place implicitly as a result of repeated interoceptive exposure.

Specific, previously unrecognized cognitions some- times become apparent during repeated exposure. For example, when Julie began to conduct repeated expo- sures to hyperventilation and spinning, she became more aware of her implicit assumption that sensations of spaciness or lightheadedness would lead her to lose control of her limbs. This related to her concern about causing an accident when driving. During repeated hy- perventilation exercises, and with prompting of “what ifs” from the therapist, Julie discovered her fear of not being able to move her arms or legs. The therapist then behaviorally challenged this assumption by having Julie overbreathe for longer periods of time, followed imme- diately by walking, picking up objects, and so on.

Homework practice is very important, because safety signals present in the clinic setting or that derive from the therapist per se may, again, prevent generalizability to the natural setting. Patients are instructed to practice the interoceptive items conducted in session on a daily basis, three times each day. Julie was to practice hyper- ventilation over the following week. She expressed some concern at doing the exercises alone, so the therapist helped Julie to use her cognitive restructuring skills in relation to being alone. In addition, more graduation of homework was suggested, so that Julie would practice

Panic Disorder and Agoraphobia 45

hyperventilating when her husband was at home the first couple of days, then when he was not at home the rest of the time.

Sessions 6 and 7

The primary goal of these sessions is to review the past week of in vivo exposure practices, design new expo- sures, review between-session practices of interocep- tive exposure, conduct repeated interoceptive exposure in session, and assign those as homework for the next week.

The in vivo exposure is reviewed, as in the previous session. In this case, Julie and Larry had done well with the movie theater practice. Julie even practiced going to the movies on her own. On that occasion, she reported higher anxiety than when she was with Larry for fear of having to get up and leave the theater and worries about bothering others in the audience. The therapist helped Julie to identify what worry led her to think about leav- ing in the first place; in other words, what did she think might happen if she could not leave? When Julie indi- cated that she had thoughts of losing control and caus- ing a scene, she was then prompted to apply her cogni- tive restructuring skills of evidence-based analyses and decatastrophizing. She was ready to move to the next items on her hierarchy: to spend 2 hours alone at home during the day and to stay alone at home as day turned to night. As with every in vivo exposure task, Julie iden- tified what she most feared happening in those situa- tions, and the best practice conditions under which to learn that either those eventualities would not happen and/or she could cope with the worst.

The past week of interoceptive exposure practice is reviewed in session with a mind toward avoidance: either overt failure to practice or covert avoidance by minimizing the intensity or duration of the sensations induced, or by limiting practice to the presence of a safety signal (e.g., a significant other) or times when background anxiety is minimal. Reasons for avoidance may include continued misinterpretation of the dangers of bodily sensations (i.e., “I don’t want to hyperven- tilate, because I’m afraid that I won’t be able to stop overbreathing and no one will be there to help me”) or the belief that anxiety will not reduce with repetition of the task.

For the first week, Julie practiced interoceptive expo- sure exercises about half of the days between sessions. The therapist used a “downward arrow” method to ex- plore Julie’s reasons for not practicing every day.

JULIE: I tried hyperventilating on my own. However, I wasn’t very successful because I felt too scared and I stopped it as soon as I noticed the strange feelings.

THERAPIST: What did you think would happen if the sensations became more intense?

JULIE: I thought the feelings would get worse and worse and worse, and just overwhelm me. I didn’t want to have that feeling of panic again.

THERAPIST: If you did become overwhelmed, then what would happen to you?

JULIE: Then I’d feel really terrible. THERAPIST: And if you felt really terrible? JULIE: Well, nothing. I’d just feel terrible. THERAPIST: The word terrible carries a lot of meaning.

Let’s see if we can pin down your anxious thoughts that make the feelings so terrible.

JULIE: I just can’t tolerate the feeling. THERAPIST: What tells you that you cannot tolerate it?

How do you know you can’t tolerate it?

And the discussion continued, so that Julie realized what was most important for her to learn by the repeated hyperventilation: She could tolerate the sensations and anxiety. However, after the subsequent week of repeated practice, Julie remained cautious for fear that the ex- ercises would cause her to revert to her state of several weeks earlier; that is, she was concerned that the induc- tions would leave her in a persistent symptomatic state. Furthermore, she was particularly reluctant to practice interoceptive exposure at the end of the day, when she was more likely to feel unreal, or on a day when an im- portant social event was scheduled. Again, these avoid- ance patterns were related to fears that the symptoms would become too intense or result in some type of men- tal or social catastrophe. These types of avoidance pat- terns are addressed in the following vignette:

THERAPIST: When did you practice deliberately spin- ning and hyperventilating?

JULIE: Usually in the mornings. One day I left it until the end of the day, and that turned out to be a bad idea. I felt terrible.

THERAPIST: Let’s think about that a bit more. What made it terrible when you practiced at the end of the day?

JULIE: Well, I was already feeling pretty unreal—I usu-

46 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

ally do around that time of the day. So I was much more anxious about the symptoms.

THERAPIST: Being more anxious implies that you thought the symptoms were more harmful. Is that what happened on the day that you practiced in- teroceptive exposure when you were already feeling unreal?

JULIE: Yes, I felt that because I was already feeling un- real, I was on the edge, and that I might push my- self over the edge if I tried to increase the feelings of unreality.

THERAPIST: What do you mean by “push myself over the edge”?

JULIE: That I would make the feelings so intense that I really would lose it—go crazy.

THERAPIST: So there is one of those hypotheses: to feel more intense unreality means to be closer to going crazy. Let’s examine the evidence. Is it necessarily the case that more intense unreality means you are closer to craziness?

In sessions, the therapist continued practice of in- teroceptive exposure with the next item on Julie’s hi- erarchy, which was to stare at a spot on the wall and to spin around.

The homework from this session is to continue self- monitoring, in vivo exposure to an item from the agora- phobia hierarchy at least three times, and daily practice of interoceptive exposure.

Sessions 8 and 9

The primary goals of these sessions are to continue in vivo exposure, as described in the prior sessions, and to extend interoceptive exposure to natural activities. Julie had practiced staying at home for 2 hours alone dur- ing the day and as daylight turned to dusk, with good results. In particular, despite experiencing a couple of panic attacks during these in vivo exposure practices, she continued with the assigned practice. This was criti- cal for Julie, because it allowed her to learn that she could survive the feeling of panic; it was the first time she had remained in a situation despite panicking.

In reviewing the week’s practice of interoceptive ex- posure, it became apparent that Julie was separating the practices from real-life experiences of bodily sensations in a way that would limit generalization. This was ad- dressed as follows:

JULIE: After spinning and hyperventilating several times, I really do feel much less anxious. I was terri- fied at the start, but now I am only mildly anxious, if at all. But this is different than what happens to me when I’m on the freeway or at home.

THERAPIST: How is it different? JULIE: I don’t know when the feelings of dizziness and

unreality are going to hit. THERAPIST: From our previous discussions, let’s think

of potential reasons why you might feel dizzy or un- real at a particular time?

JULIE: I know. I have to keep remembering that it could be my breathing, or just feeling anxious, or tired, or a bunch of different things.

THERAPIST: OK. And why is it so important to know when those feelings will occur?

JULIE: Because I don’t want them to be there at all. THERAPIST: And why not . . . what are you afraid of? JULIE: I guess it’s the same old thing . . . that I’ll lose it

somehow? THERAPIST: So let’s go back to the cognitive restructur-

ing that you have been doing. What specifically are you afraid of? How likely is it to happen? What are the alternatives?

JULIE: I understand. THERAPIST: So, now you see that whether the sensa-

tions of dizziness or unreality are produced by anxi- ety, overbreathing, diet, or the exercises we do here, they’re all the same—they are just uncomfortable physical sensations. The only reason they perturb you more when you are driving or at home is because of the meaning you still give to them in those situ- ations.

Naturalistic interoceptive exposure refers to exposure to daily tasks or activities that have been avoided or en- dured with dread because of the associated sensations. Typical examples include aerobic exercise or vigorous physical activity, running up flights of stairs, eating foods that create a sensation of fullness or are associated with sensations of choking, saunas or steamy showers, driving with the windows rolled up and the heater on, caffeine consumption, and so on. (Of course, these ex- ercises may be modified in the event of actual medical complications, such as asthma or high blood pressure.) From a list of typically feared activities and generation of items specific to the individual’s own experience, a

Panic Disorder and Agoraphobia 47

hierarchy is established. Each item is ranked in terms of anxiety ratings (0–10). Julie’s hierarchy was as fol- lows: looking out through venetian blinds (anxiety = 3); watching One Flew over the Cuckoo’s Nest (anxiety = 4); playing tennis (anxiety = 4); scanning labels on a supermarket shelf (anxiety = 5); concentrating on needlework for an hour (anxiety = 6); driving with win- dows closed and heater on (anxiety = 7); a nightclub with strobe lights (anxiety = 8); and rides at Disneyland (anxiety = 10).

Like the symptom exercises, the activity exercises are designed to be systematically graduated and repetitive. Patients may apply the breathing and cognitive skills while the activity is ongoing, if needed, to stay engaged in the activity. This is in contrast to the symptom in- duction exercises, in which coping skills are used only after completion of the symptom exercise (if at all), because the activities often are considerably longer than the symptom induction exercises. Nevertheless, patients are encouraged to focus on the sensations and experience them fully throughout the activity, and not use the coping skills to prevent or remove the sensa- tions.

Patients are instructed to identify maladaptive cogni- tions and rehearse cognitive restructuring before begin- ning each activity. In-session rehearsal of the cognitive preparation allows therapists to provide corrective feed- back. Julie did this with her therapist for her first two naturalistic activities, which were to look at venetian blinds and to watch One Flew over the Cuckoo’s Nest. Julie realized that she was most worried about sensa- tions of unreality and fears of going crazy, although, as a result of her various exposure exercises up to this point, she quickly was able to recognize that such sensa- tions were harmless and that she could tolerate them, and that such fears were unrealistic based on the evi- dence.

As with all exposures, it is important to identify and remove (gradually, if necessary) safety signals or protec- tive behaviors, such as portable phones, lucky charms, walking slowly, standing slowly, and staying in close proximity to medical facilities. These safety signals and behaviors reinforce catastrophic misappraisals about bodily sensations. Julie’s safety behaviors were identi- fied as checking the time on the clock (as a reassurance that she was in touch with reality) and pinching her- self (again, to feel reality). She was asked to practice the two naturalistic interoceptive exposures at least three times each before the next treatment session, without the safety behaviors.

Sessions 10 and 11

The primary goals of these sessions are to review the in vivo and naturalistic exposure exercises over the past week, and to combine exposure to feared and avoided agoraphobic situations with deliberate induction of feared sensations into those situations. As with ear- lier interoceptive exposure homework assignments, it is important to evaluate and correct tendencies to avoid naturalistic interoceptive exposure tasks, mainly by considering the underlying misassumptions that lead to avoidance. Remember also that a form of avoidance is to rely on safety signals or safety behaviors, so careful questioning of the way in which the naturalistic expo- sure was conducted, and under what conditions, may help to identify inadvertent reliance on these unneces- sary precautions. Julie reported that she was successful in looking at the venetian blinds, even though she expe- rienced sensations of unreality. She had more difficulty watching One Flew over the Cuckoo’s Nest because it tapped directly into her worst fears of losing touch with reality permanently; she tried but terminated the film early. The second time, she watched it with Larry, who prompted Julie to remember her cognitive and breath- ing skills, and she was able to watch the entire film. She watched the film one more time on her own. Two new naturalistic exposure items were selected for the com- ing week, with special attention to weaning or remov- ing safety signals and safety behaviors, and rehearsal of cognitive restructuring in session. For Julie, these were playing tennis (something she had avoided for years) and scanning items on supermarket shelves.

The notion of deliberately inducing feared bodily symptoms within the context of feared agoraphobic sit- uations derives from the evidence that compound rela- tionships between external and internal cues can be the most potent anxiogenic agent (i.e., deepened extinction, as reviewed in earlier sections); that is, neither just the situation nor just the bodily sensation triggers distress. It is the combination of the bodily sensation and the situation that is most distressing. Thus, effective expo- sure targets both types of cues. Otherwise, patients run the risk of later return of fear. For example, repeated practice walking through a shopping mall without feel- ing dizzy does not adequately prepare patients for occa- sions on which they feel dizzy walking through a shop- ping mall, and without such preparation, patients may be likely to panic and escape should they feel dizzy in this or similar situations in the future. Wearing heavy clothing in a restaurant helps patients to learn to be less

48 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

afraid of not only the restaurant but also of feeling hot in a restaurant. Other examples include drinking cof- fee before any of the agoraphobic tasks, turning off the air-conditioning or turning on the heater while driving, breathing very slowly in a crowded area, and so on.

Patients choose an item from their hierarchy of ago- raphobia situations, either one already completed or a new item, and also choose which symptom to induce and ways of inducing that symptom in that situation. Julie’s task was to drink coffee as she went to a movie. She expressed the following concerns:

JULIE: Do you really think I am ready to drink coffee and go to the movie?

THERAPIST: What worries you about the combination of coffee and the movie theater?

JULIE: Well, I’ve practiced in the movie theaters a lot, so that feels pretty good, but the coffee is going to make me feel very anxious.

THERAPIST: And if you feel very anxious in the movie theater, then what?

JULIE: Then, I don’t know what. Maybe I will get those old feelings again, like I have to get out.

THERAPIST: Based on everything you have learned, how can you manage those feelings?

JULIE: Well, I guess my number one rule is never to leave a situation because I am feeling anxious. I will stick it out, no matter what.

THERAPIST: That sounds great. It means you are ac- cepting the anxiety and taking the opportunity to learn that you can tolerate it. What else?

JULIE: I can ask myself what is the worst that can hap- pen. I know I am not going to die or go crazy. I will probably feel my heart rate going pretty fast because of the coffee.

THERAPIST: And if your heart rate goes fast, what does that mean?

JULIE: I guess it just means that my heart rate will go fast.

THERAPIST: This will be a really good way for you to learn that you can tolerate the anxiety and the symp- toms of a racing heart.

The homework for this session is to continue self- monitoring, to practice in vivo exposure combined with interoceptive exposure, and to continue naturalistic in- teroceptive exposure.

Session 12

The last treatment session reviews the principles and skills learned and provides the patient with a template of coping techniques for potentially high-risk situations in the future. Julie finished the program after 12 ses- sions, by which time she had not panicked in 8 weeks, rarely experienced dizziness or feelings of unreality, and was driving further distances. There were some situa- tions still in need of exposure practices (e.g., driving very long distances away from home and on the freeway at dusk). However, Julie and Larry agreed to continue in vivo exposure practices over the next few months to consolidate her learning and to continue her improve- ment.

CONCLUSION

As we noted earlier in this chapter, cognitive-behavior- al treatments for panic disorder and agoraphobia are highly effective and represent one of the success stories of psychotherapy. Between 80 and 100% of patients undergoing these treatments will be panic-free at the end of treatment and maintain these gains for up to 2 years. These results reflect substantially more durability than medication treatments. Furthermore, between 50 and 80% of these patients reach a point of “high end state,” which means their symptoms and functioning are within normative realms, and many of the remain- der have only residual symptomatology. Nevertheless, major difficulties remain.

First, these treatments are not foolproof. As many as 50% of patients retain substantial symptomatology despite improvement from baseline, and this is par- ticularly likely for those with more severe agoraphobia. Further research must determine how treatments can be improved or better individualized to alleviate con- tinued suffering. For example, one of us (D. H. B.) saw a patient several years ago who had completed an initial course of treatment but required continued periodic visits for over 4 years. This patient was essentially im- proved for approximately 9 months but found himself relapsing during a particularly stressful time at work. A few booster sessions restored his functioning, but he was back in the office 6 months later with reemerging symptomatology. This pattern essentially continued for 4 years and was characterized by symptom-free periods followed by (seemingly) stress-related relapses. Further- more, the reemerging panic disorder would sometimes

Panic Disorder and Agoraphobia 49

last from 3 to 6 months before disappearing again, per- haps with the help of a booster session.

Although this case was somewhat unusual in our ex- perience, there was no easy explanation for this pattern of relapses and remissions. The patient, who has a grad- uate degree, understood and accepted the treatment model and fully implemented the treatment program. There was also no question that he fully comprehended the nature of anxiety and panic, and the intricacies of the therapeutic strategies. While in the office, he could recite chapter and verse the nature of these emotional states, as well as the detailed process of his own reac- tion while in these states. Nevertheless, away from the office, the patient found himself repeatedly hoping that he would not “go over the brink” during a panic attack, despite verbalizing very clearly the irrationality of this concept while in the office. In addition, he continued to attempt to reduce minor physiological symptoms as- sociated with anxiety and panic, despite a full rational understanding of the nature of these symptoms (includ- ing the fact that they are the same symptoms he experi- enced during a state of excitement, which he enjoyed). His limited tolerance of these physical sensations was also puzzling in view of his tremendous capacity to en- dure pain.

Any number of factors might account for what seemed to be “overvalued ideation” or very strongly held irrational ideas during periods of anxiety, including the fact that the patient has several relatives who have repeatedly been hospitalized for emotional disorders (seemingly mood disorders or schizoaffective disorder). Nevertheless, the fact remains that we do not know why this patient did not respond as quickly as most people. Eventually, he made a full recovery, received several promotions at work, and considered treatment to be the turning point in his life. But it took 5 years.

Other patients, as noted earlier, seem uninterested in engaging in treatment, preferring to conceptualize their problems as chemical imbalances. Still others have difficulty grasping some of the cognitive strategies, and further attempts are necessary to make these treatments more “user-friendly.”

It also may seem that this structured, protocol-driv- en treatment is applied in a very standard fashion across individuals. Nothing could be further from the truth. The clinical art involved in this, and in all treatments described in this book, requires a careful adaptation of these treatment strategies to the individual case. Many of Julie’s symptoms revolved around feelings of unreal- ity (derealization and depersonalization). Emphasizing

rational explanations for the production of such feel- ings, as well as adapting cognitive and exposure exercis- es to maximize these sensations, is an important part of this treatment program. Although standard interocep- tive provocation exercises seemed sufficient to produce relevant symptomatology in Julie’s case, we have had to develop new procedures to deal with people with more idiosyncratic symptoms and fears, particularly those in- volving feelings of unreality or dissociation. Other in- novations in both cognitive and behavioral procedures will be required by individual therapists as they apply these procedures.

Although these new treatments seem highly success- ful when applied by trained therapists, treatment is not readily available to individuals with these disorders. In fact, these treatments, although brief and structured, are far more difficult to deliver than, for example, phar- macological treatments (which are also often misap- plied). Furthermore, few people are currently skilled in the application of these treatments. What seems to be needed for these and other successful psychosocial treatments is a new method of disseminating them, so that they reach the maximum number of patients. Modification of these treatment protocols into more user-friendly formats, as well as brief periods of training for qualified therapists to a point of certification, would be important steps in successfully delivering these treat- ments. This may be difficult to accomplish.

NOTE

1. Specific phobias were not assessed, but by being most cir- cumscribed, they would be hypothesized to load the least on negative affectivity.

REFERENCES

Aaronson, C. J., Shear, M. K., Goetz, R. R., Allen, L. B., Bar- low, D. H., White, K. S., et al. (2008). Predictors and time course of response among panic disorder patients treated with cognitive-behavioral therapy. Journal of Clinical Psy- chiatry, 69, 418–424.

Allen, L. B., White, K. S., Barlow, D. H., Shear, M. K., Gor- man, J. M., & Woods, S. W. (2010). Cognitive-behavior therapy (CBT) for panic disorder: Relationship of anxi- ety and depression comorbidity with treatment outcome. Journal of Psychopathology and Behavioral Assessment, 32, 185–192.

Alneas, R., & Torgersen, S. (1990). DSM-III personality disorders among patients with major depression, anxiety

50 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

disorders, and mixed conditions. Journal of Nervous and Mental Disease, 178, 693–698.

American Psychiatric Association. (1980). Diagnostic and sta- tistical manual of mental disorders (3rd ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and sta- tistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Amering, M., Katschnig, H., Berger, P., Windhaber, J., Baischer, W., & Dantendorfer, K. (1997). Embarrassment about the first panic attack predicts agoraphobia in disor- der patients. Behaviour Research and Therapy, 35, 517–521.

Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis. PLOS ONE, 5, e13196.

Antony, M. M., Brown, T. A., Craske, M. G., Barlow, D. H., Mitchell, W. B., & Meadows, E. A. (1995). Accuracy of heartbeat perception in panic disorder, social phobia, and nonanxious subjects. Journal of Anxiety Disorders, 9, 355–371.

Antony, M. M., Ledley, D. R., Liss, A., & Swinson, R. P. (2006). Responses to symptom induction exercises in panic disorder. Behaviour Research and Therapy, 44, 85–98.

Antony, M. M., Meadows, E. A., Brown, T. A., & Barlow, D. H. (1994). Cardiac awareness before and after cognitive- behavioral treatment for panic disorder. Journal of Anxiety Disorders, 8, 341–350.

Arch, J. J., Eifert, G. H., Davies, C., Plumb, J. C., Rose, R. D., & Craske, M. G. (2012). Randomized trial of cogni- tive behavioral therapy versus acceptance and commit- ment therapy for the treatment of mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80, 750–765.

Arnow, B. A., Taylor, C. B., Agras, W. S., & Telch, M. J. (1985). Enhancing agoraphobia treatment outcome by changing couple communication patterns. Behavior Ther- apy, 16, 452–467.

Arrindell, W., & Emmelkamp, P. (1987). Psychological states and traits in female agoraphobics: A controlled study. Journal of Psychopathology and Behavioral Assessment, 9, 237–253.

Asselmann, E., Wittchen, H., Lieb, R., & Beesdo-Baum, K. (2016). Risk factors for fearful spells, panic attacks and panic disorder in a community cohort of adolescents and young adults. Journal of Affective Disorders, 193, 305–308.

Baldwin, D. S. (1998). Depression and panic: Comorbidity. European Psychiatry, 13, 65s–70s.

Bandelow, B., Spath, C., Tichaner, G. A., Brooks, A., Hajak, G., & Ruther, E. (2002). Early traumatic life events, pa- rental attitudes, family history, and birth risk factors in patients with panic disorder. Comprehensive Psychiatry, 43, 269–278.

Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford Press.

Barlow, D. H. (2002). Anxiety and its disorders: The nature

and treatment of anxiety and panic (2nd ed.). New York: Guilford Press.

Barlow, D. H., Brown, T. A., & Craske, M. G. (1994). Defi- nitions of panic attacks and panic disorder in the DSM-IV: Implications for research. Journal of Abnormal Psychology, 103, 553–564.

Barlow, D. H., Cohen, A., Waddell, M., Vermilyea, J., Klos- ko, J., Blanchard, E., et al. (1984). Panic and generalized anxiety disorders: Nature and treatment. Behavior Thera- py, 15, 431–449.

Barlow, D. H., & Craske, M. G. (1994). Mastery of your anxi- ety and panic (2nd ed.) San Antonio, TX: Harcourt Brace.

Barlow, D. H., & Craske, M. G. (2006). Mastery of your anxi- ety and panic: Patient workbook (4th ed.). New York: Ox- ford University Press.

Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S. (1989). Behavioral treatment of panic disorder. Behavior Therapy, 20, 261–282.

Barlow, D. H., Ellard, K. K., Sauer-Zavala, S., Bullis, J. R., & Carl, J. R. (2014). The origins of neuroticism. Perspectives on Psychological Science, 9(5), 481–496.

Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized con- trolled trial. Journal of the American Medical Association, 283(19), 2529–2536.

Barlow, D. H., O’Brien, G. T., & Last, C. G. (1984). Couples treatment of agoraphobia. Behavior Therapy, 15(1), 41–58.

Barlow, D. H., O’Brien, G. T., Last, C. G., & Holden, A. E. (1983). Couples treatment of agoraphobia. In K. D. Craig & R. J. McMahon (Eds.), Advances in clinical behavior therapy (pp. 99–127). New York: Brunner/Mazel.

Barlow, D. H., Sauer-Zavala, S., Carl, J. R., Bullis, J. R., & Ellard, K. K. (2014). The nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical Psychological Science, 2(3), 344–365.

Barsky, A. J., Cleary, P. D., Sarnie, M. K., & Ruskin, J. N. (1994). Panic disorder, palpitations, and the awareness of cardiac activity. Journal of Nervous and Mental Disease, 182, 63–71.

Basoglu, M., Marks, I. M., Kilic, C., Brewin, C. R., & Swin- son, R. P. (1994). Alprazolam and exposure for panic dis- order with agoraphobia: Attribution of improvement to medication predicts subsequent relapse. British Journal of Psychiatry, 164, 652–659.

Beck, J. G., & Shipherd, J. C. (1997). Repeated exposure to interoceptive cues: Does habituation of fear occur in panic disorder patients?: A preliminary report. Behaviour Research and Therapy, 35, 551–557.

Beck, J. G., Shipherd, J. C., & Zebb, B. J. (1997). How does interoceptive exposure for panic disorder work?: An un- controlled case study. Journal of Anxiety Disorders, 11, 541–556.

Beck, J. G., Stanley, M. A., Baldwin, L. E., Deagle, E. A., & Averill, P. M. (1994). Comparison of cognitive therapy and

Panic Disorder and Agoraphobia 51

relaxation training for panic disorder. Journal of Consulting and Clinical Psychology, 62, 818–826.

Beesdo, K., Knappe, S., & Pine, D. S. (2007). Anxiety and anxiety disorders in children and adolescents: Develop- mental issues and implications for DSM-V. Psychiatric Clinics of North America, 32, 483–524.

Biederman, J., Faraone, S. V., Marrs, A., & Moore, P. (1997). Panic disorder and agoraphobia in consecutively referred children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 36(12), 214–223.

Bittner, A., Egger, H. L., Erkanli, A., Costello, J., Foley, D. L., & Angold, A. (2007). What do childhood anxiety dis- orders predict? Journal of Child Psychology and Psychiatry, 48, 1174–1183.

Black, D. W., Monahan, P., Wesner, R., Gabel, J., & Bowers, W. (1996). The effect of fluvoxamine, cognitive therapy, and placebo on abnormal personality traits in 44 patients with panic disorder. Journal of Personality Disorders, 10, 185–194.

Bland, K., & Hallam, R. (1981). Relationship between re- sponse to graded exposure and marital satisfaction in ago- raphobics. Behaviour Research and Therapy, 19, 335–338.

Block, R. I., Ghoneim, M. M., Fowles, D. C., Kumar, V., & Pathak, D. (1987). Effects of a subanesthetic concen- tration of nitrous oxide on establishment, elicitation and semantic and phonemic generalization of classically con- ditioned skin conductance responses. Pharmacological and Biochemical Behavior, 28, 7–14.

Bohni, M. K., Spindler, H., Arendt, M., Hougaard, E., & Rosenberg, N. K. (2009). A randomized study of massed three-week cognitive behavioural therapy schedule for panic disorder. Acta Psychiatrica Scandinavica, 120(3), 187–195.

Bonn, J. A., Harrison, J., & Rees, W. (1971). Lactate-induced anxiety: Therapeutic application. British Journal of Psy- chiatry, 119, 468–470.

Bouchard, S., Gauthier, J., Laberge, B., French, D., Pelletier, M., & Godbout, D. (1996). Exposure versus cognitive re- structuring in the treatment of panic disorder with ago- raphobia. Behaviour Research and Therapy, 34, 213–224.

Bouchard, S., Paquin, B., Payeur, R., Allard, M., Rivard, V., Gournier, T., et al. (2004). Delivering cognitive-behavior therapy for panic disorder with agoraphobia in videocon- ference [Special issue: Telemedicine in Canada]. Telemedi- cine and e-Health, 10(1), 13–24.

Bouton, M. E. (1993). Context, time and memory retrieval in the interference paradigms of Pavlovian learning. Psycho- logical Bulletin, 114, 90–99.

Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A mod- ern learning-theory perspective on the etiology of panic disorder. Psychological Review, 108(1), 4–32.

Bouton, M. E., & Swartzentruber, D. (1991). Sources of re- lapse after extinction in Pavlovian conditioning and in- strumental conditioning. Behavioral Neuroscience, 104, 44–55.

Broocks, A., Bandelow, B., Pekrun, G., George, A., Meyer, T., Bartmann, U., et al. (1998). Comparison of aerobic exercise, clomipramine, and placebo in the treatment of panic disorder. American Journal of Psychiatry, 155, 603– 609.

Brown, T. A., Antony, M. M., & Barlow, D. H. (1995). Diag- nostic comorbidity in panic disorder: Effect on treatment outcome and course of comorbid diagnoses following treatment. Journal of Consulting and Clinical Psychology, 63, 408–418.

Brown, T. A., & Barlow, D. H. (1995). Long-term outcome in cognitive-behavioral treatment of panic disorder: Clinical predictors and alternative strategies for assessment. Journal of Consulting and Clinical Psychology, 63, 754–765.

Brown, T. A., & Barlow, D. H. (2014). Anxiety Disorders In- terview Schedule–5. New York: Oxford University Press.

Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime co- morbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110(4), 585–599.

Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Struc- tural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology, 107(2), 179–192.

Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110(1), 49–58.

Brown, T. A., & Tung, E. S. (2018). The contribution of worry behaviors to the diagnosis of generalized anxiety disorder. Journal of Psychopathology and Behavioral Assess- ment, 40, 636–644.

Brown, T. A., White, K. S., Forsyth, J. P., & Barlow, D. H. (2004). The structure of perceived emotional control: Psy- chometric properties of a revised Anxiety Control Ques- tionnaire. Behavior Therapy, 35(1), 75–99.

Buglass, P., Clarke, J., Henderson, A., & Presley, A. (1977). A study of agoraphobic housewives. Psychological Medicine, 7, 73–86.

Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Re- view, 26, 17–31.

Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hof- mann, S. G. (2006). Acceptability and suppression of negative emotion in anxiety and mood disorders. Emotion, 6(4), 587–595.

Carlbring, P., Ekselius, L., & Andersson, G. (2003). Treat- ment of panic disorder via the Internet: A randomized trial of CBT vs. applied relaxation. Journal of Behavior Therapy and Experimental Psychiatry, 34, 129–140.

Carlbring, P., Nilsson-Ihrfelt, E., Waara, J., Kollenstam, C., Buhrman, M., Klado, V., et al. (2005). Treatment of panic

52 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

disorder: Live therapy vs. self-help via the Internet. Behav- iour Research and Therapy, 43, 1321–1333.

Carter, M. M., Sbrocco, T., Gore, K. L., Marin, N. W., & Lewis, E. L. (2003). Cognitive-behavioral group therapy versus a wait-list control in the treatment of African Amer- ican women with panic disorder. Cognitive Therapy and Research, 27(5), 505–518.

Cerny, J. A., Barlow, D. H., Craske, M. G., & Himadi, W. G. (1987). Couples treatment of agoraphobia: A two-year follow-up. Behavior Therapy, 18, 401–415.

Chambless, D. L., Caputo, G., Bright, P., & Gallagher, R. (1984). Assessment of fear in agoraphobics: The Body Sen- sations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychol- ogy, 52, 1090–1097.

Chambless, D. L., Caputo, G., Gracely, S., Jasin, E., & Wil- liams, C. (1985). The Mobility Inventory for Agoraphobia. Behaviour Research and Therapy, 23, 35–44.

Chambless, D. L., & Renneberg, B. (1988, September). Per- sonality disorders of agoraphobics. Paper presented at World Congress of Behavior Therapy, Edinburgh, Scotland.

Clark, D. M. (1986). A cognitive approach to panic. Behav- iour Research and Therapy, 24, 461–470.

Clark, D. M. (1996). Panic disorder: From theory to therapy. In P. M. Salkovskis (Ed.), From frontiers of cognitive ther- apy: The state of art and beyond (pp. 318–344). New York: Guilford Press.

Clark, D. M., & Ehlers, A. (1993). An overview of the cogni- tive theory and treatment of panic disorder. Applied and Preventive Psychology, 2, 131–139.

Clark, D. M., Salkovskis, P., & Chalkley, A. (1985). Respi- ratory control as a treatment for panic attacks. Journal of Behavior Therapy and Experimental Psychiatry, 16, 23–30.

Clark, D. M., Salkovskis, P., Gelder, M., Koehler, C., Mar- tin, M., Anastasiades, P., et al. (1988). Tests of a cognitive theory of panic. In I. Hand & H. Wittchen (Eds.), Panic and phobias II (pp. 71–90). Berlin: Springer-Verlag.

Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychia- try, 164, 759–769.

Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Ludgate, J., & Gelder, M. (1999). Brief cognitive therapy for panic disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 67, 583–589.

Côté, G., Gauthier, J. G., Laberge, B., Cormier, H. J., & Plamondon, J. (1994). Reduced therapist contact in the cognitive behavioral treatment of panic disorder. Behavior Therapy, 25, 123–145.

Cox, B. J., Endler, N. S., & Swinson, R. P. (1995). An exami- nation of levels of agoraphobic severity in panic disorder. Behaviour Research and Therapy, 33, 57–62.

Craske, M. G., & Barlow, D. H. (1988). A review of the rela-

tionship between panic and avoidance. Clinical Psychology Review, 8, 667–685.

Craske, M. G., & Barlow, D. H. (1989). Nocturnal panic. Journal of Nervous and Mental Disease, 177(3), 160–167.

Craske, M. G., & Barlow, D. H. (2007). Mastery of your anxi- ety and panic: Therapist guide (3rd ed.). New York: Oxford University Press.

Craske, M. G., Brown, T. A., & Barlow, D. H. (1991). Behav- ioral treatment of panic disorder: A two-year follow-up. Behavior Therapy, 22, 289–304.

Craske, M. G., DeCola, J. P., Sachs, A. D., & Pontillo, D. C. (2003). Panic control treatment of agoraphobia. Journal of Anxiety Disorders, 17(3), 321–333.

Craske, M. G., Farchione, T., Allen, L., Barrios, V., Stoya- nova, M., & Rose, D. (2007). Cognitive behavioral thera- py for panic disorder and comorbidity: More of the same or less of more. Behaviour Research and Therapy, 45(6), 1095–1109.

Craske, M. G., & Freed, S. (1995). Expectations about arous- al and nocturnal panic. Journal of Abnormal Psychology, 104, 567–575.

Craske, M. G., Glover, D., & DeCola, J. (1995). Predicted versus unpredicted panic attacks: Acute versus general dis- tress. Journal of Abnormal Psychology, 104, 214–223.

Craske, M. G., Golinelli, D., Stein, M. B., Roy-Byrne, P., Bystritsky, A., & Sherbourne, C. (2005). Does the addi- tion of cognitive behavioral therapy improve panic dis- order treatment outcome relative to medication alone in the primary-care setting? Psychological Medicine, 35(11), 1645–1654.

Craske, M. G., Kircanski, K., Epstein, A., Wittchen, H.-U., Pine, D. S., Lewis-Fernandez, R., et al. (2010). Panic dis- order: A review of DSM-IV panic disorder and proposals for DSM-V. Depression and Anxiety, 27, 93–112.

Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing in- hibitory learning during exposure therapy. Behaviour Re- search and Therapy, 46, 5–27.

Craske, M. G., Lang, A. J., Aikins, D., & Mystkowski, J. L. (2005). Cognitive behavioral therapy for nocturnal panic. Behavior Therapy, 36, 43–54.

Craske, M. G., Lang, A. J., Rowe, M., DeCola, J. P., Sim- mons, J., Mann, C., et al. (2002). Presleep attributions about arousal during sleep: Nocturnal panic. Journal of Abnormal Psychology, 111, 53–62.

Craske, M. G., Liao, B., Brown, L., & Vervliet, B. (2012). Role of inhibition in exposure therapy. Journal of Experi- mental Psychopathology, 3(3), 322–345.

Craske, M. G., Maidenberg, E., & Bystritsky, A. (1995). Brief cognitive-behavioral versus non directive therapy for panic disorder. Journal of Behavior Therapy and Experimental Psychiatry, 26, 113–120.

Craske, M. G., Miller, P. P., Rotunda, R., & Barlow, D. H. (1990). A descriptive report of features of initial unex-

Panic Disorder and Agoraphobia 53

pected panic attacks in minimal and extensive avoiders. Behaviour Research and Therapy, 28, 395–400.

Craske, M. G., Poulton, R., Tsao, J. C. I., & Plotkin, D. (2001). Paths to panic–agoraphobia: An exploratory analy- sis from age 3 to 21 in an unselected birth cohort. American Journal of Child and Adolescent Psychiatry, 40, 556–563.

Craske, M. G., Rapee, R. M., & Barlow, D. H. (1988). The significance of panic–expectancy for individual patterns of avoidance. Behavior Therapy, 19, 577–592.

Craske, M. G., Rose, R. D., Lang, A., Welch, S., Campbell- Sills, L., Sullivan, G., et al. (2009). Computer-assisted delivery of cognitive-behavioral therapy for anxiety disor- ders in primary care settings. Depression and Anxiety, 26, 235–242.

Craske, M. G., & Rowe, M. K. (1997). Nocturnal panic. Clinical Psychology: Science and Practice, 4, 153–174.

Craske, M. G., Rowe, M., Lewin, M., & Noriega-Dimitri, R. (1997). Interoceptive exposure versus breathing retraining within cognitive-behavioural therapy for panic disorder with agoraphobia. British Journal of Clinical Psychology, 36, 85–99.

Craske, M. G., Roy-Byrne, P., Stein, M. B., Donald-Sher- bourne, C., Bystritsky, A., Katon, W., et al. (2002). Treat- ing panic disorder in primary care: A collaborative care intervention. General Hospital Psychiatry, 24(3), 148–155.

Craske, M. G., Roy-Byrne, P., Stein, M. B., Sullivan, G., Hazlett-Stevens, H., Bystritsky, A., et al. (2006). CBT in- tensity and outcome for panic disorder in a primary care setting. Behavior Therapy, 37, 112–119.

Craske, M. G., Stein, M. B., Sullivan, G., Sherbourne, C., Bystritsky, A., Rose, D., et al. (2011). Disorder specific im- pact of CALM treatment for anxiety disorders in primary care. Archives of General Psychiatry, 68, 378–388.

Craske, M. G., & Tsao, J. C. I. (1999). Self-monitoring with panic and anxiety disorders. Psychological Assessment, 11, 466–479.

Culver, N., Stoyanova, M. S., & Craske, M. G. (2012). Emo- tional variability and sustained arousal during exposure. Journal of Behavior Therapy and Experimental Psychiatry, 43, 787–793.

Culver, N., Vervliet, B., & Craske, M. G. (2015). Compound extinction: Using the Rescorla–Wagner model to maxi- mize the effects of exposure therapy for anxiety disorders. Clinical Psychological Science, 3, 335–348.

Dattilio, F. M., & Salas-Auvert, J. A. (2000). Panic disorder: Assessment and treatment through a wide-angle lens. Phoe- nix, AZ: Zeig, Tucker.

de Beurs, E., Lange, A., van Dyck, R., & Koele, P. (1995). Respiratory training prior to exposure in vivo in the treat- ment of panic disorder with agoraphobia: Efficacy and predictors of outcome. Australian and New Zealand Jour- nal of Psychiatry, 29, 104–113.

de Beurs, E., van Balkom, A. J., Lange, A., Koele, P., & van Dyck, R. (1995). Treatment of panic disorder with agora-

phobia: Comparison of fluvoxamine, placebo, and psycho- logical panic management combined with exposure and of exposure in vivo alone. American Journal of Psychiatry, 152, 683–691.

De Cort, K., Hermans, D., Spruyt, A., Griez, E., & Schruers, K. (2008). A specific attentional bias in panic disorder? Depression and Anxiety, 25(11), 951–955.

de Jong, M. G., & Bouman, T. K. (1995). Panic disorder: A baseline period: Predictability of agoraphobic avoidance behavior. Journal of Anxiety Disorders, 9, 185–199.

de Jonge, P., Roest, A. M., Lim, C. C., Florescu, S. E., Brom- et, E. J., Stein, D. J., et al. (2016). Cross-national epide- miology of panic disorder and panic attacks in the world mental health surveys. Depression and Anxiety, 33(12), 1155–1177.

Deacon, B., & Abramowitz, J. (2006). A pilot study of two- day cognitive-behavioral therapy for panic disorder. Be- haviour Research and Therapy, 44, 807–817.

Deacon, B., Lickel, J. J., Nelson, E. A., Abramowitz, J. S., Mahaffey, B., & Wolitzky-Taylor, K. B. (2012). Do cog- nitive reappraisal and diaphragmatic breathing augment interoceptive exposure for anxiety sensitivity? Journal of Cognitive Psychotherapy, 26, 257–269.

Debiec, J., & LeDoux, J. E. (2004). Disruption of reconsoli- dation but not consolidation of auditory fear conditioning by noradrenergic blockade in the amygdala. Neuroscience, 129(2), 267–272.

Deckert, J., Nothen, M. M., Franke, P., Delmo, C., Fritze, J., Knapp, M., et al. (1998). Systematic mutation screening and association study of the A1 and A2a adenosine recep- tor genes in panic disorder suggest a contribution of the A2a gene to the development of disease. Molecular Psychia- try, 3, 81–85.

Dewey, D., & Hunsley, J. (1990). The effects of marital ad- justment and spouse involvement on the behavioral treat- ment of agoraphobia: A meta-analytic review. Anxiety Re- search, 2(2), 69–83.

Di Nardo, P., Brown, T. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule—Fourth Edition (ADIS-IV). New York: Oxford University Press.

Domschke, K., Agineszka, G., Winter, B., Hermann, M. J., Warrings B., Muhlberger, A., et al. (2011). ADORA2A gene variation, caffeine, and emotional processing: A multi-level interaction on startle reflex. Neuropsychophar- macology, 37, 759–769.

Dow, M., Kenardy, J., Johnston, D., Newman, M., Taylor, C., & Thomson, A. (2007). Prognostic indices with brief and standard CBT for panic disorder: I. Predictors of out- come. Psychological Medicine, 27, 1493–1502.

Dreessen, L., Arntz, A., Luttels, C., & Sallaerts, S. (1994). Personality disorders do not influence the results of cogni- tive behavior therapies for anxiety disorders. Comprehen- sive Psychiatry, 35(4), 265–274.

Dworkin, B. R., & Dworkin, S. (1999). Heterotopic and ho-

54 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

motopic classical conditioning of the baroreflex. Integra- tive Physiological and Behavioral Science, 34(3), 158–176.

Ehlers, A. (1995). A 1-year prospective study of panic attacks: Clinical course and factors associated with maintenance. Journal of Abnormal Psychology, 104, 164–172.

Ehlers, A., & Breuer, P. (1992). Increased cardiac awareness in panic disorder. Journal of Abnormal Psychology, 101, 371–382.

Ehlers, A., & Breuer, P. (1996). How good are patients with panic disorder at perceiving their heartbeats? Biological Psychology, 42, 165–182.

Ehlers, A., Breuer, P., Dohn, D., & Fiegenbaum, W. (1995). Heartbeat perception and panic disorder: Possible expla- nations for discrepant findings. Behaviour Research and Therapy, 33, 69–76.

Ehlers, A., & Margraf, J. (1989). The psychophysiological model of panic attacks. In P. M. G. Emmelkamp (Ed.), Anxiety disorders: Annual series of European research in be- havior therapy (Vol. 4, pp. 1–29). Amsterdam: Swets.

Ehlers, A., Margraf, J., Davies, S., & Roth, W. T. (1988). Se- lective processing of threat cues in subjects with panic at- tacks. Cognition and Emotion, 2, 201–219.

Ehlers, A., Margraf, J., Roth, W. T., Taylor, C. B., & Birn- baumer, N. (1988). Anxiety induced by false heart rate feedback in patients with panic disorder. Behaviour Re- search and Therapy, 26(1), 1–11.

Eifert, G. H., & Heffner, M. (2003). The effects of accep- tance versus control contexts on avoidance of panic-related symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 34(3–4), 293–312.

Eley, T. C. (2001). Contributions of behavioral genetics re- search: Quantifying genetic, shared environmental and nonshared environmental influences. In M. W. Vasey & M. R. Dadds (Eds.), The developmental psychopathology of anxiety (pp. 45–59). New York: Oxford University Press.

Emmelkamp, P. (1980). Agoraphobics’ interpersonal prob- lems: Their role in the effects of exposure in vivo therapy. Archives of General Psychiatry, 37, 1303–1306.

Emmelkamp, P. M., & Wittchen, H.-U. (2009). Specific phobias. In G. Andrews (Ed.), Stress-induced and fear cir- cuitry disorders: Advancing the research agenda for DSM-V (pp. 77–104). Arlington, VA: American Psychiatric Asso- ciation.

Evans, L., Holt, C., & Oei, T. P. S. (1991). Long term follow- up of agoraphobics treated by brief intensive group cogni- tive behaviour therapy. Australian and New Zealand Jour- nal of Psychiatry, 25, 343–349.

Eysenck, H. J. (1967). The biological basis of personality. Springfield, IL: Charles C Thomas.

Faravelli, C., Pallanti, S., Biondi, F., Paterniti, S., & Scarpato, M. A. (1992). Onset of panic disorder. American Journal of Psychiatry, 149, 827–828.

Feigenbaum, W. (1988). Long-term efficacy of ungraded ver- sus graded massed exposure in agoraphobics. In I. Hand & H. Wittchen (Eds.), Panic and phobias: Treatments and

variables affecting course and outcome (pp. 83–88). Berlin: Springer-Verlag.

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bul- letin, 99, 20–35.

Foa, E. B., & McNally, R. J. (1996). Mechanisms of change in exposure therapy. In R. M. Rapee (Ed.), Current contro- versies in the anxiety disorders (pp.  329–343). New York: Guilford Press.

Forsyth, J. P., Palav, A., & Duff, K. (1999). The absence of relation between anxiety sensitivity and fear conditioning using 20% versus 13% CO2-enriched air as unconditioned stimuli. Behaviour Research and Therapy, 37(2), 143–153.

Friedman, S., & Paradis, C. (1991). African-American pa- tients with panic disorder and agoraphobia. Journal of Anxiety Disorders, 5, 35–41.

Friedman, S., Paradis, C. M., & Hatch, M. (1994). Char- acteristics of African-American and white patients with panic disorder and agoraphobia. Hospital and Community Psychiatry, 45, 798–803.

Fry, W. (1962). The marital context of an anxiety syndrome. Family Process, 1, 245–252.

Garssen, B., de Ruiter, C., & van Dyck, R. (1992). Breathing retraining: A rational placebo? Clinical Psychology Review, 12, 141–153.

Ghosh, A., & Marks, I. M. (1987). Self-treatment of agora- phobia by exposure. Behavior Therapy, 18, 3–16.

Glenn, D., Golinelli, D., Rose, R., Roy-Byrne, P., Stein, M., Sullivan, G., et al. (2013). Who gets the most out of cogni- tive behavioral therapy for anxiety disorders?: The role of treatment dose and patient engagement. Journal of Con- sulting and Clinical Psychology, 81, 639–649.

Gloster, A. T., Hauke, C., Höfler, M., Einsle, F., Fydrich, T., Hamm, A., et al. (2013). Long-term stability of cognitive behavioral therapy effects for panic disorder with agora- phobia: A two-year follow-up study. Behaviour Research and Therapy, 51(12), 830–839.

Gloster, A. T., Wittchen, H.-U., Einsle, F., Lang, T., Helbig- Lang, S., Fydrich, T., et al. (2011). Psychological treat- ment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided ex- posure in situ in CBT. Journal of Consulting and Clinical Psychology, 79, 406–420.

Goisman, R. M., Goldenberg, I., Vasile, R. G., & Keller, M. B. (1995). Comorbidity of anxiety disorders in a multi- center anxiety study. Comprehensive Psychiatry, 36, 303– 311.

Goisman, R. M., Warshaw, M. G., Peterson, L. G., Rogers, M. P., Cuneo, P., Hunt, M. F., et al. (1994). Panic, agora- phobia, and panic disorder with agoraphobia: Data from a multicenter anxiety disorders study. Journal of Nervous and Mental Disease, 182, 72–79.

Goldstein, A. J., & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9, 47–59.

Goodwin, R. D., Fergusson, D. M., & Horwood, L. J.

Panic Disorder and Agoraphobia 55

(2005). Childhood abuse and familial violence and the risk of panic attacks and panic disorder in young adult- hood. Psychological Medicine, 35, 881–890.

Gorman, J. M., Papp, L. A., Coplan, J. D., Martinez, J. M., Lennon, S., Goetz, R. R., et al. (1994). Anxiogenic effects of CO2 and hyperventilation in patients with panic disor- der. American Journal of Psychiatry, 151(4), 547–553.

Gould, R. A., & Clum, G. A. (1995). Self-help plus mini- mal therapist contact in the treatment of panic disorder: A  replication and extension. Behavior Therapy, 26, 533– 546.

Gould, R. A., Clum, G. A., & Shapiro, D. (1993). The use of bibliotherapy in the treatment of panic: A preliminary investigation. Behavior Therapy, 24, 241–252.

Gray, J. A. (1982). The neuropsychology of anxiety: An enqui- ry into the functions of the septo-hippocampal system. New York: Oxford University Press.

Griez, E., & van den Hout, M. A. (1986). CO2 inhalation in the treatment of panic attacks. Behaviour Research and Therapy, 24, 145–150.

Grilo, C. M., Money, R., Barlow, D. H., Goddard, A. W., Gorman, J. M., Hofmann, S. G., et al. (1998). Pretreat- ment patient factors predicting attrition from a multi- center randomized controlled treatment study for panic disorder. Comprehensive Psychiatry, 39, 323–332.

Haby, M., Donnelly, M., Corry, J., & Vos, T. (2006). Cogni- tive behavioural therapy for depression, panic disorder and generalized anxiety disorder: A meta-regression of factors that may predict outcome. Australian and New Zealand Journal of Psychiatry, 40, 9–19.

Hafner, R. J. (1984). Predicting the effects on husbands of behavior therapy for agoraphobia. Behaviour Research and Therapy, 22, 217–226.

Hamilton, S. P., Fyer, A. J., Durner, M., Heiman, G. A., Baisre de Leon, A., Hodge, S. E., et al. (2003). Further genetic evidence for a panic disorder syndrome mapping to chromosome 13q. Proceedings of National Academy of Sci- ences of the USA, 100, 2550–2555.

Hamilton, S. P., Slager, S. L., De Leon, A. B., Heiman, G. A., Klein, D. F., Hodge, S. E., et al. (2004). Evidence for genetic linkage between a polymorphism in the adenosine 2A receptor and panic disorder. Neuropsychopharmacology, 29, 558–565.

Hamilton, S. P., Slager, S. L., Helleby, L., Heiman, G. A., Klein, D. F., Hodge, S. E., et al. (2001). No association or linkage between polymorphisms in the genes encoding cholecystokinin and the cholecystokinin B receptor and panic disorder. Molecular Psychiatry, 6, 59–65.

Hand, I., & Lamontagne, Y. (1976). The exacerbation of in- terpersonal problems after rapid phobia removal. Psycho- therapy: Theory, Research and Practice, 13, 405–411.

Haslam, M. T. (1974). The relationship between the effect of lactate infusion on anxiety states and their amelioration by carbon dioxide inhalation. British Journal of Psychiatry, 125, 88–90.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Ac- ceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.

Hayes, S. C., Wilson, K. G., Gifford, E. V., & Follette, V. M. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treat- ment. Journal of Consulting and Clinical Psychology, 64(6), 1152–1168.

Hayward, C., Killen, J. D., Hammer, L. D., Litt, I. F., Wil- son, D. M., Simmonds, B., et al. (1992). Pubertal stage and panic attack history in sixth- and seventh-grade girls. American Journal of Psychiatry, 149, 1239–1243.

Hayward, C., Killen, J. D., Kraemer, H. C., & Taylor, C. B. (2000). Predictors of panic attacks in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 39(2), 1–8.

Hecker, J. E., Losee, M. C., Fritzler, B. K., & Fink, C. M. (1996). Self-directed versus therapist-directed cognitive behavioral treatment for panic disorder. Journal of Anxiety Disorders, 10, 253–265.

Hecker, J. E., Losee, M. C., Roberson-Nay, R., & Maki, K. (2004). Mastery of your anxiety and panic and brief thera- pist contact in the treatment of panic disorder. Journal of Anxiety Disorders, 18(2), 111–126.

Hedman, E., Ljótsson, B., Rück, C., Bergström, J., Anders- son, G., Kaldo, V., et al. (2013). Effectiveness of Internet- based cognitive behaviour therapy for panic disorder in routine psychiatric care. Acta Psychiatrica Scandinavica, 128(6), 457–467.

Helbig-Lang, S., & Petermann, F. (2010). Tolerate or elimi- nate?: A systematic review on the effects of safety behavior across anxiety disorders. Clinical Psychology: Science and Practice, 17(3), 218–233.

Heldt, E., Manfro, G. G., Kipper, L., Blaya, C., Isolan, L., & Otto, M. W. (2006). One-year follow-up of pharmaco- therapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Outcome and predictors of re- mission. Behaviour Research and Therapy, 44(5), 657–665.

Hermans, D., Craske, M. G., Mineka, S., & Lovibond, P. F. (2006). Extinction in human fear conditioning. Biological Psychiatry, 60, 361–368.

Heuzenroeder, L., Donnelly, M., Haby, M. M., Mihalopou- los, C., Rossell, R., Carter, R., et al. (2004). Cost-effec- tiveness of psychological and pharmacological interven- tions for generalized anxiety disorder and panic disorder. Australian and New Zealand Journal of Psychiatry, 38(8), 602–612.

Hibbert, G., & Pilsbury, D. (1989). Hyperventilation: Is it a cause of panic attacks? British Journal of Psychiatry, 155, 805–809.

Himadi, W., Cerny, J., Barlow, D., Cohen, S., & O’Brien, G. (1986). The relationship of marital adjustment to agora- phobia treatment outcome. Behaviour Research and Ther- apy, 24, 107–115.

Hoffart, A. (1995). A comparison of cognitive and guided

56 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

mastery therapy of agoraphobia. Behaviour Research and Therapy, 33, 423–434.

Hoffart, A. (1997). Interpersonal problems among patients suffering from panic disorder with agoraphobia before and after treatment. British Journal of Medical Psychology, 70(2), 149–157.

Hoffart, A., & Hedley, L. M. (1997). Personality traits among panic disorder with agoraphobia patients before and after symptom-focused treatment. Journal of Anxiety Disorders, 11, 77–87.

Hoffart, A., Sexton, H., Hedley, L., & Martinsen, E. W. (2008). Mechanisms of change in cognitive therapy for panic disorder with agoraphobia. Journal of Behavior Ther- apy and Experimental Psychiatry, 39(3), 262–275.

Hofmann, S. G., Shear, M. K., Barlow, D. H., Gorman, J. M., Hershberger, D., Patterson, M., et al. (1988). Effects of panic disorder treatments on personality disorder char- acteristics. Depression and Anxiety, 8(1), 14–20.

Hofmann, S. G., Suvak, M. K., Barlow, D. H., Shear, M. K., Meuret, A. E., et al. (2007). Preliminary evidence for cognitive mediation during cognitive-behavioral therapy of panic disorder. Journal of Consulting and Clinical Psy- chology, 75(3), 374–379.

Holden, A. E. O., O’Brien, G. T., Barlow, D. H., Stetson, D., & Infantino, A. (1983). Self-help manual for agoraphobia: A preliminary report of effectiveness. Behavior Therapy, 14, 545–556.

Holt, P., & Andrews, G. (1989). Hyperventilation and anxi- ety in panic disorder, agoraphobia, and generalized anxiety disorder. Behaviour Research and Therapy, 27, 453–460.

Hope, D. A., Rapee, R. M., Heimberg, R. G., & Dombeck, M. J. (1990). Representations of the self in social phobia: Vulnerability to social threat. Cognitive Therapy and Re- search, 14, 177–189.

Hornsveld, H., Garssen, B., Fiedeldij Dop, M., & van Spie- gel, P. (1990). Symptom reporting during voluntary hy- perventilation and mental load: Implications for diagnos- ing hyperventilation syndrome. Journal of Psychosomatic Research, 34, 687–697.

Huppert, J. D., Bufka, L. F., Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2001). Therapist, therapist variables, and cognitive-behavioral therapy outcome in a multicenter trial for panic disorder. Journal of Consulting and Clinical Psychology, 69(5), 747–755.

Huppert, J. D., Kivity, Y., Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2014). Therapist effects and the outcome–alliance correlation in cognitive behav- ioral therapy for panic disorder with agoraphobia. Behav- iour Research and Therapy, 52, 26–34.

Issakidis, C., & Andrews, G. (2004). Pretreatment attrition and dropout in an outpatient clinic for anxiety disorders. Acta Psychiatrica Scandinavica, 109(6), 426–433.

Ito, L. M., Noshirvani, H., Basoglu, M., & Marks, I. M. (1996). Does exposure to internal cues enhance exposure

to external exposure to external cues in agoraphobia with panic. Psychotherapy and Psychosomatics, 65, 24–28.

Izard, C. E. (1992). Basic emotions, relations among emo- tions, and emotion cognition relations. Psychological Re- view, 99, 561–565.

Jacob, R. G., Furman, J. M., Clark, D. B., & Durrant, J. D. (1992). Vestibular symptoms, panic, and phobia: Overlap and possible relationships. Annals of Clinical Psychiatry, 4(3), 163–174.

Kampfe, C. K., Gloster, A. T., Wittchen, H.-U., Helbig- Lang, S., Lang, T., & Gerlach, A. L. (2012). Experiential avoidance and anxiety sensitivity in patients with panic disorder and agoraphobia: Do both constructs measure the same? International Journal of Clinical and Health Psychol- ogy, 12, 5–22.

Kampman, M., Keijsers, G. P. J., Hoogduin, C. A. L., & Hendriks, G.-J. (2002). A randomized, double-blind, placebo-controlled study of the effects of adjunctive par- oxetine in panic disorder patients unsuccessfully treated with cognitive-behavioral therapy alone. Journal of Clini- cal Psychiatry, 63(9), 772–777.

Katon, W., Von Korff, M., Lin, E., Lipscomb, P., Russo, J., Wagner, E., et al. (1990). Distressed high utilizers of medi- cal care: DSM-III-R diagnoses and treatment needs. Gen- eral Hospital Psychiatry, 12(6), 355–362.

Katschnig, H., & Amering, M. (1998). The long-term course of panic disorder and its predictors. Journal of Clinical Psy- chopharmacology, 18(6, Suppl. 2), 6S–11S.

Keijsers, G. P., Kampman, M., & Hoogduin, C. A. (2001). Dropout prediction in cognitive behavior therapy for panic disorder. Behavior Therapy, 32(4), 739–749.

Keijsers, G. P., Schaap, C. P., Hoogduin, C. A., & Lammers, M. W. (1995). Patient–therapist interaction in the behav- ioral treatment of panic disorder with agoraphobia. Behav- ior Modification, 19, 491–517.

Keller, M. L., & Craske, M. G. (2008). Panic disorder and agoraphobia. In J. Hunsley & E. J. Mash (Eds.), A guide to assessments that work (pp. 229–253). New York: Oxford University Press.

Kendler, K. S., Bulik, C. M., Silberg, J., Hettema, J. M., Myers, J., & Prescott, C. A. (2000). Childhood sexual abuse and adult psychiatric and substance use disorders in women: An epidemiological and co-twin analysis. Archives of General Psychiatry, 57, 953–959.

Kendler, K. S., Heath, A. C., Martin, N. G., & Eaves, L. J. (1987). Symptoms of anxiety and symptoms of depression: Same genes, different environments? Archives of General Psychiatry, 44, 451–457.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distri- butions of DSM-IV disorders in the National Comorbid- ity Survey Replication. Archives of General Psychiatry, 62, 593–602.

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E.

Panic Disorder and Agoraphobia 57

(2005). Lifetime prevalence and age-of-onset distribu- tions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602.

Kessler, R. C., Chiu, W. T., Jin, R., Ruscio, A. M., Shear, K., & Walters, E. E. (2006). The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Archives of General Psy- chiatry, 63, 415–424.

Kessler, R. C., Davis, C. G., & Kendler, K. S. (1997). Child- hood adversity and adult psychiatric disorder in the U.S. National Comorbidity Survey. Psychological Medicine, 27, 1101–1119.

Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H.-U. (2012). Twelve-month and life- time prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21(3), 169–184.

Keyl, P. M., & Eaton, W. W. (1990). Risk factors for the onset of panic disorder and other panic attacks in a prospective, population-based study. American Journal of Epidemiology, 131, 301–311.

Kikuchi, M., Komuro, R., Hiroshi, O., Kidani, T., Hanaoka, A., & Koshino, Y. (2005). Panic disorder with and without agoraphobia: Comorbidity within a half-year of the onset of panic disorder. Psychiatry and Clinical Neurosciences, 58, 639–643.

Kindt, M., Soeter, M., & Vervliet, B. (2009). Beyond extinc- tion: Erasing human fear responses and preventing the re- turn of fear. Nature Neuroscience, 12, 256–258.

Kircanski, K., Craske, M. G., Epstein, A. M., & Wittchen, H.-U. (2009). Subtypes of panic attacks: A critical review of the empirical literature. Depression and Anxiety, 26, 878–887.

Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A., Myst- kowski, J., Yi, R., et al. (2011). Challenges to the tradi- tional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43, 745–751.

Kiropoulos, L. A., Klein, B., Austin, D. W., Gilson, K., Pier, C., Mitchell, J., et al. (2008). Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT? Journal of Anxiety Disorders, 22, 1273–1284.

Kraft, A. R., & Hoogduin, C. A. (1984). The hyperventila- tion syndrome: A pilot study of the effectiveness of treat- ment. British Journal of Psychiatry, 145, 538–542.

Kroeze, S., & van den Hout, M. A. (2000). Selective atten- tion for cardiac information in panic patients. Behaviour Research and Therapy, 38, 63–72.

Krystal, J. H., Woods, S. W., Hill, C. L., & Charney, D. S. (1991). Characteristics of panic attack subtypes: Assess- ment of spontaneous panic, situational panic, sleep panic, and limited symptom attacks. Comprehensive Psychiatry, 32(6), 474–480.

Kushner, M. G., Donahue, C., Sletten, S., Thuras, P., Abrams, K., Peterson, J., & Frye, B. (2006). Cognitive behavioral treatment of comorbid anxiety disorder in al- coholism treatment patients: Presentation of a prototype program and future directions. Journal of Mental Health, 15(6), 697–707.

Kushner, M. G., Maurer, E. W., Thuras, P., Donahue, C., Frye, B., Menary, K. R., et al. (2013). Hybrid cognitive be- havioral therapy versus relaxation training for co-occurring anxiety and alcohol disorder: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 81, 422–429.

Lake, R. I., Eaves, L. J., Maes, H. H., Heath, A. C., & Martin, N. G. (2000). Further evidence against the environmental transmission of individual differences in neuroticism from a collaborative study of 45,850 twins and relatives of two continents. Behavior Genetics, 30(3), 223–233.

Lang, A. J., & Craske, M. G. (2000). Manipulations of expo- sure-based therapy to reduce return of fear: A replication. Behaviour Research and Therapy, 38, 1–12.

Lehman, C. L., Brown, T. A., & Barlow, D. H. (1998). Ef- fects of cognitive-behavioral treatment for panic disorder with agoraphobia on concurrent alcohol abuse. Behavior Therapy, 29, 423–433.

Lelliott, P., Marks, I., McNamee, G., & Tobena, A. (1989). Onset of panic disorder with agoraphobia: Toward an in- tegrated model. Archives of General Psychiatry, 46, 1000– 1004.

Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy, 35, 747–766.

Lewis-Fernandez, R., Hinton, D. E., Laria, A. J., Patterson, E. H., Hofmann, S. G., Craske, M. et al. (2010). Culture and the anxiety disorders: Recommendations for DSM-V. Depression and Anxiety, 27, 212–229.

Lidren, D. M., Watkins, P., Gould, R. A., Clum, G. A., Asterino, M., & Tulloch, H. L. (1994). A comparison of bibliotherapy and group therapy in the treatment of panic disorder. Journal of Consulting and Clinical Psychology, 62, 865–869.

Lissek, S., Powers, A. S., McClure, E. B., Phelps, E. A., Wol- derhawariat, G., Grillon, C., et al. (2005). Classical fear conditioning in the anxiety disorders: A meta-analysis. Be- haviour Research and Therapy, 43, 1391–1424.

Lissek, S., Rabin, S. J., Heller, R. E., Lukenbaugh, D., Ger- aci, M., Pine, D. S., et al. (2010). Overgeneralization of conditioned fear as a pathogenic marker of panic disorder. American Journal of Psychiatry, 167(1), 47–55.

Lissek, S., Rabin, S. J., McDowell, D. J., Divir, S., Bradford, D. E., Geraci, M., et al. (2009). Impaired discriminative fear-conditioning resulting from elevated fear responding to learned safety cues among individuals with panic disor- der. Behaviour Research and Therapy, 47(2), 111–118.

58 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Lovibond, P. F., Davis, N. R., & O’Flaherty, A. S. (2000). Protection from extinction in human fear conditioning. Behaviour Research and Therapy, 38, 967–983.

Maidenberg, E., Chen, E., Craske, M., Bohn, P., & Bys- tritsky, A. (1996). Specificity of attentional bias in panic disorder and social phobia. Journal of Anxiety Disorders, 10, 529–541.

Maier, S. F., Laudenslager, M. L., & Ryan, S. M. (1985). Stressor controllability, immune function and endogenous opiates. In F. R. Brush & J. B. Overmeier (Eds.), Affect, conditioning and cognition: Essays on the determinants of be- havior (pp. 183–201). Hillsdale, NJ: Erlbaum.

Maller, R. G., & Reiss, S. (1992). Anxiety sensitivity in 1984 and panic attacks in 1987. Journal of Anxiety Disorders, 6(3), 241–247.

Mannuzza, S., Fyer, A. J., Liebowitz, M. R., & Klein, D. F. (1990). Delineating the boundaries of social phobia: Its relationship to panic disorder and agoraphobia. Journal of Anxiety Disorders, 4(1), 41–59.

Marchand, A., Goyer, L. R., Dupuis, G., & Mainguy, N. (1998). Personality disorders and the outcome of cognitive- behavioural treatment of panic disorder with agoraphobia. Canadian Journal of Behavioural Science, 30(1), 14–23.

Margraf, J., Taylor, C. B., Ehlers, A., Roth, W. T., & Agras, W. S. (1987). Panic attacks in the natural environment. Journal of Nervous and Mental Disease, 175, 558–565.

Marks, I. M., Swinson, R. P., Basoglu, M., Kuck, K., Noshirvani, H., O’Sullivan, G., et al. (1993). Alprazolam and exposure alone and combined in panic disorder with agoraphobia: A controlled study in London and Toronto. British Journal of Psychiatry, 162, 776–787.

Martin, N. G., Jardine, R., Andrews, G., & Heath, A. C. (1988). Anxiety disorders and neuroticism: Are there ge- netic factors specific to panic? Acta Psychiatrica Scandi- navica, 77, 698–706.

Mavissakalian, M., & Hamman, M. (1987). DSM-III per- sonality disorder in agoraphobia: II. Changes with treat- ment. Comprehensive Psychiatry, 28, 356–361.

McLean, P. D., Woody, S., Taylor, S., & Koch, W. J. (1998). Comorbid panic disorder and major depression: Implica- tions for cognitive-behavioral therapy. Journal of Consult- ing and Clinical Psychology, 66, 240–247.

McNally, R. J., & Lorenz, M. (1987). Anxiety sensitivity in agoraphobics. Journal of Behavior Therapy and Experimen- tal Psychiatry, 18(1), 3–11.

McNally, R. J., Riemann, B. C., Louro, C. E., Lukach, B. M., & Kim, E. (1992). Cognitive processing of emotional information in panic disorder. Behaviour Research and Therapy, 30, 143–149.

McNamee, G., O’Sullivan, G., Lelliott, P., & Marks, I. M. (1989). Telephone-guided treatment for housebound ago- raphobics with panic disorder: Exposure vs. relaxation. Behavior Therapy, 20, 491–497.

Mellman, T. A., & Uhde, T. W. (1989). Sleep panic attacks:

New clinical findings and theoretical implications. Ameri- can Journal of Psychiatry, 146, 1204–1207.

Messenger, C., & Shean, G. (1998). The effects of anxiety sensitivity and history of panic on reactions to stressors in a non-clinical sample. Journal of Behavior Therapy, 29, 279–288.

Meuret, A. E., Rosenfield, D., Seidel, A., Bhaskara, L., & Hofmann, S. G. (2010). Respiratory and cognitive media- tors of treatment change in panic disorder: Evidence for intervention specificity. Journal of Consulting and Clinical Psychology, 78, 691–704.

Meuret, A. E., Twohig, M. P., Rosenfield, D., Hayes, S. C., & Craske, M. G. (2012). Brief acceptance and commitment therapy and exposure for panic disorder: A pilot study. Cognitive and Behavioral Practice, 19(4), 606–618.

Meuret, A. E., Wilhelm, F. H., Ritz, T., & Roth, W. T. (2008). Feedback of end-tidal pCO2 as a therapeutic ap- proach for panic disorder. Journal of Psychiatric Research, 42(7), 560–568.

Michelson, L., Mavissakalian, M., Marchione, K., Ulrich, R., Marchione, N., & Testa, S. (1990). Psychophysiological outcome of cognitive, behavioral, and psychophysiologi- cally based treatments of agoraphobia. Behaviour Research and Therapy, 28, 127–139.

Milton, F., & Hafner, J. (1979). The outcome of behavior therapy for agoraphobia in relation to marital adjustment. Archives of General Psychiatry, 36, 807–811.

Mineka, S., Cook, M., & Miller, S. (1984). Fear conditioned with escapable and inescapable shock: The effects of a feedback stimulus. Journal of Experimental Psychology: Ani- mal Behavior Processes, 10, 307–323.

Mitsopoulou, T., Kasvikis, Y., Koumantanou, L., Giaglis, G., Skapinakis, P., & Mavreas, V. (2020). Manualized single- session behavior treatment with self-help manual for panic disorder with or without agoraphobia. Psychotherapy Re- search, 30, 776–787.

Moisan, D., & Engels, M. L. (1995). Childhood trauma and personality disorder in 43 women with panic disorder. Psy- chological Reports, 76, 1133–1134.

Murphy, M. T., Michelson, L. K., Marchione, K., Marchione, N., & Testa, S. (1998). The role of self-directed in vivo ex- posure in combination with cognitive therapy, relaxation training, or therapist-assisted exposure in the treatment of panic disorder with agoraphobia. Behaviour Research and Therapy, 12, 117–138.

Mystkowski, J. L., Craske, M. G., Echiverri, A. M., & Labus, J. S. (2006). Mental reinstatement of context and return of fear in spider-fearful participants. Behavior Therapy, 37(1), 49–60.

Nader, K., Schafe, G. E., & LeDoux, J. E. (2000). Fear mem- ories require protein synthesis in the amygdala for recon- solidation after retrieval. Nature, 406, 722–726.

Nations, K. R., Smits, J. A., Tolin, D. F., Rothbaum, B. O., Hofmann, S. G., Tart, C. D., et al. (2012). Evaluation of

Panic Disorder and Agoraphobia 59

the glycine transporter inhibitor Org 25935 as augmen- tation to cognitive-behavioral therapy for panic disorder: A multicenter, randomized, double-blind, placebo-con- trolled trial. Journal of Clinical Psychiatry, 73, 647–653.

Néron, S., Lacroix, D., & Chaput, Y. (1995). Group vs indi- vidual cognitive behaviour therapy in panic disorder: An open clinical trial with a six month follow-up. Canadian Journal of Behavioural Science, 27, 379–392.

Neumann, D. L., Lipp, O. V., & Cory, S. E. (2007). Con- ducting extinction in multiple contexts does not necessar- ily attenuate the renewal of shock expectancy in a fear- conditioning procedure with humans. Behaviour Research and Therapy, 45, 385–394.

Niles, A. N., Sherbourne, C., Roy-Byrne, P., Stein, M., Sul- livan, G., Bystritsky, A., et al. (2013). Anxiety treatment improves physical functioning with oblique scoring of the SF-12 Short Form Health Survey. General Hospital Psy- chiatry, 35(3), 291–296.

Norberg, M. M., Krystal, J. H., & Tolin, D. F. (2008). A meta-analysis of D-cycloserine and the facilitation of fear extinction and exposure therapy. Biological Psychiatry, 63, 1118–1126.

Nordgreen, T., Haug, T., Öst, L. G., Andersson, G., Carl- bring, P., Kvale, G., et al. (2016). Stepped care versus direct face-to-face cognitive behavior therapy for social anxiety disorder and panic disorder: A randomized effec- tiveness trial. Behavior Therapy, 47(2), 166–183.

Norton, G. R., Cox, B. J., & Malan, J. (1992). Nonclinical panickers: A critical review. Clinical Psychology Review, 12, 121–139.

Norton, P., & Price, E. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. Journal of Nervous and Mental Disease, 195, 521–531.

Noyes, R., Clancy, J., Garvey, M. J., & Anderson, D. J. (1987). Is agoraphobia a variant of panic disorder or a sepa- rate illness? Journal of Anxiety Disorders, 1, 3–13.

Noyes, R., Crowe, R. R., Harris, E. L., Hamra, B. J., McChesney, C. M., & Chaudhry, D. R. (1986). Relation- ship between panic disorder and agoraphobia: A family study. Archives of General Psychiatry, 43, 227–232.

Noyes, R., Reich, J., Suelzer, M., & Christiansen, J. (1991). Personality traits associated with panic disorder: Change associated with treatment. Comprehensive Psychiatry, 32, 282–294.

Okamura, N., Garau, C., Duangdao, D. M., Clark, S. D., Jungling, K., Hans-Christian, P., et al. (2011). Neuropep- tide S enhances memory during the consolidation phase and interacts with noradrenergic systems in the brain. Neuropsychopharmacology, 36(4), 744–752.

Olatunji, B. O., & Wolitzky-Taylor, K. B. (2009). Anxiety sensitivity and the anxiety disorders: A meta-analytic re- view and synthesis. Psychological Bulletin, 135, 974–999.

Öst, L.-G. (1988). Applied relaxation vs. progressive relax-

ation in the treatment of panic disorder. Behaviour Re- search and Therapy, 26, 13–22.

Öst, L.-G., Thulin, U., & Ramnero, J. (2004). Cognitive behavior therapy vs exposure in vivo in the treatment of panic disorder with agoraphobia. Behaviour Research and Therapy, 42(1), 1105–1127.

Öst, L.-G., & Westling, B. E. (1995). Applied relaxation vs cognitive behavior therapy in the treatment of panic disor- der. Behaviour Research and Therapy, 33, 145–158.

Öst, L.-G., Westling, B. E., & Hellström, K. (1993). Applied relaxation, exposure in vivo, and cognitive methods in the treatment of panic disorder with agoraphobia. Behaviour Research and Therapy, 31, 383–394.

Otto, M. W., Pollack, M. H., & Sabatino, S. A. (1996). Maintenance of remission following cognitive behavior therapy for panic disorder: Possible deleterious effects of concurrent medication treatment. Behavior Therapy, 27, 473–482.

Otto, M. W., Tolin, D. F., Simon, N. M., Pearlson, G. D., Basden, S., Meunier, S. A., et al. (2010). Efficacy of D- cycloserine for enhancing response to cognitive-behavior therapy for panic disorder. Biological Psychiatry, 67(4), 365–370.

Pauli, P., Amrhein, C., Muhlberger, A., Dengler, W., & Wi- edemann, G. (2005). Electrocortical evidence for an early abnormal processing of panic-related words in panic disor- der patients. International Journal of Psychophysiology, 57, 33–41.

Pennebaker, J. W., & Roberts, T. (1992). Toward a his and hers theory of emotion: Gender differences in visceral per- ception. Journal of Social and Clinical Psychology, 11(30), 199–212.

Perna, G., Bertani, A., Arancio, C., Ronchi, P., & Bellodi, L. (1995). Laboratory response of patients with panic and obsessive–compulsive disorders to 35% CO2 challenges. American Journal of Psychiatry, 152, 85–89.

Prenoveau, J. M., Zinbarg, R. E., Craske, M. G., Mineka, S., Griffith, J. W., & Epstein, A. (2010). Testing a hierarchical model of anxiety and depression in adolescents: A trilevel model. Journal of Anxiety Disorders, 24, 334–344.

Rachman, S., Lopatka, C., & Levitt, K. (1988). Experimen- tal analyses of panic: II. Panic patients. Behaviour Research and Therapy, 26, 33–40.

Rachman, S., Shafran, R., Radomsky, A. S., & Zysk, E. (2011). Reducing contamination by exposure plus safety behaviour. Journal of Behavior Therapy and Experimental Psychiatry, 42, 397–404.

Rapee, R. (1986). Differential response to hyperventilation in panic disorder and generalized anxiety disorder. Journal of Abnormal Psychology, 95, 24–28.

Rapee, R. M. (1994). Detection of somatic sensations in panic disorder. Behaviour Research and Therapy, 32, 825–831.

Rapee, R. M., Brown, T. A., Antony, M. M., & Barlow, D. H. (1992). Response to hyperventilation and inhalation

60 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

of 5.5% carbon dioxide-enriched air across the DSM-III- R anxiety disorders. Journal of Abnormal Psychology, 101, 538–552.

Rapee, R. M., Craske, M. G., & Barlow, D. H. (1990). Sub- ject described features of panic attacks using a new self- monitoring form. Journal of Anxiety Disorders, 4, 171–181.

Rapee, R. M., Craske, M. G., & Barlow, D. H. (1995). As- sessment instrument for panic disorder that includes fear of sensation-producing activities: The Albany Panic and Phobia Questionnaire. Anxiety, 1, 114–122.

Rapee, R. M., Craske, M. G., Brown, T. A., & Barlow, D. H. (1996). Measurement of perceived control over anxiety- related events. Behavior Therapy, 27(2), 279–293.

Rapee, R. M., & Medoro, L. (1994). Fear of physical sensa- tions and trait anxiety as mediators of the response to hy- perventilation in nonclinical subjects. Journal of Abnormal Psychology, 103(4), 693–699.

Rapee, R. M., & Murrell, E. (1988). Predictors of agorapho- bic avoidance. Journal of Anxiety Disorders, 2, 203–217.

Rathus, J. H., Sanderson, W. C., Miller, A. L., & Wetzler, S. (1995). Impact of personality functioning on cognitive be- havioral treatment of panic disorder: A preliminary report. Journal of Personality Disorders, 9, 160–168.

Razran, G. (1961). The observable unconscious and the in- ferable conscious in current Soviet psychophysiology: In- teroceptive conditioning, semantic conditioning, and the orienting reflex. Psychological Review, 68, 81–147.

Reich, J., Perry, J. C., Shera, D., Dyck, I., Vasile, R., Gois- man, R. M., et al. (1994). Comparison of personality dis- orders in different anxiety disorder diagnoses: Panic, ago- raphobia, generalized anxiety, and social phobia. Annals of Clinical Psychiatry, 6(2), 125–134.

Reiss, S. (1980). Pavlovian conditioning and human fear: An expectancy model. Behavior Therapy, 11, 380–396.

Reiss, S., Peterson, R., Gursky, D., & McNally, R. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1–8.

Rescorla, R. A. (2006). Deepened extinction from compound stimulus presentation. Journal of Experimental Psychology: Animal Behavior Processes, 32, 135–144.

Richards, J. C., Klein, B., & Austin, D. W. (2006). Internet cognitive behavioural therapy for panic disorder: Does the inclusion of stress management information improve end- state functioning? Clinical Psychologist, 10(1), 2–15.

Richards, J., Klein, B., & Carlbring, P. (2003). Internet-based treatment for panic disorder. Cognitive Behaviour Therapy, 32, 125–135.

Rowe, M. K., & Craske, M. G. (1998). Effects of an expand- ing-spaced vs massed exposure schedule on fear reduction and return of fear. Behaviour Research and Therapy, 36, 701–717.

Roy-Byrne, P. P., & Cowley, D. S. (1995). Course and out- come in panic disorder: A review of recent follow-up stud- ies. Anxiety, 1, 151–160.

Roy-Byrne, P., Craske, M. G., Stein, M. B., Sullivan, G.,

Bystritsky, A., Katon, W., et al. (2005). A randomized ef- fectiveness trial of cognitive-behavioral therapy and medi- cation for primary care panic disorder. Archives of General Psychiatry, 62, 290–298.

Roy-Byrne, P., Craske, M. G., Sullivan, G., Rose, R. D., Ed- lund, M. J., Lang, A. J., et al. (2010). Delivery of evidence- based treatment for multiple anxiety disorders in primary care. Journal of American Medicine, 303(19), 1921–1928.

Roy-Byrne, P. P., Mellman, T. A., & Uhde, T. W. (1988). Biologic findings in panic disorder: Neuroendocrine and sleep-related abnormalities [Special issue: Perspectives on Panic-Related Disorders]. Journal of Anxiety Disorders, 2, 17–29.

Roy-Byrne, P., Stein, M. B., Russo, J., Craske, M. G., Katon, W., Sullivan, G., et al. (2005). Medical illness and re- sponse to treatment in primary care panic disorder. Gen- eral Hospital Psychiatry, 27(4), 237–243.

Roy-Byrne, P. P., Stein, M. B., Russo, J., Mercier, E., Thomas, R., McQuaid, J., et al. (1999). Panic disorder in the pri- mary care setting: Comorbidity, disability, service utiliza- tion, and treatment. Journal of Clinical Psychiatry, 60(7), 492–499.

Rudaz, M., Craske, M. G., Becker, E. S., Ledermann, T., & Margraf, J. (2010). Health anxiety and fear of fear in panic disorder and agoraphobia vs. social phobia: A pro- spective longitudinal study. Depression and Anxiety, 27(4), 404–411.

Safren, S. A., Gershuny, B. S., Marzol, P., Otto, M. W., & Pol- lack, M. H. (2002). History of childhood abuse in panic disorder, social phobia, and generalized anxiety disorder. Journal of Nervous and Mental Disease, 190(7), 453–456.

Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account [Special issue: The Changing Face of Behavioural Psycho- therapy]. Behavioural Psychotherapy, 19(1), 6–19.

Salkovskis, P. M., Clark, D. M., & Gelder, M. G. (1996). Cognition–behaviour links in the persistence of panic. Be- haviour Research and Therapy, 34, 453–458.

Salkovskis, P., Clark, D., & Hackmann, A. (1991). Treatment of panic attacks using cognitive therapy without exposure or breathing retraining. Behaviour Research and Therapy, 29, 161–166.

Schade, A., Marquenie, L. A., van Balkom, A. J., Koeter, M. W., de Beurs, E., van den Brink, W., et al. (2005). The effectiveness of anxiety treatment on alcohol-dependent patients with a comorbid phobic disorder: A randomized controlled trial. Alcoholism: Clinical and Experimental Re- search, 29(5), 794–800.

Schmidt, N. B., Lerew, D. R., & Jackson, R. J. (1997). The role of anxiety sensitivity in the pathogenesis of panic: Prospective evaluation of spontaneous panic attacks dur- ing acute stress. Journal of Abnormal Psychology, 106, 355–364.

Schmidt, N. B., Lerew, D. R., & Jackson, R. J. (1999). Pro- spective evaluation of anxiety sensitivity in the pathogen-

Panic Disorder and Agoraphobia 61

esis of panic: Replication and extension. Journal of Abnor- mal Psychology, 108, 532–537.

Schmidt, N. B., McCreary, B. T., Trakowski, J. J., Santiago, H. T., Woolaway-Bickel, K., & Ialong, N. (2003). Effects of cognitive behavioral treatment on physical health status in patients with panic disorder. Behavior Therapy, 34(1), 49–63.

Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santia- go, H., Storey, J., Koselka, M., et al. (2000). Dismantling cognitive-behavioral treatment for panic disorder: Ques- tioning the utility of breathing retraining. Journal of Con- sulting and Clinical Psychology, 68(3), 417–424.

Schmidt, N. B., Zvolensky, M. J., & Maner, J. K. (2006). Anxiety sensitivity: Prospective prediction of panic attacks and Axis I pathology. Journal of Psychiatric Research, 40(8), 691–699.

Schneider, A. J., Mataix-Cols, D., Marks, I. M., & Bachofen, M. (2005). Internet-guided self-help with or without expo- sure therapy for phobic and panic disorders. Psychotherapy and Psychosomatics, 74(3), 154–164.

Schumacher, J., Jamra, R. A., Becker, T., Klopp, N., Franke, P., Jacob, C., et al. (2005). Investigation of the DAOA/ G30 locus in panic disorder. Molecular Psychiatry, 10, 428–429.

Seidel, A., Rosenfield, D., Bhaskara, L., Hofmann, S. G., & Meuret, A. E. (2009). Pathways of biobehavioral change in exposure therapy of panic disorder. Paper presented at the 43rd annual convention of the Association of Advance- ment for Behavioral and Cognitive Therapies, New York.

Sharp, D. M., Power, K. G., Simpson, R. J., Swanson, V., & Anstee, J. A. (1997). Global measures of outcome in a con- trolled comparison of pharmacological and psychological treatment of panic disorder and agoraphobia in primary care. British Journal of General Practice, 47, 150–155.

Sharp, D. M., Power, K. G., & Swanson, V. (2004). A com- parison of the efficacy and acceptability of group versus individual cognitive behaviour therapy in the treatment of panic disorder and agoraphobia in primary care. Clinical Psychology and Psychotherapy, 11(2), 73–82.

Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., Sho- lomskas, D. E., Woods, S. W., et al. (1997). Multicenter collaborative Panic Disorder Severity Scale. American Journal of Psychiatry, 154, 1571–1575.

Shear, M. K., Rucci, P., Williams, J., Frank, E., Grochocin- ski, V., Vander-Bilt, J., et al. (2001). Reliability and valid- ity of the Panic Disorder Severity Scale: Replication and extension. Journal of Psychiatric Research, 35(5), 293–296.

Shear, M. K., & Schulberg, H. C. (1995). Anxiety disorders in primary care. Bulletin of the Menninger Clinic, 59(2, Suppl. A), A73–A85.

Shulman, I. D., Cox, B. J., Swinson, R. P., Kuch, K., & Reichman, J. T. (1994). Precipitating events, locations and reactions associated with initial unexpected panic attacks. Behaviour Research and Therapy, 32, 17–20.

Sloan, T., & Telch, M. J. (2002). The effects of safety-seeking

behavior and guided threat reappraisal on fear reduction during exposure: An experimental investigation. Behav- iour Research and Therapy, 40(3), 235–251.

Soeter, M., & Kindt, M. (2010). Dissociating response sys- tems: Erasing fear from memory. Neurobiology of Learning and Memory, 94(1), 30–41.

Sokolowska, M., Siegel, S., & Kim, J. A. (2002). Intraadmin- istration associations: Conditional hyperalgesia elicited by morphine onset cues. Journal of Experimental Psychology: Animal Behavior Processes, 28(3), 309–320.

Sotres-Bayon, F., Cain, C. K., & LeDoux, J. E. (2006). Brain mechanisms of fear extinction: Historical perspectives on the contribution of prefrontal cortex. Biological Psychiatry, 60, 329–336.

Spiegel, D. A., Bruce, T. J., Gregg, S. F., & Nuzzarello, A. (1994). Does cognitive behavior therapy assist slow-taper alprazolam discontinuation in panic disorder? American Journal of Psychiatry, 151(6), 876–881.

Stein, M. B., Walker, J. R., Anderson, G., Hazen, A. L., Ross, C. A., Eldridge, G., et al. (1996). Childhood physical and sexual abuse in patients with anxiety disorders and a community sample. American Journal of Psychiatry, 153, 275–277.

Sturges, L. V., Goetsch, V. L., Ridley, J., & Whittal, M. (1998). Anxiety sensitivity and response to hyperventila- tion challenge: Physiologic arousal, interoceptive acuity, and subjective distress. Journal of Anxiety Disorders, 12(2), 103–115.

Suárez, L., Bennett, S., Goldstein, C., & Barlow, D. H. (2008). Understanding anxiety disorders from a “triple vulnerabilities” framework. In M. M. Anthony & M. B. Stein (Eds.), Oxford handbook of anxiety and related dis- orders (pp. 153–172). New York: Oxford University Press.

Swinson, R. P., Fergus, K. D., Cox, B. J., & Wickwire, K. (1995). Efficacy of telephone-administered behavioral therapy for panic disorder with agoraphobia. Behaviour Research and Therapy, 33, 465–469.

Taylor, S., Koch, W. J., & McNally, R. J. (1992). How does anxiety sensitivity vary across the anxiety disorders? Jour- nal of Anxiety Disorders, 6, 249–259.

Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heim- berg, R. G., Ledley, D. R., et al. (2007). Robust dimen- sions of anxiety sensitivity: Development and initial vali- dation of the Anxiety Sensitivity Index–3. Psychological Assessment, 19(2), 176–188.

Teachman, B. A., Marker, C. D., & Smith-Janik, S. B. (2008). Automatic associations and panic disorder: Trajectories of change over the course of treatment. Journal of Consulting and Clinical Psychology, 76(6), 988–1002.

Telch, M. J., Brouillard, M., Telch, C. F., Agras, W. S., & Taylor, C. B. (1989). Role of cognitive appraisal in panic- related avoidance. Behaviour Research and Therapy, 27, 373–383.

Telch, M. J., Lucas, J. A., & Nelson, P. (1989). Nonclinical panic in college students: An investigation of prevalence

62 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

and symptomatology. Journal of Abnormal Psychology, 98, 300–306.

Telch, M. J., Lucas, J. A., Schmidt, N. B., Hanna, H. H., LaNae Jaimez, T., & Lucas, R. A. (1993). Group cogni- tive-behavioral treatment of panic disorder. Behaviour Re- search and Therapy, 31, 279–287.

Telch, M. J., Sherman, M., & Lucas, J. (1989). Anxiety sensi- tivity: Unitary personality trait or domain specific apprais- als? Journal of Anxiety Disorders, 3, 25–32.

Thorgeirsson, T. E., Oskarsson, H., Desnica, N., Kostic, J. P., Stefansson, J. G., Kolbeinsson, H., et al. (2003). Anxiety with panic disorder linked to chromosome 9q in Iceland. American Journal of Human Genetics, 72, 1221–1230.

Thyer, B. A., Himle, J., Curtis, G. C., Cameron, O. G., & Nesse, R. M. (1985). A comparison of panic disorder and agoraphobia with panic attacks. Comprehensive Psychiatry, 26, 208–214.

Tiemens, B. G., Ormel, J., & Simon, G. E. (1996). Occur- rence, recognition, and outcome of psychological disor- ders in primary care. American Journal of Psychiatry, 153, 636–644.

Tsao, J. C. I., Lewin, M. R., & Craske, M. G. (1998). The effects of cognitive-behavior therapy for panic disorder on comorbid conditions. Journal of Anxiety Disorders, 12, 357–371.

Tsao, J. C. I., Mystkowski, J. L., Zucker, B. G., & Craske, M. G. (2002). Effects of cognitive-behavioral therapy for panic disorder on comorbid conditions: Replication and extension. Behavior Therapy, 33, 493–509.

Tsao, J. C. I., Mystkowski, J. L., Zucker, B. G., & Craske, M. G. (2005). Impact of cognitive-behavioral therapy for panic disorder on comorbidity: A controlled investigation. Behaviour Research and Therapy, 43, 959–970.

Uhde, T. W. (1994). The anxiety disorders: Phenomenology and treatment of core symptoms and associated sleep dis- turbance. In M. Kryger, T. Roth, & W. Dement (Eds.), Principles and practice of sleep medicine (pp.  871–898). Philadelphia: Saunders.

van Balkom, A. J., de Beurs, E., Koele, P., Lange, A., & van Dyck, R. (1996). Long-term benzodiazepine use is associ- ated with smaller treatment gain in panic disorder with agoraphobia. Journal of Nervous and Mental Disease, 184, 133–135.

van Beek, N., Schruers, K. R., & Friez, E. J. (2005). Prevalence of respiratory disorders in first-degree relatives of panic dis- order patients. Journal of Affective Disorders, 87, 337–340.

van den Hout, M., Arntz, A., & Hoekstra, R. (1994). Ex- posure reduced agoraphobia but not panic, and cognitive therapy reduced panic but not agoraphobia. Behaviour Re- search and Therapy, 32, 447–451.

van den Hout, M., Brouwers, C., & Oomen, J. (2006). Clini- cally diagnosed Axis II co-morbidity and the short term outcome of CBT for Axis I disorders. Clinical Psychology and Psychotherapy, 13(1), 56–63.

van Megen, H. J., Westenberg, H. G., Den Boer, J. A., &

Kahn, R. S. (1996). The panic-inducing properties of the cholecystokinin tetrapeptide CCK4 in patients with panic disorder. European Neuropsychopharmacology, 6, 187–194.

Vansteenwegen, D., Vervliet, B., Iberico, C., Baeyens, F., van den Bergh, O., & Hermans, D. (2007). The repeated con- frontation with videotapes of spiders in multiple contexts attenuates renewal of fear in spider-anxious students. Be- haviour Research and Therapy, 45(6), 1169–1179.

Veltman, D. J., van Zijderveld, G., Tilders, F. J., & van Dyck, R. (1996). Epinephrine and fear of bodily sensations in panic disorder and social phobia. Journal of Psychopharma- cology, 10(4), 259–265.

Verburg, K., Griez, E., Meijer, J., & Pols, H. (1995). Respira- tory disorders as a possible predisposing factor for panic disorder. Journal of Affective Disorders, 33, 129–134.

Vos, S. P., Huibers, M. J., Diels, L., & Arntz, A. (2012). A randomized clinical trial of cognitive behavioral therapy and interpersonal psychotherapy for panic disorder with agoraphobia. Psychological Medicine, 42(12), 2661–2672.

Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transport- ing an empirically supported treatment for panic disorder to a service clinic setting: A benchmarking strategy. Jour- nal of Consulting and Clinical Psychology, 66, 231–239.

Walker, D. L., & Davis, M. (2002). The role of amygdala glu- tamate receptors in fear learning, fear-potentiated startle, and extinction. Pharmacology, 71, 379–392.

Wardle, J., Hayward, P., Higgitt, A., Stabl, M., Blizard, R., & Gray, J. (1994). Effects of concurrent diazepam treat- ment on the outcome of exposure therapy in agoraphobia. Behaviour Research and Therapy, 32, 203–215.

Watson, D., & Clark, L. A. (1984). Negative affectivity: The disposition to experience aversive emotional states. Psycho- logical Bulletin, 96(3), 465–490.

Weck, F., Grikscheit, F., Höfling, V., Kordt, A., Hamm, A. O., Gerlach, A. L., et al. (2016). The role of treatment de- livery factors in exposure-based cognitive behavioral ther- apy for panic disorder with agoraphobia. Journal of Anxiety Disorders, 42, 10–18.

Weems, C. F., Hayward, C., Killen, J., & Taylor, C. B. (2002). A longitudinal investigation of anxiety sensitiv- ity in adolescence. Journal of Abnormal Psychology, 111(3), 471–477.

Welkowitz, L., Papp, L., Cloitre, M., Liebowitz, M., Mar- tin, L., & Gorman, J. (1991). Cognitive-behavior therapy for panic disorder delivered by psychopharmacologically oriented clinicians. Journal of Nervous and Mental Disease, 179, 473–477.

Westra, H. A., Stewart, S. H., & Conrad, B. E. (2002). Natu- ralistic manner of benzodiazepine use and cognitive be- havioral therapy outcome in panic disorder and agorapho- bia. Journal of Anxiety Disorders, 16(3), 223–246.

White, K. S., Allen, L. B., Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2010). Attrition in a mul- ticenter clinical trial of panic disorder. Journal of Nervous and Mental Diseases, 198, 665–671.

Panic Disorder and Agoraphobia 63

White, K. S., Payne, L. A., Gorman, J. M., Shear, M. K., Woods, S. W., Saska, J. R., et al. (2013). Does mainte- nance CBT contribute to long-term treatment response of panic disorder with or without agoraphobia?: A random- ized controlled clinical trial. Journal of Consulting and Clinical Psychology, 81, 47–57.

Wilkinson, D. J., Thompson, J. M., Lambert, G. W., Jen- nings, G. L., Schwarz, R. G., Jefferys, D., et al. (1998). Sympathetic activity in patients with panic disorder at rest, under laboratory mental stress, and during panic attacks. Archives of General Psychiatry, 55(6), 511–520.

Williams, K. E., & Chambless, D. (1990). The relationship between therapist characteristics and outcome of in vivo exposure treatment for agoraphobia. Behavior Therapy, 21, 111–116.

Williams, K. E., & Chambless, D. L. (1994). The results of exposure-based treatment in agoraphobia. In S. Friedman (Ed.), Anxiety disorders in African Americans (pp. 149–165). New York: Springer.

Williams, S. L., & Falbo, J. (1996). Cognitive and perfor- mance-based treatments for panic attacks in people with varying degrees of agoraphobic disability. Behaviour Re- search and Therapy, 34, 253–264.

Williams, S. L., & Zane, G. (1989). Guided mastery and stimulus exposure treatments for severe performance anxi-

ety in agoraphobics. Behaviour Research and Therapy, 27, 237–245.

Wittchen, H.-U., Gloster, A. T., Beesdo-Baum, K., Fava, G. A., & Craske, M. G. (2010). Agoraphobia: A review of the diagnostic classificatory position and criteria. Depression and Anxiety, 27, 113–133.

Wolitzky-Taylor, K., Castriotta, N., Lenze, E., Stanley, M. A., & Craske, M. G. (2010). Anxiety disorders in older adults: A comprehensive review. Depression and Anxiety, 27, 190–211.

Wolitzky-Taylor, K., Krull, J. L., Rawson, R., Roy-Byrne, P., Ries, R., & Craske, M. G. (2018). Randomized clinical trial evaluating the preliminary effectiveness of an inte- grated anxiety disorder treatment in substance use dis- order specialty clinics. Journal of Consulting and Clinical Psychology, 86, 81–88.

Zinbarg, R. E., & Barlow, D. H. (1996). Structure of anxiety and the anxiety disorders: A hierarchical model. Journal of Abnormal Psychology, 105(2), 184–193.

Zinbarg, R. E., Barlow, D. H., & Brown, T. A. (1997). Hi- erarchical structure and general factor saturation of the Anxiety Sensitivity Index: Evidence and implication. Psy- chological Assessment, 9, 277–284.

Zoellner, L. A., & Craske, M. G. (1999). Interoceptive ac- curacy and panic. Behaviour Research and Therapy, 37, 1141–1158.

64

Severe, unexpected trauma may occur in less than a minute but have lifelong consequences. The tragedy that is posttraumatic stress disorder (PTSD) is brought into stark relief when the origins of the trauma occur in the context of people’s inhumanity to others. In this chapter, the case of “Tom” illustrates the psychopathology associated with PTSD in all its nuances and provides a very personal account of its impact. In one of any number of events summarized dryly every day in the middle pages of the newspaper, Tom, in the fog of war in Iraq, shoots and kills a pregnant woman and her young child in the presence of her husband and father. The impact of this event devastates him. The sensi- tive and skilled therapeutic intervention described in this chapter is a model for new therapists and belies the notion that, in these severe cases, manualized therapy can be rote and automated. In addi- tion, “cognitive processing therapy,” the evidence-based treatment for PTSD utilized with this case, is sufficiently detailed to allow knowledgeable practitioners to incorporate this treatment program into their practice. This comprehensive treatment program takes advantage of the latest developments in our knowledge of the psychopathology of trauma impact by incorporating treatment strategies specifically tailored to overcome trauma-related psychopathology and does so in the context of the significant changes to diagnostic criteria in DSM-5. —D. H. B.

PREVALENCE

Epidemiological studies document significant rates of trauma exposure and posttraumatic stress disorder (PTSD) across the world (e.g., Atwoli, Stein, Koenen, & McLaughlin, 2015; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kessler, Berglund, et al., 2005; Kes- sler, Chiu, Demler, Merikangas, & Walters, 2005; Kil- patrick, Saunders, Veronen, Best, & Von, 1987; Kulka et al., 1990). In a national (U.S.) random probability sample of 4,008 women, Resnick, Kilpatrick, Dansky, Saunders, and Best (1993) found a high rate of trauma experiences (69%). When they extrapolated their re- sults to the U.S. population based on census statistics for 1989, they estimated that 66 million women in the United States had experienced at least one major trau-

matic event. Of those who had experienced a criterion A stressor, Resnick and colleagues found the following lifetime PTSD rates: completed rape, 32%; other sexual assault, 31%; physical assault, 39%; homicide of fam- ily or friend, 22%; any crime victimization, 26%; and noncrime trauma (e.g., natural and manmade disasters, accidents, injuries), 9%.

In the first large national civilian prevalence study of the psychological effects of trauma, Kessler and col- leagues (1995) surveyed a representative U.S. national sample of 5,877 persons (2,812 men and 3,065 women). They assessed 12 categories of traumatic stressors and revealed that a majority of people had experienced at least one major traumatic event. They found that, whereas 20.4% of women and 8.2% of men were likely to have PTSD following exposure to trauma, the rates

C H A P T E R 2

Posttraumatic stress Disorder

Candice M. Monson Philippe Shnaider Kathleen M. Chard

Posttraumatic Stress Disorder 65

for specific traumas were often much higher. For ex- ample, rape was identified as the trauma most likely to lead to PTSD among men, as well as women. Moreover, 65% of men and 46% of women who identified rape as their most distressing trauma were diagnosed with PTSD. Among men who identified other traumas as most distressing, the probability of having PTSD was 39% for those with combat exposure, 24% for those who suffered childhood neglect, and 22% of those who experienced childhood physical abuse. Among women, aside from rape, PTSD was associated with physical abuse in childhood (49%), threat with a weapon (33%), sexual molestation (27%), and physical attack (21%). As with Resnick and colleagues’ (1993) study, accidents and natural disasters were much less likely to precipitate PTSD among men and women. On the other hand, Norris (1992) pointed out that although motor vehicle accidents (MVAs) occur less frequently than some trau- mas (e.g., tragic death or robbery) and are less traumatic than some events (sexual and physical assault), when both frequency and impact are considered together, MVAs may be the single most significant event. The lifetime frequency of MVAs is 23%, and the PTSD rate is 12%, which results in a rate of 28 seriously distressed people for every 1,000 adults in the United States, just from one type of event. Kessler, Berg lund, and colleagues (2005) reported on another large National Comorbidity Survey with over 9,200 respondents. The overall prevalence of PTSD was 6.8% in this study; this compares to the 7.8% population prevalence reported in the 1995 study.

Atwoli and colleagues (2015) reviewed PTSD preva- lence from a more global perspective. They noted that the rates of experiencing trauma, and even the type of trauma experienced, can vary significantly by country or region, often due to social or political reasons (e.g., civil war or state-sanctioned discrimination). They found that trauma exposure rates were higher in lower- income countries, and PTSD rates were highest in post- conflict settings. Of the countries surveyed, most re- ported global lifetime rates between 1.3% (Japan) and 2.4% (Italy), with Northern Ireland reporting the high- est rate of 8.8%. Using 26 population surveys from the World Health Organization, Koenen and colleagues (2017) found an overall lifetime PTSD prevalence of 5.6% in those who had been exposed to a traumatic event.

The largest study of combat veterans to date, the National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990), was mandated by the

U.S. Congress in 1983 to assess PTSD and other psy- chological problems following the Vietnam War. Dur- ing the years of the war, over 8 million people served in the U.S. military. Of those, 3.1 million served in Vietnam (theater veterans) and the remainder served in other areas abroad or in the U.S. (era veterans). Women comprised 7,200 of those serving in Vietnam, and over 255,000 of those serving elsewhere during the Vietnam era. The NVVRS conducted in-depth interviews and assessments with three groups: 1,632 Vietnam theater veterans, 716 Vietnam era veterans, and 668 nonvet- erans/civilian counterparts, for a total of 3,016 partici- pants.

The results of the NVVRS indicated that the major- ity of Vietnam theater veterans made a successful read- justment to civilian life and did not suffer from PTSD or other problems. However, the researchers also found that 31% of men and 27% of women veterans had a diagnosis of PTSD at some time during their lives. Fur- thermore, 15% of men and 9% of women veterans had PTSD at the time of the study, over a decade after the end of the war. These rates translated to 479,000 Viet- nam veterans with current PTSD at the time that the study was conducted.

Data from the NVVRS were reevaluated using very strict criteria that only included those incidents that could be verified through historical records. Dohren- wend and colleagues (2006) found very little falsifica- tion of events and a strong relationship between the amount of trauma exposure and rates of PTSD (i.e., dose–response relationship). They did, however, find lower rates of PTSD after controlling for people who developed PTSD before or after their deployment to Vietnam and eliminating those people with unverifi- able events. Using these stricter criteria, they found that 18.7% of the veterans met criteria for war-related PTSD at some point, and 9.1% still had PTSD when assessed 11 to 12 years later. These rates should be con- sidered minimum likelihood rates given that people can be traumatized by events that may not be verifiable in historical accounts of war (e.g., rape, accidents). A follow-up study, the National Vietnam Veterans Lon- gitudinal Study (NVVLS; Marmar et al., 2015), evalu- ated the long-term effects of trauma exposure in the same sample. The researchers were able to obtain data from 78.8% of the original sample (N= 1,450), and they found a current PTSD rate of 4.5% and a lifetime rate of 17%, 40 years after the war had ended.

The wars in Iraq and Afghanistan saw the first at- tempts to assess PTSD during a war (Hoge et al., 2004;

66 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Hoge, Auchterlonie, & Milliken, 2006). Hoge and his colleagues (2004) studied 2,530 Army soldiers and Marines before and 3,671 after deployment to Iraq or Afghanistan. They found that mental health problems were significantly greater among those who returned from deployment than among those not yet deployed, and that mental health problems were greater in those who deployed to Iraq compared with Afghanistan. Prior to deployment, 9% of the service personnel ex- ceeded the self-reported PTSD symptom cutoff score used for likely PTSD, whereas 11.5% of those deployed to Afghanistan and 18–20% of those deployed to Iraq exceeded the cutoff. There was a linear relationship be- tween the number of firefights reported and the sever- ity of PTSD. Being wounded or otherwise physically injured was also associated with greater PTSD symp- tomatology.

Because the U.S. military began screening all mili- tary personnel for PTSD following deployment, a population-based study of 303,905 Army soldiers and Marines who deployed to Afghanistan, Iraq, or other locations could be conducted for a 1-year period (May 2003 to April 2004; Hoge et al., 2006). As with the pre- vious report, servicemen and women were more likely to report mental health problems after serving in Iraq (19.1%) than after serving in Afghanistan (11.3%) or other locations (8.5%). In this study, they also assessed 32,500 women, comprising 10.7% of the total sample. There was an overall gender difference in mental health concerns, with 23.6% of women compared with 18.6% of men reporting a mental health concern. However, this gender comparison did not take into account pre- existing traumas or PTSD, exposure to combat traumas or sexual assault, or other variables that might explain these differences (Street, Gradus, Vogt, Giasson, & Resick, 2013).

The National Health Study for a New Generation of U.S. Veterans (NewGen; Dursa, Reinhard, Barth, & Schneiderman, 2014) was launched by the U.S. De- partment of Veterans Affairs to determine the rates of PTSD in Iraq and Afghanistan veterans (15.8%) com- pared with nondeployed veterans (10.9%). They found higher rates of PTSD among African Americans (odds ratio [OR] = 1.61), those who served in the Army (OR = 2.67) and those on active duty (OR = 1.69). A meta- analysis (Fulton et al., 2015) of 33 studies published between 2007 and 2013 revealed a PTSD prevalence rate among veterans who served in Iraq and/or Afghan- istan of around 23% (range 1.4–60%). The authors found that disparities in prevalence were often related

to methods of obtaining diagnosis, anonymity of re- porting, degree of combat exposure, and military sta- tus (e.g., active duty vs. reserve). In keeping with prior research, non-White veterans were more likely to have a diagnosis of PTSD; however, in this study, men were more likely than women to have PTSD.

THEORETICAL MODELS

As researchers and clinicians began to study and treat survivors of rape trauma and Vietnam veterans in the 1970s, they began to draw on learning theory as an ex- planation for the symptoms they were observing. Mow- rer’s two-factor theory (1947) of classical and operant conditioning was first proposed to account for post- trauma symptoms (Becker, Skinner, Abel, Axelrod, & Cichon, 1984; Holmes & St. Lawrence, 1983; Keane, Zimering, & Caddell, 1985; Kilpatrick, Veronen, & Best, 1985; Kilpatrick, Veronen, & Resick, 1982). Clas- sical conditioning was used to explain the high levels of distress and fear observed in trauma victims in reaction to trauma-related stimuli. Operant conditioning ex- plained the onset of PTSD avoidance symptoms, as well as the maintenance of fear over time, despite the fact that the unconditioned stimulus, the traumatic stressor, does not recur. Because the trauma memory and other cues (conditioned stimuli) elicit fear and anxiety (con- ditioned emotional responses), people avoid (or escape from) these cues, and the result is a reduction in fear and anxiety. In this manner, avoidance of the condi- tioned stimuli is negatively reinforced, which prevents deterioration of the link between the trauma cues and anxiety that would normally be expected without rep- etition of the trauma itself.

Although learning theory accounts for much of the onset and maintenance of the fear and avoidance in PTSD, it does not fully explain intrusion symptoms. Based on Lang’s (1977) information processing theory of anxiety development, Foa, Steketee, and Rothbaum (1989) suggested that PTSD emerges due to the devel- opment of a fear network in memory that elicits escape and avoidance behavior. Mental fear structures include stimuli, response, and meaning elements. Anything as- sociated with the trauma may elicit the fear structure or schema and subsequent avoidance behavior. The fear network in people with PTSD is thought to be stable and to generalize broadly, so that it is easily accessed. Chemtob, Roitblat, Hamada, Carlson, and Twentyman (1988) proposed that these structures are always at least

Posttraumatic Stress Disorder 67

weakly activated in individuals with PTSD and guide their interpretation of events as potentially dangerous. When the fear network is activated by reminders of the trauma, the information in the network enters con- sciousness (intrusive symptoms). Attempts to avoid this activation result in the avoidance symptoms of PTSD. According to information processing theory, repetitive exposure to the traumatic memory in a safe environ- ment results in habituation of fear and subsequent changes in the fear structure. As emotion decreases, clients with PTSD begin to modify their meaning el- ements spontaneously, and consequently change their self-statements and reduce their generalization.

Social-cognitive theories are also concerned with in- formation processing, but they focus on the semantic content of the survivor’s belief system and the adjust- ments that are necessary to reconcile a traumatic event with prior beliefs and expectations. The first and most influential cognitive theorist, Horowitz (1986), moved from a more psychodynamic view to a cognitive pro- cessing theory. Horowitz proposed that processing is driven by a “completion tendency,” the psychological need for new, incompatible information to be inte- grated with existing beliefs. The completion tendency keeps the trauma information in active memory until the processing is complete and the event is resolved. Horowitz also theorized that there is a basic conflict between the person’s need to resolve and reconcile the event into his/her history, and the desire to avoid emo- tional pain. When images of the event (flashbacks, nightmares, intrusive recollections), thoughts about the meanings of the trauma, and emotions associated with the trauma become overwhelming, psychological defense mechanisms take over, and the person exhibits numbing or avoidance. Horowitz suggested that a per- son with PTSD oscillates between phases of intrusion and avoidance, and that if successfully processed, the oscillations become less frequent and less intense. Ac- cording to this theory, chronic PTSD occurs because the trauma remains in active memory without becom- ing fully integrated; therefore, it is still able to stimulate intrusive and avoidant reactions.

Several other social-cognitive researchers and theo- rists propose that basic assumptions about the world and oneself are “shattered” following exposure to a trau- matic event. Constructivist theories are based on the idea that people actively create their own internal rep- resentations of the world (and themselves). New experi- ences are assigned meaning based on a person’s model of the world (Janoff-Bulman, 1985, 1992; Mahoney &

Lyddon, 1988; McCann & Pearlman, 1990). The task for recovery is to reconstruct fundamental beliefs and establish equilibrium. Janoff-Bulman (1985) suggested that this process is accomplished by reinterpreting the event to reduce the distance between the prior beliefs and the new beliefs. Other theorists have proposed that if one’s preexisting beliefs are particularly positive or particularly negative, then more severe PTSD symp- toms result (McCann & Pearlman, 1990; Resick, Mon- son, & Chard, 2017; Resick & Schnicke, 1992). Foa et al. (1989) focused particularly on beliefs regarding the predictability and controllability of the trauma, where- as McCann and Pearlman (1990) proposed that several areas of cognition might be either disrupted or seem- ingly confirmed, that is, beliefs regarding safety, trust, power/control, esteem, and intimacy. Resick, Monson, and Chard (2017) model focuses particularly on the “just world” myth and the human desire (and illusion) that we can predict and control our lives.

In a social-cognitive model, affective expression is needed, not for habituation but for the trauma memory to be processed fully. It is assumed that the natural af- fect, once accessed, dissipates rather quickly, and that the work of accommodating the memory with beliefs can begin. Once faulty beliefs regarding the event (e.g., inappropriate self- or other-blame) and overgeneralized beliefs about oneself and the world (e.g., safety, trust, power/control, esteem, intimacy) are challenged, then the secondary or manufactured emotions also decrease, along with the intrusive reminders. The fact that both stress inoculation training without trauma exposure ex- ercises (Foa, Rothbaum, Riggs, & Murdock, 1991; Foa et al., 1999) and cognitive therapy without written or oral accounts of the traumatic experience (e.g., Ehlers et al., 2003; Resick et al., 2008; Resick, Wachen, et al., 2017; Tarrier et al., 1999) are effective treatments for PTSD undermines the assumption that habituation is the sole mechanism of change. In fact, recent work has suggested that cognitive change may be a central mech- anism by which exposure-based therapies treat PTSD (e.g., Zalta et al., 2014).

Ehlers and Clark (2000) proposed a cognitive model of PTSD that focuses on perceived threat and memory. Although the event occurred in the past, Ehlers and Clark propose that people with PTSD are unable to see the event as time-limited and assume that it has larger implications for the future. Individuals with PTSD ap- praise the event such that they believe themselves to be currently at risk. There are several ways in which this misappraisal happens. One is to overgeneralize based

68 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

on the event and assume that normal activities are more dangerous than they objectively are. Individuals may overestimate the probability that the event will recur. After the trauma happens, they may misconstrue the meaning of their PTSD symptoms such that they per- ceive themselves to be in greater danger (false alarms are assumed to be true alarms) or interpret their symp- toms to mean that they cannot cope with events in the future.

Ehlers and Clark’s (2000) cognitive theory also considers the apparent memory disturbance that oc- curs, such that persons with PTSD may have trouble intentionally accessing their memory of the event but have involuntary intrusions of parts of the event. They propose that because memory encoded at the time of the trauma is poorly elaborated and integrated with other memories with regard to details, context of time, sequence, and so forth, this might explain why people with PTSD have poor autobiographical memory, yet may be triggered to have memory fragments that have a here-and-now quality (no time context) or lack appro- priate posttrauma appraisals (e.g., “I did not die”). Like the emotional processing models, Ehlers and Clark also propose that strong associative learning is paired with fear responses and may generalize. In response to perceptions of threat, people with PTSD adopt vari- ous maladaptive coping strategies, depending on their appraisals. For example, people who believe they will go crazy if they think about the traumatic event try to avoid thoughts about the trauma and keep their minds occupied as much as possible. Someone who believes he/she must figure out why the traumatic event oc- curred to keep it from happening again will ruminate about how it could have been prevented. Those who think they were being punished for their actions may become immobilized and be unable to make decisions. These maladaptive strategies, most often avoidance be- haviors, may (1) increase symptoms, (2) prevent change in negative appraisals, or (3) prevent change in the trau- ma memory.

In an attempt to reconcile the theories of PTSD, Brewin, Delgleish, and Joseph (1996; Brewin, Gregory, Lipton, & Burgess, 2010) proposed a dual-representa- tion theory that incorporates both information pro- cessing and social-cognitive theories, and incorporates research and theory from neuroscience with regard to memory. They suggest that the concept of a single emo- tional memory is too narrow to describe the full range of memory that has been evident in research and clini- cal observations. Based on prior research, they proposed

that sensory input is subject to both low-level and high- level memory and representation. High-level memory and representations comprise information that is con- textually bound and represented (contextual memory [C-memory]). Contextual representations (C-reps) of these memories can be deliberately retrieved and ma- nipulated. C-reps contain some sensory information, information about emotional and physical reactions, and the personal meaning of the event. Although C- reps might be reasonably detailed, they may also be very selective, because attention is narrowed under con- ditions of stress, and short-term memory capacity may be decreased.

In contrast, low-level memory and representation consists of sensory and affective elements (sensation- based memory [S-memory]). Representations of these memories (S-reps) cannot be accessed deliberately and are not as easily altered or edited as the more explic- itly accessed C-reps. Accordingly, S-reps are typically experienced as intrusive sensory images or flashbacks accompanied by physiological arousal.

Dual-representation theory posits two types of emo- tional reactions: One type is conditioned during the event (e.g., fear, anger), recorded in the S-memory, and activated along with reexperienced sensory and physi- ological information. The other type, secondary emo- tions, result from the consequences and implications (meaning) of the trauma.

Brewin and colleagues (1996) proposed that emo- tional processing of trauma has two elements. One element of the processing is the activation of S-reps (as suggested by information processing theories), the purpose of which is to aid in cognitive readjustment by supplying detailed sensory and physiological informa- tion concerning the trauma. The activation of S-reps may eventually diminish in frequency when they are blocked by the creation of new S-reps, or when they are altered by the incorporation of new information. Even- tually, if the S-reps are replaced or altered sufficiently, there is a reduction in negative emotions and a subse- quent reduction in attentional bias and accessibility of the memory.

The second element (as proposed by the social- cognitive theorists) is the conscious attempt to search for meaning, to ascribe cause or blame, and to resolve conflicts between the event and prior expectations and beliefs. The goal of this process is to reduce the nega- tive emotions and to restore a sense of relative safety and control in one’s environment. To obtain this second goal, the traumatized person may have to edit his/her

Posttraumatic Stress Disorder 69

autobiographical memory (C-reps) to reconcile con- flicts between the event and his/her belief system.

Brewin and colleagues (1996) suggest that for cases in which the emotions are primary and driven by S- reps, exposure therapy may be all that is needed. How- ever, when secondary emotions such as guilt or shame are present, cognitive therapy may be needed. Although both exposure and cognitive therapies have been found to be effective in treating PTSD, no research thus far has matched types of therapy to client profiles.

Another multirepresentational cognitive model called the schematic, propositional, analogue, and as- sociative representational system (SPAARS; Dalgleish, 2004) was originally proposed to explain everyday emotional experience and was then applied to PTSD. This model also endeavors to encompass previous theo- ries. The model proposes four types or levels of mental representation systems: schematic, propositional, ana- logue, and associative. The schematic level represents abstract generic information, or schemas. Proposition- al-level information has verbally accessible meanings, similar to C-reps, whereas information at the analogue level is stored as “images” across all types of sensory sys- tems, similar to S-reps. Associative representations are similar to the fear structures hypothesized in emotional processing theory as representing the connections be- tween other types of representations. In the SPAARS model, emotions are generated through two routes. One, similar to Ehlers and Clark’s (2000) cognitive model, is through appraisals at the schematic level, in which events are compared against important goals. A person appraises an event to be threatening if it blocks an important goal, then experiences fear. Because trau- matic events are threats to survival, they are appraised as threatening and elicit fear. The second route to emo- tion is through associative learning, which is automatic and similar to the fear activation described by Foa and colleagues (1989).

Within the SPAARS model, a traumatic event trig- gers intense appraisal-driven fear, helplessness, or hor- ror, as well as a range of other emotions. Information about the traumatic event is encoded in the schematic, propositional, and analogue levels simultaneously. Be- cause the memory of the traumatic event represents an ongoing threat to goals, the person is left with low-level fear activation, cognitive bias to attend to threat ap- praisals, and intrusive sensory images and appraisals. The trauma memory exists across different levels of mental representation but is unincorporated into the person’s larger mental representations; the memory may

be elicited as flashbacks or nightmares. Such strong memory and emotional intrusions result in efforts to cope through avoidance.

Research on intimate relationship problems associ- ated with PTSD (Taft, Watkins, Stafford, Street, & Monson, 2011) has highlighted the importance of the interpersonal context in which PTSD exists and has led to the development of treatment innovations to address these concerns (e.g., Monson & Fredman, 2012). In this vein, interpersonal models of PTSD have been pro- posed to account for the occurrence of, maintenance of, and reciprocal associations between PTSD and inter- personal relationship problems. These models include cognitive-behavioral interpersonal theory (C-BIT) of PTSD (Monson, Fredman, & Dekel, 2010), as well as the couple adaptation to stress (CATS) model (Nelson Goff & Smith, 2005), which frame PTSD within a dy- adic relationship. C-BIT proposes that individual-level cognitive, behavioral, and emotional factors within each partner, as well as shared relationship-level factors that exist within the dyadic relationship, serve to in- fluence recovery, the psychological well-being of one’s partner, and relationship functioning following expo- sure to a traumatic event. Each factor is considered to uniquely contribute to, as well as interact with, other factors in the model to impact each partner and their relationship adjustment (Monson et al., 2010). Similar- ly, the CATS model proposes three factors that influ- ence adaptation posttrauma: each partner’s individual functioning, predisposing factors and resources, and couple-level functioning. These factors are considered to interact with one another to influence each partner’s posttraumatic reactions (Nelson Goff & Smith, 2005). Both C-BIT and the CATS model highlight the inter- personal nature of PTSD, proposing bidirectional re- lationships between both individual psychopathology and relationship functioning.

ASSESSMENT

Any comprehensive assessment of PTSD must capture whether or not a life event meets the requirements of a traumatic stressor (criterion A), as well as the presence and severity of the 20 associated symptoms (criteria B–E) listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; Ameri- can Psychiatric Association, 2013). Although interview- based measures are considered the “gold standard” for assessing PTSD, a number of self-report measures have

70 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

been developed in recent years to provide a quicker, less resource-heavy method for assessing PTSD.

Assessment of Traumatic Events

The first essential step in the assessment of PTSD is to identify traumas in the patient’s history. Often this is difficult to achieve, because many trauma survivors, especially rape and child sexual abuse trauma survivors, do not spontaneously disclose their trauma history. This is consistent with general patterns of avoidance of trauma-related reminders and may reflect shame, embarrassment, and self-blame regarding the inci- dents. Even when seeking treatment for mental health problems, trauma survivors often fail to recognize that their psychological difficulties may be associated with their trauma histories. There are other reasons survi- vors might not be forthcoming with this information, including fear of a negative reaction to disclosure, es- pecially if previous disclosure has resulted in disbelief or blame. Additionally, many trauma survivors do not recognize or label their experience as “trauma,” “rape,” or “abuse,” especially if the assailant was an acquain- tance or a relative, or if the trauma was experienced by many people, as in combat. Finally, in the absence of a strong alliance with the therapist, many people choose not to disclose such deeply personal information. It is therefore important for the clinician to forge a positive alliance as early as possible and be forthcoming about the purpose of the questioning, any limits of confiden- tiality, and how obtained information may be used (i.e., diagnosis, treatment planning, research purposes).

In terms of questions regarding the presence of trau- matic experiences, a behavioral, descriptive prompt such as “Has anyone ever touched you when you did not want them to or made you have unwanted sexual contact?” is more detailed and is preferable to asking, “Have you ever been raped?” In the latter case, someone who is married (or dating) and has been sexually assaulted may say “no,” because “rape” might not be a term that they associate with forced sex by one’s partner. The same problem may exist with child abuse. A client may indicate that he was not abused as a child but readily admit, when asked, that a parent whipped him with a belt until he had welts. In general, it is recommended that clinicians always begin with broad questions about experiences, then move to more specific, behaviorally anchored questions.

Some structured interviews have been developed with the primary purpose of assessing traumas in more

detail. The Potential Stressful Events Interview (Kil- patrick, Resnick, & Freedy, 1991) has behaviorally an- chored questions that are particularly good for assessing interpersonal victimization, as well as a range of other traumatic stressors. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2018), reviewed in more detail later, includes a self-report screening scale (Life Events Checklist), followed by in- terviewer prompts to establish whether a trauma meets criterion A.

In addition to the Life Events Checklist, the Brief Trauma Questionnaire (BTQ; Schnurr, Spiro, Viel- hauer, Findler, & Hamblen, 2002) the Trauma History Questionnaire (THQ; Hooper, Stockton, Krupnick, & Green, 2011), the Traumatic Life Events Questionnaire (TLEQ; Kubany et al., 2000), and the Trauma History Screen (Carlson et al., 2011) all assess a number of dif- ferent types of trauma, including accidents, natural di- sasters, sexual assault, and threats of, or actual, physical harm. The Posttraumatic Stress Diagnostic Scale (PDS; Foa et al., 2016) has two sections prior to assessment of symptoms. The first section assesses 13 potentially traumatic events, whereas the second section has ques- tions to determine whether an event meets criterion A.

Structured Diagnostic Interviews

The CAPS-5 (Weathers et al., 2018), a “gold-standard” assessment measure, is one of the most widely used di- agnostic interviews for PTSD. In addition to a detailed assessment of individual trauma experiences with the Life Events Checklist, it assesses both severity and fre- quency of symptoms using specific criteria related to behavior change following the traumatic event. The CAPS-5 also includes questions on associated features of PTSD, including dissociation, survivor guilt, and so- cial and occupational impairment. The CAPS-5 has a large body of research demonstrating its reliability and validity across a wide variety of trauma populations. One disadvantage is its length of administration, an av- erage of about 45 minutes, and the need for administra- tion by a mental health clinician.

The Structured Clinical Interview for DSM-5 (SCID-5; First, Williams, Karg, & Spitzer, 2016), one of the most widely used diagnostic interview scales, in- cludes a Trauma- and Stressor-Related Disorders mod- ule, and was developed for use by experienced clini- cians. Although it assesses all of the symptoms of PTSD and can provide information about whether an individ-

Posttraumatic Stress Disorder 71

ual meets criteria for the diagnosis, it is important to note that this interview does not assess for frequency or severity of individual symptoms. Thus, one can only determine a count of the number of positive symptoms, thereby limiting its utility in research or clinical set- tings in which a continuous measure of severity may be desirable.

The PTSD Symptom Scale—Interview for DSM-5 (PSS-I-5; Foa et al., 2016) has a particular advantage in its ease of administration and brevity. The PSS-I-5 consists of 24 items that match the 20-symptom PTSD criteria in DSM-5, as well as questions related to the distress level, onset, and duration of symptoms. The PSS-I-5 can result in continuous scores to reflect fre- quency of symptoms or to determine PTSD diagnosis.

Self‑Report Instruments

There are a number of self-report scales of PTSD that have good psychometric properties and are consistent with the DSM-5 nomenclature. The two most widely known are the PDS-5 (Foa et al., 2016) and the PTSD Checklist–5 (PCL-5; Weathers et al., 2013). The 20- item PCL-5 also has a longer version that includes an exploration of criterion A experiences. With any self- report measure, there are limitations to relying exclu- sively on questionnaires for diagnosis or symptom se- verity. Used in conjunction with structured interviews, however, they can be useful for screening purposes and for demonstrating changes over time as a result of a particular intervention. There is also evidence that self- report and clinician interview of PTSD symptoms are correlated over the course of treatment (Monson et al., 2008).

In response to a need to screen large numbers of people for PTSD after combat or disasters, or in medi- cal settings when time is limited, a brief PTSD screen has been developed for use in primary care settings or for large-group administrations, such as those with military personnel following deployment. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5; Prins et al., 2016) was developed for such a purpose and is now being used routinely in the United States with anyone returning from military deployment or receiving any kind of treatment in the VA medical system (Hoge et al., 2006). This scale includes an initial item to deter- mine trauma exposure, followed by five yes–no items that represent the five major symptom clusters found in most PTSD factor-analytic studies that separate effort-

ful avoidance from numbing. A cutoff of 3 is recom- mended as an optimally efficient score for both men and women, and a cutoff of 2 is recommended for max- imum sensitivity.

Other Assessment Considerations

The ideal assessment for PTSD includes measure- ment in multiple response channels, including bio- logical changes or responses. This is especially true in PTSD assessment, because physiological reactivity to trauma cues is one of the criteria of the disorder. Re- search attempting to identify biological underpinnings for PTSD, including organic, cellular, and molecular levels, has exploded over the past 20 years, with a po- tential goal of establishing a biological test for PTSD. This work has focused on the areas of structural and functional neuroimaging, endocrinological, genetic and molecular biological studies. Although the state of the research, costs, required technology, and neces- sary expertise may prevent psychophysiological testing in clinical settings, it is important to be aware of the research in this area and to be alert to obvious physi- ological symptoms in patients when talking about their trauma experiences (e.g., signs of agitation, sweat- ing, flushing). Research has demonstrated consistent group differences in physiological reactivity between individuals with and without PTSD when exposed to trauma-related stimuli, such as through the use of in- dividualized trauma scripts (for a systematic review of this body of research, see Pitman et al., 2012). Vietnam veterans with PTSD have consistently been found to be more reactive to combat imagery than combat veterans without PTSD, even when the comparison samples had other anxiety disorders or other psychological prob- lems (Keane et al., 1998; Pitman, Orr, Forgue, & Alt- man, 1990). Similar results have been found in people with PTSD as a result of MVAs and child sexual abuse (Blanchard, Hickling, Buckley, & Taylor, 1996; Orr et al., 1998).

In general, there are two major aims in assessment in clinical practice: diagnosis and treatment plan- ning. Whether the primary purpose of assessment is diagnosis or treatment planning, a multidimensional, multimethod approach is desirable. Certainly, for the purposes of treatment, ongoing assessment of symp- tom patterns and treatment effectiveness is essential. In addition, given the likelihood of comorbid conditions and problems, objective assessment of these potential

72 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

symptoms and problems is recommended. Given the significant comorbidity between PTSD and depressive disorders, and the role of depression in increasing sui- cide risk in clients with PTSD, depression should also be assessed in patients with a probable PTSD diagnosis (Panagioti, Gooding, & Tarrier, 2012; Stanley, Rogers, Hanson, Gutierrez, & Joiner, 2019). Second, a growing body of research suggests that individuals with PTSD are at increased risk of perpetrating physical aggression against others. McFall, Fontana, Raskind, and Rosen- heck (1999) found that male Vietnam veteran inpatients with PTSD were more likely than inpatients without PTSD or a community sample of Vietnam veterans to perpetrate acts of violence toward objects or others. This finding was replicated in a survey of 1,388 veter- ans from the wars in Iraq and Afghanistan, showing that veterans with PTSD and alcohol misuse (35.9%) and those with PTSD alone (10%) were more likely to commit violence than those without a PTSD diagnosis (5.3%; Elbogen et al., 2014). Given also that one of the DSM-5 symptoms of PTSD is outbursts of anger, it is important that history of aggressive acts (under crite- rion E), as well as current impulses toward aggression (e.g., angry mood in criterion D), be carefully assessed and addressed.

TREATMENT

Types of Therapy for PTSD

Treatment guidelines and reviews have identified four general types of evidence-based therapies for PTSD: exposure-based treatments, cognitive therapy, eye movement desensitization and reprocessing (EMDR) and skills-focused treatments (e.g., Ostacher & Cifu, 2019; Schnyder & Clotire, 2015). In addition, there are several promising treatments that have done well in ini- tial studies but need additional independent research to determine their efficacy, including cognitive-behavioral conjoint therapy (CBCT; Monson & Fredman, 2012), dialectical behavior therapy/prolonged exposure (DBT/ PE; Harned, Korslund, & Linehan, 2014), interperson- al psychotherapy (IPT; Bleiberg & Markowitz, 2019), narrative exposure therapy (NET; Schauer, Neuner, & Elbert, 2011), skills training in affective and inter- personal regulation (STAIR; Cloitre, Koenen, Cohen, & Han, 2002), and written exposure therapy (WET; Sloan & Marx, 2019). Before reviewing the research on treatment outcomes for PTSD, we describe the most empirically supported treatment protocols.

Exposure Techniques

Beginning in the early 1980s, forms of exposure thera- py were investigated as a treatment for PTSD. Although systematic desensitization (SD) has been demonstrated to be effective for treating PTSD in a number of case study reports and controlled studies, it was not widely adopted as a preferred treatment (Bowen & Lambert, 1986; Brom, Kleber, & Defares, 1989; Shalev, Orr, & Pitman, 1992). Because people with PTSD may fear and avoid a wide range of trauma-related stimuli, SD may require a number of hierarchies that can be quite inefficient.

Extended exposure to feared cues or to the trauma memory itself is a more efficient treatment and has been employed more widely. Known variously as direct therapeutic exposure (DTE), flooding, or prolonged ex- posure (PE), these exposure techniques require clients to confront feared situations in vivo, to imagine them- selves in a fear-producing situation, or to recall their particular trauma for extended periods of time. In ad- dition, several researchers have demonstrated that ima- ginal exposure can be facilitated using virtual reality techniques (virtual reality exposure therapy [VRET]; Kothgassner et al., 2019; Rothbaum, Hodges, Ready, Graap, & Alarcon, 2001). VRET is often utilized with veterans with PTSD and allows them to take a virtu- al helicopter trip in Vietnam, complete with gunfire, or drive a vehicle in Middle Eastern streets, as well as experience other stimuli that may evoke memories of traumatic events.

Foa and colleagues (1991) were the first to focus ex- tensively on the specific trauma memory rather than fear-producing stimuli. PE is conducted individually in eight to 15 weekly or biweekly 90-minute sessions. The first two sessions are for information gathering, treatment planning, and explanation of the treatment rationale. A hierarchical list of major stimuli that are feared and avoided is created. Clients are instructed to confront feared cues for at least 30–45 minutes a day, starting with a moderately anxiety-provoking stimulus on the hierarchy. Beginning with Session 3, the trauma scene is relived in imagination, and the client is asked to describe it aloud in the present tense. The level of detail is left to the client for the first two exposures, but thereafter he/she is encouraged to include more and more detail about external cues and internal cues, such as thoughts, physiological responses, and feared consequences. Descriptions are repeated several times each session (for 30–45 minutes) and audio-recorded.

Posttraumatic Stress Disorder 73

Clients are assigned as homework listening to the re- cording and engaging in in vivo tasks. Care is taken in sessions to ensure that the client’s anxiety decreases be- fore the session is terminated, aided by the therapist, if necessary (Foa, Hembree, Rothbaum, & Rauch, 2019).

Cognitive Interventions

Cognitive therapy for PTSD has generally taken two forms. One form is more present-focused and typically uses daily diaries or monitoring forms to elicit current thoughts that the client has recorded during the week. These homework sheets form the basis of the cogni- tive interventions that occur during treatment through the use of teaching and Socratic questioning. Clients are taught to identify and to dispute their unrealistic or exaggerated thoughts about themselves, the world, and their futures with more probabilistic reasoning and evidence-based argument. Examples of research- ers who have used this model of cognitive restructuring are Blanchard and colleagues (2003) and Foa and col- leagues (2005).

The other form of cognitive therapy, trauma-focused and constructivist (e.g., Ehlers & Clark, 2000; Resick et al., 2017), focuses on the particular meanings that the traumatic event(s) has for the client and how those interpretations of the event contradict or seemingly confirm previously held beliefs about self and others. These distorted assumptions about the event (e.g., “I should have been able to stop the event, so it is my fault that it happened”) may maintain a belief in a just world or a sense of controllability, but at the cost of reduced self-esteem, shame, or guilt. The focus of treatment is on how clients may have distorted the event itself to maintain prior beliefs about justice or the role of oth- ers (assimilation), or conversely, how they may have changed their beliefs about themselves and the world too much (overaccommodation) in an attempt to regain a sense of control or safety in the present or the future (“I cannot trust other people at all any more”). Treat- ment includes Socratic dialogue and use of cognitive worksheets to teach clients to challenge their thinking about their traumatic events and the implications they have constructed.

Cognitive processing therapy (CPT) initially was de- veloped specifically to treat the PTSD in sexual assault survivors (Resick & Schnicke, 1992, 1993), but it has since been updated and applied to a range of trauma survivors (Resick et al., 2017). CPT, which can be de- livered in individual, group, or combined formats, is a

12-session (with option to end earlier or later depending on symptom response) structured therapy program that is predominantly a cognitive therapy. After an intro- duction to PTSD symptoms and the therapy, clients are asked to write an Impact Statement, which is a descrip- tion of how their most distressing traumatic event has affected them. Clients are asked to focus on any guilt or self-blame they experience regarding the trauma and the effects of the event on their beliefs about self and others. This statement is used to understand how they may have distorted the cause of the event or overgener- alized its meaning, such that their functioning has been compromised. For example, if someone thinks that he/ she should have been able to stop the event, then the individual might feel guilt afterward. If a client has de- cided that the event means no one is to be trusted, then he/she will behave as though this is true. These dis- torted assumptions are labeled as Stuck Points that have prevented the client from recovering and then placed on a log for future examination.

Before challenging Stuck Points in depth, the client is taught to label emotions and recognize the connec- tion among events, thoughts, and feelings. The thera- pist helps the client begin to examine his/her problem- atic thinking about the traumatic event with Socratic dialogue, then teaches the client the skill of challeng- ing thoughts and assumptions with Socratic questions through a series of worksheets. The client is first taught to question a single Stuck Point, then to look for patterns of problematic thinking, and, finally, to generate alter- native, more balanced thoughts about the event itself, then overgeneralized assumptions about self and world. In the last five sessions, clients are provided modules to assist them in thinking about specific themes that are commonly disrupted following traumatic events: safety, trust, power and control, esteem, and intimacy. An al- ternative form of CPT, CPT+A, asks the client to write an account of their most traumatic event after Sessions 3 and 4 and to read it to themselves every day and to the therapist in the following sessions. While reading the account, the client is encouraged to feel his/her natural emotions resonating from the event, and to identify any Stuck Points associated with the event(s).

Eye Movement Desensitization and Reprocessing

Eye movement desensitization and reprocessing (EMDR) is a controversial therapy that evolved not from theory or application of effective techniques for other disorders but from a personal observation. As

74 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

originally developed by Shapiro (2018), EMDR was based on a chance observation that troubling thoughts were resolved when her eyes followed the waving of leaves during a walk in the park. Shapiro developed EMDR on the basis of this observation and argues that lateral eye movements facilitate cognitive processing of the trauma. Subsequently, EMDR has been alterna- tively conceptualized as a cognitive-behavioral treat- ment aimed at facilitating information processing of traumatic events and cognitive interventions for nega- tive, trauma-related cognitions and/or as an exposure therapy focused on replaying the traumatic memories in the mind.

EMDR for PTSD typically follows a course similar to the other trauma therapies, including weekly 60- to 90-minute sessions for up to 3 months. EMDR is an eight-phase treatment that includes history taking, client preparation, target assessment, desensitization, installation, body scan, closure, and reevaluation of treatment effects. Most EMDR sessions include expo- sure and cognitive components, as well as the lateral eye movements. In the basic EMDR protocol, clients are asked to identify and focus on a traumatic image or memory (target assessment phase). Next, the therapist elicits negative cognitions or belief statements about the memory. Clients are asked to assign a rating to the memory and negative cognitions on an 11-point scale of distress and to identify the physical location of the anxiety. The therapist helps clients generate positive cognitions that would be preferable to associate with the memory. These are rated on a 7-point scale of how much the client believes the statement. Once the thera- pist has instructed a client in the basic EMDR proce- dure, he/she is are asked to do four things simultane- ously (desensitization phase): (1) visualize the memory; (2) rehearse the negative cognitions; (3) concentrate on the physical sensations of the anxiety; and (4) visually track the therapist’s index finger. While the client does this, the therapist rapidly moves his/her index finger back and forth from right to left, 30–35 centimeters from the client’s face, with two back-and-forth move- ments per second (there are light bars available to do this). These are repeated up to 24 times. Then, the cli- ent is asked to blank out the memory and take a deep breath. Subsequently, the client brings back the memo- ry and cognitions and rates the level of distress. Sets of eye movements (saccades) are repeated until the distress rating equals 0 or 1. At this point, the client is asked how he/she feels about the positive cognition and gives a rating for it (installation phase).

Skills‑Focused Treatments

Two therapies have focused less on the traumatic memories or thoughts resonating from the memories, and place more emphasis on learning skills to manage clients’ current unhealthy relationships or behavioral interactions. Both therapies have been used as com- parison treatments in outcome studies and have been utilized with varied populations.

STRESS INOCULATION TRAINING

Based on Meichenbaum’s (1985) approach to anxiety, the aim of SIT is to give clients a sense of mastery over their fears by teaching a variety of coping skills. Origi- nally described as an approach specifically for use with rape survivors (Kilpatrick & Amick, 1985; Kilpatrick et al., 1982), SIT has been used with individuals with other traumas, including veterans (Jackson, Baity, Bobb, Swick, & Giorgio, 2019). The approach is tai- lored to the individual problems and needs of each cli- ent, so it is flexible and can be used in individual or group settings. SIT typically lasts around 3 months and includes 60- to 90-minute weekly sessions that are approached in phases. The first phase, preparation for treatment, includes an educational element to provide an explanatory or conceptual framework from which the client can understand the nature and origin of his/ her fear and anxiety, and make sense of the trauma and its aftermath. In SIT, a social learning theory expla- nation is used. Along with this, fear and anxiety reac- tions are explained as occurring along three channels (Lang, 1968): (1) the physical or autonomic channel; (2) the behavioral or motoric channel; and (3) the cogni- tive channel. Specific examples are given for each, and the patient identifies his/her own reactions within each channel. Interrelationships among the three channels are explained and discussed. The second phase of SIT is the training of coping skills directed at each of these channels of response. It includes, in sequence, a defini- tion of the coping skill, a rationale, an explanation of the mechanism by which the skill works, a demonstration of the skill, application by the client of the skill to a prob- lem area unrelated to the target behaviors, a review of how well the skill worked, and, finally, application and practice of the skill with one of the target fears. Skills taught most often for coping with fear in the physical channel are muscle relaxation and breathing control.

For the behavioral channel, covert modeling and role playing are the coping skills usually taught. The

Posttraumatic Stress Disorder 75

client is taught to visualize a fear- or anxiety-provoking situation and to imagine confronting it successfully. For the cognitive channel, the client is taught guided self-dialogue. The client is taught to focus on his/her internal dialogue and trained to label negative, irratio- nal, and maladaptive self-statements. The client is then taught to substitute more adaptive self-verbalizations. Self-dialogue is taught in four categories: preparation, confrontation and management, coping with feelings of being overwhelmed, and reinforcement. For each of these categories, a series of questions and/or statements is generated that encourages the client to assess the ac- tual probability that the negative event will occur, to manage the overwhelming fear and avoidance behavior, to control self-criticism and self-devaluation, to engage in the feared behavior, and finally to reinforce him/ herself for making the attempt and following the steps.

PRESENT-CENTERED THERAPY

Present-centered therapy (PCT; Frost, Laska, & Wampold, 2014; Schnurr et al., 2003) was originally designed as a control condition for treatment outcome studies that accounted for the nonspecific elements of psychotherapy. The main elements of change include psychoeducation regarding the impact of trauma, ex- amination of the present maladaptive relationship or behavioral patterns and problem-solving techniques. The treatment does not involve a direct examination of the traumatic events, and homework is minimal, with a focus only on problem-solving choices identified by the client. The therapy typically entails nine to 15 weekly sessions and can be conducted in an individual or group format.

Evidence for Treatment Efficacy

Meta-analyses and systematic reviews underpinning treatment guidelines have summarized the vast number of clinical trials that have been conducted to investigate the efficacy of various interventions for PTSD. Across meta-analyses, trauma-focused cognitive-behavioral therapies such as exposure therapy, including PE, and cognitive therapy, including CPT, as well as EMDR, have demonstrated significant large effect size increases for the treatment of PTSD (Cusak et al., 2016; Forbes, Bisson, Monson, & Berliner, 2021; Watts et al., 2013). When examining and factoring in the strength of the evidence supporting these treatments, multiple treat- ment guidelines for PTSD have recommended trauma-

focused exposure and trauma-focused cognitive therapy, as well as EMDR, as first line treatments (Department of Veterans Affairs & Department of Defense, 2017; Forbes et al., 2021; National Institute for Health and Care Excellence, 2018; Phoenix Australia Centre for Posttraumatic Mental Health, 2013). In contrast, oth- ers have indicated stronger support for trauma-focused cognitive-behavioral therapies over EMDR (American Psychological Association, 2017).

Meta-analyses have also revealed that trauma-focused cognitive-behavioral therapies and EMDR are sig- nificantly more effective than wait-list and treatment- as-usual conditions, and generally better than therapies designed to control for the essential and nonspecific elements of efficacious psychotherapy (Forbes et al., 2021). Moreover, comparisons of trauma-focused ex- posure and trauma-focused cognitive therapies, as well as trauma-focused cognitive-behavioral therapies and EMDR, have demonstrated equivocal findings (Forbes et al., 2021) or have indicated insufficient evidence to suggest a difference (Cusack et al., 2016).

Evidence for skills-focused interventions, often re- ferred to as non-trauma-focused therapies, which in- clude SIT and PCT, has been more modest in com- parison to that of trauma-focused cognitive-behavioral interventions and EMDR reviewed earlier. Although these interventions have been shown to lead to sig- nificant improvements compared to wait-list and treat- ment-as-usual conditions, the relatively limited number of studies hampers their support (Cusak et al., 2016; Forbes et al., 2021; Watts et al., 2013). Where com- parisons have been possible, evidence supports the use of trauma-focused cognitive-behavioral therapies over PCT (Forbes et al., 2021). Existing treatment guide- lines have been more tentative in their endorsement of these interventions, typically indicating that they may be considered in cases where trauma-focused therapies are unavailable or have not sufficiently addressed symp- toms, as well as in cases in which an individual is un- willing to participate in a trauma-focused therapy for PTSD (Department of Veterans Affairs & Department of Defense, 2017; Forbes et al., 2021; National Institute for Health and Care Excellence, 2018; Phoenix Austra- lia Centre for Posttraumatic Mental Health, 2013).

Numerous interventions have also recently garnered attention and emerged as promising practices in the treatment of PTSD. These interventions have built on research on factors associated with PTSD and its treat- ment to develop novel ways to provide care for those with this condition. Building on research on comorbid

76 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

borderline personality disorder and PTSD, as well as increased suicidality across these conditions, Harned and colleagues (2014) have investigated an approach that combines DBT with PE. Similarly, appreciating the interpersonal context of trauma recovery, Mon- son and Fredman (2012) developed CBCT for PTSD, which has now been tested in a number of studies (see Liebman, Whitfield, Sijercic, Ennis, & Monson, 2020). Finally, examining whether there is a need for exposure to be included in the treatment of PTSD, Markowitz and colleagues (2015), investigated the efficacy of IPT. Results of these studies have demonstrated preliminary efficacy for these interventions. Although the evidence for these approaches is still emerging, they represent unique and novel ways to provide care for individuals with PTSD.

Moderators of and Process Factors Associated with Treatment

As the evidence for treatments for PTSD grows, there has been increasing attention on factors that may mod- erate treatment outcomes. This has included an ex- amination of how specific client- and treatment-level variables impact outcomes. Notably, given that trauma- focused therapies for PTSD have received the most research, examination of these moderating variables is largely limited to these interventions.

Among the available research, there is some evidence to suggest that client factors such as gender and civil- ian versus veteran status may be associated with treat- ment outcome. Extant work suggests that women may be more likely to benefit from psychotherapy for PTSD, and that men may be more likely to drop out of treat- ment (Wade et al., 2016). In contrast, others have in- dicated that these differences may be better explained by confounding variables, underrepresentation of gen- ders in treatment studies of samples of specific types of trauma exposure (e.g., underrepresentation of men in studies of sexual assault and of women in studies of combat trauma), as well as studies not being designed or being underpowered to evaluate gender differences (see Blain, Galovski, & Robinson, 2010 for review). With regard to civilian versus veteran status, studies have documented differences in treatment response, such that veteran samples exhibit smaller effect size improve- ments with treatment in comparison to those of civilian samples (Dillon, LoSavio, Henry, Murphy, & Resick, 2019; Gobin et al., 2018; Goodson et al., 2011; Mor- land et al., 2015).

Treatment-level factors associated with clinical deci- sions on how to move forward with treatment based on symptom presentation and comorbid issues have also been the focus of recent investigation. This has includ- ed research on how best to proceed when individuals present with comorbid PTSD and substance use dis- orders. The high rate of comorbidity between PTSD and substance use disorders has been well documented (Pietrzak, Goldstein, Southwick, & Grant, 2011), lead- ing clinicians to wonder whether substance use needs to be treated effectively before endeavoring to treat PTSD. The extant research, however, suggests that de- spite poorer outcomes among individuals with comor- bid PTSD and substance use disorders, trauma-focused therapies confer some benefit (Roberts, Roberts, Jones, & Bisson, 2016), resulting in treatment guidelines sug- gesting that treatment for PTSD should be offered to individuals with this comorbidity (Department of Vet- erans Affairs & Department of Defense, 2017).

Within CPT, preliminary research suggests differen- tial effects based on the presence of dissociative symp- toms. In a dismantling trial of CPT for women who were victims of interpersonal violence, Resick, Suvak, Johnides, Mitchell, and Iverson (2012) documented a differential effect of the treatments based on dissocia- tion symptoms. Women with higher levels of pretreat- ment dissociation demonstrated a better treatment response when they received the version of CPT that in- cluded written trauma accounts (CPT+A). In contrast, women with low levels of pretreatment dissociation had a better treatment response when they received the ver- sion without written trauma accounts (CPT; Resick et al., 2012). The study authors suggested that this differ- ential response may be explained by the written trauma accounts serving to help reconstruct a fragmented trau- ma memory among those who are highly dissociative, prior to assisting them in processing the trauma mem- ory and challenging maladaptive cognitions associated with it through Socratic dialogue.

Recent work has also raised the question of whether existing treatments for PTSD adequately address the distinct but related construct of moral injury. Moral in- jury involves the violation of one’s deeply held beliefs or expectations, and can occur via the perpetration of acts, as well as witnessing or learning about them (see Litz et al., 2009, for summary). Traumatic events, particularly those of an interpersonal nature, may often include an element of moral injury. With growing research in this area, some have purported that existing treatments for PTSD may not adequately address moral injury, high-

Posttraumatic Stress Disorder 77

lighting issues associated with PTSD initially being conceptualized as a fear-based disorder, as well as its treatment being developed in response to this fear- based conceptualization. Moreover, some have argued that cognitions underlying moral injury may be fun- damentally different than those underlying PTSD re- sulting from other traumatic events (see Held, Klassen, Brennan, & Zalta, 2018, for summary). In response to these critiques, preliminary work has examined the ap- plication of existing first-line treatments for PTSD to those considered to have moral injury. Although lim- ited to case studies, preliminary findings support that existing interventions for PTSD, such as CPT and PE, can adequately address this issue without modifications (Held et al., 2018).

Factors associated with the mode and format of treat- ment delivery have also been examined in an effort to more efficiently deliver services to those in need. De- livery of treatment in a group format is often a con- sideration in settings in which the availability of ser- vices is scarce, in an effort to more efficiently treat a larger number of individuals. Although limited, there is some evidence that group interventions for PTSD can be beneficial (Resick et al., 2015, 2017; Schnurr et al., 2003), with studies favoring trauma-focused cognitive- behavioral therapy groups over PCT groups (Forbes et al., 2021). However, it is important to note that the bulk of the evidence favors individual over group therapy for PTSD (Cusak et al., 2016; Forbes et al., 2021; Resick et al., 2017; Watts et al., 2013).

Advances in technology have also allowed for delivery of treatments via telehealth (i.e., services delivered via videoconferencing or telephone). Studies of treatment for PTSD delivered via telehealth have been found to be efficacious in the treatment of PTSD and not inferior to treatment delivered in person. Additionally, dropout rates do not appear to be negatively impacted when treatment is delivered via telehealth, and may even be better than in face-to-face therapy (see Moring et al., 2020, for review). Although factors related to ensuring privacy and confidentiality, setting clients’ expectations related to their participation via telehealth, and file/ document sharing require adjustments when transition- ing to telehealth delivery, the existing research suggests that these are surmountable barriers and that telehealth presents a unique opportunity to effectively deliver treatment for PTSD.

Finally, studies have also examined the importance of treatment fidelity when delivering protocol therapies for PTSD (Farmer, Mitchell, Parker-Guilbert, & Ga-

lovski, 2017; Holder, Holliday, Williams, Mullen, & Surís, 2018; Marques et al., 2019). These studies have tested whether adherence to the “essential elements” of protocoled therapies for PTSD, as well as competence in delivering them, is associated with treatment outcomes. Although the pattern of findings has differed among studies, as a whole, they suggest that both adherence and competence are associated with improvements in PTSD and comorbid symptoms (Farmer et al., 2017; Holder et al., 2018; Marques et al., 2019). Moreover, when considering therapists’ modifications during the delivery of a protocol therapy, modifications that are classified as fidelity-consistent appear to be associated with greater reductions in PTSD and comorbid symp- toms compared to those classified as fidelity-inconsis- tent (Marques et al., 2019). These findings highlight the importance of therapist adherence and competence in delivering the essential ingredients of evidence-based treatments for PTSD, while demonstrating that it is possible to make treatment adaptations to better serve one’s clients in a way that preserves fidelity to these pro- tocoled therapies.

CASE STUDY

“Tom” is a 25-year-old, married, male who presented for treatment approximately 1 year after a traumatic event that occurred during his military deployment to Iraq. Tom received CPT while on active duty.

Background

Tom was the third of four children born to his parents. He described his father as an alcoholic who was fre- quently absent from the home due to work travel prior to his parents’ divorce. Tom indicated that his father was always emotionally distant from the family, espe- cially after the divorce. Tom had close relationships with his mother and siblings. He denied having any significant mental health or physical health problems in his childhood. However, he described two signifi- cant traumatic events in his adolescence. Specifically, he described witnessing his best friend commit suicide by gunshot to the head. Tom indicated that this event severely affected him, as well as his entire community. He went on to report that he still felt responsible for not preventing his friend’s suicide. The second traumatic event was the death of Tom’s brother in an automobile accident when Tom was 17 years old. Tom did not re-

78 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

ceive any mental health treatment during his childhood or after these events, though he indicated that he began using alcohol and illicit substances after these traumatic events in his youth. He admitted using cannabis nearly daily during high school, as well as daily use of alcohol, drinking as much as a 24-pack of beer per day until he passed out. Tom reported that he decreased his alcohol consumption and ceased using cannabis after his enlist- ment.

Tom served in the Infantry. He went to Basic Train- ing, then attended an advanced training school prior to being deployed directly to Iraq. While in Iraq, Tom witnessed and experienced a number of traumatic incidents. He spoke about fellow soldiers who were killed and injured in service, as well as convoys that he witnessed being hit by improvised explosive devices (IEDs). However, the traumatic event that he identified as most distressing and anxiety-provoking was shooting a pregnant woman and child.

Tom described this event as follows: Suicide bomb- ers had detonated several bombs in the area where Tom served, and a control point had been set up to contain the area. During the last few days of his deployment, Tom was on patrol at this control point. It was dark outside. A car began approaching the checkpoint, and officers on the ground signaled for the car to stop. The car did not stop in spite of these warnings. It continued to approach the control point, entering the area where the next level of Infantrymen were guarding the en- trance. Per protocol, Tom fired a warning shot to stop the approaching car, but the car continued toward the control point. About 25 yards from the control point gate, Tom and at least one other soldier fired upon the car several times.

After a brief period of disorientation, a crying man with clothes soaked with blood emerged from the car with his hands in the air. The man quickly fell to his knees, with his hands and head resting on the road. Tom could hear the man sobbing. According to Tom, the sobs were guttural and full of despair. Tom looked over to find in the pedestrian seat a dead woman who was apparently pregnant. A small child in the backseat was also dead. Tom never confirmed this, but he and his fellow soldiers believed that the man crying on the road was the husband of the woman and the father of the child and fetus.

Tom was immediately distressed by the event, and a Combat Stress Control unit in the field eventually had him sent back to a Forward Operating Base because of his increasing intrusive and arousal symptoms. Tom

was eventually brought to a major Army hospital, where he received individual CPT.

Tom was administered the CAPS at pretreatment; his score was in the severe range, and he met diagnos- tic criteria for PTSD. He also completed the Patient Health Questionnaire–9 (PHQ-9) and the General- ized Anxiety Disorder–7 (GAD-7). His depression and anxiety symptoms at pretreatment were in the severe range. Tom was provided feedback about his assess- ment results in a session focused on an overview of his psychological assessment results and on obtaining his informed consent for a course of CPT. After providing feedback about his assessment, the therapist gave Tom an overview of CPT, with an emphasis on its trauma- focused nature, expectation of out-of-session practice adherence, and the client’s active role in getting well. Tom signed a “CPT Treatment Contract” detailing this information and was provided a copy of the contract for his records. The CPT protocol began in the next session.

Session 1

Tom arrived 15 minutes early to his first scheduled ap- pointment of CPT. He sat down in the chair the ther- apist gestured that he sit in, but he was immediately restless and repositioned frequently. Tom quickly asked to move to a different chair in the room, so that his back was not facing the exterior door and his gaze could monitor both the door and the window. He asked the therapist how long his session would take and whether he would have to “feel anything.” The therapist re- sponded that this session would last 50–60 minutes, and that, compared with other, future sessions, she would be doing most of the talking. She added that, as discussed during the treatment contracting session, the focus would be on Tom’s feelings in reaction to the traumatic event but that the current session would focus less on this. The therapist also explained that she would have the treatment manual in her lap, and would refer to it throughout to make sure that she delivered the psychotherapy as it was prescribed. She encouraged Tom to ask any questions he might have as the session unfolded.

The therapist explained that at the beginning of each session they would develop an agenda for the session. The purposes of the first therapy session were to (1) de- scribe the symptoms of PTSD; (2) give Tom a frame- work for understanding why these symptoms had not remitted; (3) present an overview of treatment to help

Posttraumatic Stress Disorder 79

Tom understand why practice outside of session and therapy attendance were important to elicit cooperation and to explain the progressive nature of the therapy; (4) build rapport between Tom and the therapist; and (5) give Tom an opportunity to talk briefly about his most distressing traumatic event or other issues.

The therapist then proceeded to give didactic infor- mation about the symptoms of PTSD. She asked Tom to provide examples of the various clusters of PTSD symptoms he was experiencing, emphasizing how in- trusive symptoms are related thoughts and emotions about the trauma, which are tied to arousal symptoms. She emphasized how hyperarousal symptoms elicit a desire to avoid or become numb. The paradoxical ef- fect of avoidance and numbing in maintaining, or even increasing, PTSD symptoms was also discussed. Tom indicated that this was the first time someone had ex- plained the symptoms of PTSD in this way, putting them “in motion” by describing how they interact with one another.

The therapist transitioned to a description of trauma aftereffects within an information processing frame- work. She described in lay terms how traumas may be schema-discrepant events; traumatic events often do not fit with one’s prior beliefs about oneself, others, or the world. To incorporate this event into one’s memory, the person may alter his/her perception of the event (assimi- late the event into an existing belief system). Examples of assimilation include looking back on the event and believing that some other course of action should have been taken (“undoing” the event) or blaming oneself because it occurred. The therapist went on to explain that Tom could have also attempted to change his prior belief system radically to overaccommodate the event to his prior beliefs. Overaccommodationwas described as changing beliefs too much as a result of the traumatic event (e.g., “I can’t trust myself about anything”). She explained that several areas of beliefs are often affected by trauma, including safety, trust, power/control, es- teem, and intimacy. She further explained that these beliefs could be about the self and/or others. The thera- pist also pointed out that if Tom had negative beliefs prior to the traumatic event relative to any of these top- ics, the event could serve to strengthen, and seemingly confirm, these preexisting negative beliefs.

At this point, Tom described his childhood and ado- lescent experiences, and how they had contributed to his premilitary trauma beliefs. The therapist noted that Tom tended to blame himself and to internalize the bad things that had happened in his family and the suicide

of his friend. She also noted his comment, “I wonder if my father drank to cope with me and my siblings.” In Tom’s case, it seemed likely that the traumatic experi- ence served more to confirm his preexisting beliefs that he had caused or contributed to bad things happening around and to him.

Tom then spent some time describing how drastical- ly things had changed after his military traumas. Prior to his military experiences and, specifically, the shoot- ing of the woman and child, Tom described himself as “proud of being a soldier” and “pulling his life together.” He indicated that the military structure had been very good for him in developing self-discipline and improv- ing his self-esteem. He indicated that he felt good about serving his country. He felt camaraderie with his fellow soldiers and was planning a career in the military. He denied any authority problems and in fact believed that his commanding officers had been role models of the type of leader he wished to be. After his return from Iraq, Tom indicated that he did not trust anyone, es- pecially anyone associated with the U.S. government. Tom expressed his disillusionment with the war effort and distrust of the individuals who commanded his unit. He also articulated distrust of himself: “I always make bad decisions when the chips are down.” He stat- ed that he felt completely unsafe in his environment. In his immediate postdeployment period, Tom had occa- sionally believed snipers on the base grounds had placed him in their crosshairs to kill him. He indicated that he minimally tolerated being close to his wife, including sexual contact between the two of them.

The therapist introduced the notion of Stuck Points, or ways of making sense of the trauma or of think- ing about himself, others, and the world, as getting in the way of Tom’s recovery from the traumatic events. The therapist noted that a large number of individuals are exposed to trauma. In fact, military personnel are among the most trauma-exposed individuals. However, most people recover from their trauma exposure. Thus, a primary goal of the therapy was to figure out what had prevented Tom from recovering (i.e., how his thinking had got him “stuck,” leading to the maintenance of his PTSD symptoms).

The therapist then asked Tom to provide a 5-minute account of his index traumatic event. Tom immediately responded, “There were so many bad things over there. How could I pick one?” The therapist asked, “Which of those events do you have the most thoughts or images about? Which of those events do you dislike thinking about the most?” The therapist indicated that Tom did

80 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

not need to provide a fine-grained description of the event, but rather a brief overview of what happened. Tom provided a quick account of the shooting of the woman and child. The therapist praised Tom for shar- ing about the event with her and asked about his feel- ings as a result of sharing the information. Tom said that he felt anxious and wanted the session to be over. The therapist used this as an opportunity to describe the differences between natural and manufactured emotions.

The therapist first described naturalemotions as those automatic feelings that are commensurate reactions to experiences that have occurred. These feelings require minimal conscious processing. For example, if some- one has violated us, it is natural to feel anger. If we en- counter a threatening situation, it is natural to feel fear. Natural emotions have a self-limited and diminishing course. If we allow ourselves to feel these natural emo- tions, they will naturally dissipate. The therapist used the analogy of the energy contained in a bottle of car- bonated soda to illustrate this concept. If the top of the bottle is removed, the pressure initially comes out with some force, but that force subsides and eventually has no energy forthcoming. On the other hand, there are manufacturedemotions, or emotions that a person has a role in making. Our conscious thoughts contribute to the nature and course of these emotions. The more that we “fuel” these emotions with our self-statements, the more we can increase the “pressure” of these emotions. For example, if a person tells himself over and over that he is a stupid person and reminds himself of more and more situations in which he perceived that he made mistakes, then he is likely to have more and more anger toward himself. The therapist summarized for Tom the three major goals of the therapy: (1) to remember and accept what happened to him by not avoiding those memories and associated emotions; (2) to allow him- self to feel his natural emotions and let them run their course, so the memory could be put away without such strong feelings still attached; and (3) to balance beliefs that had been disrupted or reinforced, so that Tom did not manufacture unhelpful emotions.

The therapist made a strong pitch for the importance of out-of-session practice adherence before assigning Tom the first practice assignment. The therapist told Tom that there appeared to be no better predictor of response to the treatment than how much effort a pa- tient puts into it. She pointed out that of the 168 hours in a week, Tom would be spending 1–2 hours of that week in psychotherapy sessions (Note: We have found it

helpful to do twice-weekly sessions, at least in the initial portion of the therapy, to facilitate rapport building, to overcome avoidance, and to capitalize on early gains in the therapy.) If Tom only spent the time during psycho- therapy sessions focused on these issues, he would be spending less than 1% of his week focused on his recov- ery. To get better, he would be using daily worksheets and other writing assignments to promote needed skills in his daily life and to decrease his avoidance. The therapist also pointed out that at the beginning of each session they would review the practice assignments that Tom had completed. The therapist asked Tom if this made sense, and he responded, “Sure. It makes sense that you get out of it what you put into it.”

Tom’s first assignment was to write an “Impact State- ment” about the meaning of the event to determine how he had made sense of the traumatic event, and to help him begin to determine what assimilation, accom- modation, and overaccommodation had occurred since the event. Stuck Points that get in the way of recovery are identified with this first assignment. Tom was in- structed to start writing the assignment later that day to address directly any avoidance about completing the assignment. He was specifically reminded that this was not a trauma account and that this assignment was spe- cifically designed to get at the meaning of the event in his life, and how it had impacted his belief systems.

The specific assignment was as follows:

“Please write at least a one-page statement on why you think your most distressing traumatic event occurred. You are not being asked to write specific details about this event. Write about what you have been thinking about the cause of this event. Also, consider the effects this traumatic event has had on your beliefs about yourself, others, and the world in the following areas: safety, trust, power/control, es- teem, and intimacy. Bring this statement with you to the next session.”

Session 2

The purposes of the second session are to (1) discuss the meaning of the event and (2) to help Tom begin to recognize thoughts, label emotions, and see the connec- tion between what he says to himself and how he feels. Tom arrived with obvious anger and appeared defen- sive throughout most of the session. He stated that he had been feeling quite angry all week, and that he was “disgusted” with society and particularly politicians,

Posttraumatic Stress Disorder 81

who were “all self-interested or pandering to those with money.” He expressed a great deal of anger over the re- ports of alleged torture at Abu Ghraib prison, which was a major news item during his therapy. The therapist was interested in the thinking behind Tom’s anger about the events at Abu Ghraib. However, she first reviewed Tom’s practice assignment, writing the first Impact Statement, to reinforce the completion of this work and to maintain the session structure she had outlined in the first session.

The therapist asked Tom to read his Impact State- ment aloud. Clients in individual CPT are always asked to read their practice assignments aloud. Should the therapist read them, the client could dissociate or oth- erwise avoid his/her own reactions to the material. Tom had written:

“The reason that this traumatic event happened is be- cause I was friggin’ stupid and made a bad decision. I killed an innocent family, without thinking. I mur- dered a man’s wife and child. I can’t believe that I did it. I took that man’s wife and child, and oh, yeah, his unborn child, too. I feel like I don’t deserve to live, let alone have a wife and child on the way. Why should I be happy when that man was riddled with despair, and that innocent woman, child, and unborn child died? Now, I feel like I’m totally unsafe. I don’t feel safe even here on the hospital grounds, let alone in the city or back home with my family. I feel like someone is watching me and is going to snipe at me and my family because the terrorists had information about the situation and passed it on. I also don’t feel that people are safe around me. I might go off and hurt someone, and God forbid it be my own family. With my wife pregnant, I am really concerned that I might hurt her. I don’t trust anyone around me, and especially the government. I don’t even trust the mil- itary treating me. I also don’t trust myself. If I made a bad decision at that time, who is to say that I won’t make a bad decision again? About power and control, I feel completely out of control of myself, and like the military and my commanding officer have complete control over me. My self-esteem is in the toilet. Why wouldn’t it be given the crappy things that I have done? I don’t think there are many positive things that I’ve done with my life, and when the chips are down, I always fail and let others down. I’m not sure what other-esteem is, but I do like my wife. In fact, I don’t think she deserves to have to deal with me, and I think they would be better without me around. I don’t want to be close to my wife, or anyone for that

matter. It makes me want to crawl out of my skin when my wife touches me. I feel like I’ll never get over this. It wasn’t supposed to be like this.”

The therapist first reinforced Tom for completing the assignment. She then asked Tom what it was like to write and then read the Impact Statement aloud. Tom responded that it had been very difficult, and that he had avoided the assignment until the evening before his session. She used the opportunity to gently address the role of avoidance in maintaining PTSD symptoms. She asked specific Socratic questions aimed at elucidating the distress associated with anticipatory anxiety, and wondered aloud with Tom about what it would have been like to have completed the assignment earlier in the week. She also asked Socratic questions aimed at highlighting the fact that Tom felt better, not worse, after completing the assignment.

Tom’s first Impact Statement and the information he shared in the first session made evident the Stuck Points that would have to be challenged. In CPT, areas of as- similation are prioritized as the first targets of treat- ment. Assimilation is targeted first, because changes in the interpretation of the event itself are integrally related to the other, more generalized beliefs involved in overaccommodation. In Tom’s case, he was assimi- lating the event by blaming himself. He used the term murdererto describe his role in the event, disregarding important contextual factors that surrounded the event. These beliefs would be the first priority for challeng- ing. Tom’s overaccommodation is evident in his general distrust of society and authority figures, and his belief that he will make bad decisions in difficult situations. His overaccommodation is also evident in his sense of threat in his environment (e.g., snipers) and low esteem for others and himself.

The therapist returned to Tom’s anger about Abu Ghraib to get a better sense of possible Stuck Points and also to experiment with Tom’s level of cognitive rigid- ity or openness to cognitive challenging. The following exchange ensued between Tom and the therapist:

THERAPIST: Earlier you mentioned that you were feel- ing angry about the reports from Abu Ghraib. Can you tell me what makes you angry?

TOM: I can’t believe that they would do that to those prisoners.

THERAPIST: What specifically upsets you about Abu Ghraib?

82 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

TOM: Haven’t you heard the reports? I can’t believe that they would humiliate and hurt them like that. Once again, the U.S. military’s use of force is unacceptable.

THERAPIST: Do you think your use of force as a mem- ber of the U.S. military was unacceptable?

TOM: Yes. I murdered innocent civilians. I am no dif- ferent than those military people at Abu Ghraib. In fact, I’m worse because I murdered them.

THERAPIST: Murder. That’s a strong word. TOM: Yeah? THERAPIST: From what you’ve told me, it seems like you

killed some people who may or may not have been “innocent.” Your shooting occurred in a very specific place and time, and under certain circumstances.

TOM: Yes, they died at my hands. THERAPIST: Yes, they died, and it seems, at least in

part, because of your shooting. Does that make you a murderer?

TOM: Innocent people died and I pulled the trigger. I murdered them. That’s worse than what happened at Abu Ghraib.

THERAPIST: (quietly) Really, you think it is worse? TOM: Yes. In one case, people died, and in another they

didn’t. Both are bad, and both were caused by sol- diers, but I killed people and they didn’t.

THERAPIST: The outcomes are different—that is true. I’m curious if you think how it happened matters?

TOM: Huh? THERAPIST: Does it matter what the soldiers’ intentions

were in those situations, regardless of the outcome? TOM: No. The bottom line is killing versus no killing. THERAPIST: (realizing that there was minimal flexibility

at this point) I agree that there is no changing the fact that the woman and child died, and that your shooting had something to do with that. However, I think we might slightly disagree on the use of the term murder. It is clear that their deaths have been a very difficult thing for you to accept, and that you are trying to make sense of that. The sense that you appear to have made of their deaths is that you are a “murderer.” I think this is a good example of one of those Stuck Points that seem to have prevented you from recovering from this traumatic event. We’ll definitely be spending more time together on under- standing your role in their deaths.

In addition to testing Tom’s cognitive flexibility, the therapist also wanted to plant the seeds of a different interpretation of the event. She was careful not to push too far and retreated when it was clear that Tom was not amenable to an alternative interpretation at this point in the therapy. He was already defensive and somewhat angry, and she did not want to exacerbate his defensive- ness or possibly contribute to dropout from the therapy.

From there, the therapist described how important it was to be able to label emotions and to begin to iden- tify what Tom was saying to himself. The therapist and Tom discussed how different interpretations of events can lead to very different emotional reactions. They generated several examples of how changes in thoughts result in different feelings. The therapist also reminded Tom that some interpretations and reactions follow naturally from situations and do not need to be altered. For example, Tom indicated that he was saddened by the death of the family; the therapist did not challenge that statement. She encouraged Tom to feel his sadness and to let it run its course. He recognized that he had lost something, and it was perfectly natural to feel sad as a result. At this point Tom responded, “I don’t like to feel sad. In fact, I don’t like to feel at all. I’m afraid I’ll go crazy.” The therapist gently challenged this be- lief. “Have you ever allowed yourself to feel sad?” Tom responded that he worked very hard to avoid any and all feelings. The therapist encouraged Tom, “Well, given that you don’t have much experience with feeling your feelings, we don’t know that you’re going to go crazy if you feel your feelings, right?” She also asked him whether he had noticed anyone in his life who had felt sad and had not gone crazy. He laughed. The therapist added, “Not feeling your feelings hasn’t been working for you so far. This is your opportunity to experiment with feeling these very natural feelings about the trau- matic event to see whether it can help you recover now from what has happened.”

Tom was given a number of A-B-C Worksheets (Ac- tivating Event, Belief, Consequence) as practice assign- ments to begin to identify what he was telling himself and his resulting emotions, including at least one sheet related to his most traumatic event. In the first column, under A, “Something happens,” Tom was instructed to write down an event. Under the middle column, B, “I tell myself something,” he was asked to record his thoughts about the event. Under column C, “I feel and/ or do something,” Tom was asked to write down his behavioral and emotional responses to the event. The

Posttraumatic Stress Disorder 83

therapist pointed out that if Tom says something to himself a lot, it becomes automatic. After a while, he can go straight to the feeling. It is important to stop and recognize automatic thoughts to decide whether they either make sense or should be challenged and changed.

Session 3

Tom handed the therapist his practice assignments as soon as he arrived. The therapist went over the indi- vidual A-B-C Worksheets Tom had completed and emphasized that he had done a good job in identifying his feelings and recognizing his thoughts. Some of this work is shown in Figure 2.1.

The purpose of reviewing this work at this point in the therapy is to identify thoughts and feelings, not to heavily challenge the content of those thoughts. The therapist did a minor correction of Tom’s identification of the thought “I feel like I’m a bad person” (bolded in Figure 2.1) as a feeling. She commented that feel- ings are almost always one word and what you feel in your “gut,” and that adding the stem “I feel . . .” does not necessarily make it a feeling. The therapist noticed

the pattern of thoughts that Tom tended to record (i.e., internalizing and self-blaming), as well as the character- istic emotions he reported.

The therapist noted the themes of assimilation that again emerged (i.e., self-blame) and chose to focus on mildly challenging these related thoughts. She specifi- cally chose to focus on Tom’s thoughts and feelings re- lated to his wife’s pregnancy, which ultimately seemed to be related to his assimilation of the traumatic event.

THERAPIST: You don’t think you deserve to have a fam- ily? Can you say more about that?

TOM: Why should I get to have a family when I took someone else’s away?

THERAPIST: OK, so it sounds like this relates to the first thought that you wrote down on the A-B-C Worksheet about being a murderer. When you say to yourself, “I took someone else’s family away,” how do you feel?

TOM: I feel bad. THERAPIST: Let’s see if we can be a bit more precise.

FIGURE 2.1. A-B-C Worksheet for Tom. Adapted from Resick, Monson, and Chard (2017). Copyright © 2017 The Guil- ford Press. Adapted by permission.

Activating Event Belief/Stuck Point Consequence A B C

“Something happens” “I tell myself something” “I feel something”

I killed an innocent family.

My wife is pregnant.

Abu Ghraib

Going to therapy

“I am a murderer.”

“I don’t deserve to have a family.”

“The government sucks.”

“I’m weak. I shouldn’t have PTSD. PTSD is only for the weak.”

I feel like I’m a bad person. Avoid talking about it. Guilty

Angry

Angry

Are my thoughts above in column B realistic or helpful? Yes.

What can I tell myself on such occasions in the future? ?

84 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

What brand of bad do you feel? Remember how we talked about the primary colors of emotion? Which of those might you feel?

TOM: I feel so angry at myself for doing what I did. THERAPIST: OK. Let’s write that down—anger at self.

So, I’m curious, Tom, do the other people you’ve told about this situation, or who were there at the time, think what you did was wrong?

TOM: No, but they weren’t the ones who did it, and they don’t care about the Iraqi people like I do.

THERAPIST: Hmm  .  .  . that makes me think about something, Tom. In the combat zone in which you were involved in Iraq, how easy was it to determine who you were fighting?

TOM: Not always particularly easy. There were lots of insurgents who looked like everyday people.

THERAPIST: Like civilians? Innocent civilians? (pause) TOM: I see where you are going. I feel like it is still

wrong because they died. THERAPIST: I believe you when you say that it feels that

way. However, feeling a certain way doesn’t neces- sarily mean that it is based on the facts or the truth. We’re going to work together on seeing whether that feeling of guilt or wrongdoing makes sense when we look at the situation very carefully in our work to- gether.

Because the goal is for Tom to challenge and dis- mantle his own beliefs, the therapist probed and plant- ed seeds for alternative interpretations of the traumatic event but did not pursue the matter too far. Although Tom did move some from his extreme stance within the session, the therapist was not expecting any dramatic changes. She focused mostly on helping Tom get the connections among thoughts, feelings, and behaviors, and developing a collaborative relationship in which cognitive interventions could be successfully delivered.

The therapist praised Tom for his ability to recognize and label thoughts and feelings, and gave him the as- signment to complete an A-B-C Worksheet each day fo- cused on his thoughts about the index trauma of shoot- ing the pregnant woman and child at the checkpoint.

Session 4

Tom came to the session having done an A-B-C Work- sheet each day prior to the session. The therapist praised

Tom for his hard work, then asked him to share the sheets that he thought were most helpful and/or dif- ficult for him. One of the trauma-related sheets that Tom shared was related to the thought, “I murdered an innocent child” and the associated feelings of guilt and shame. The therapist took the opportunity to jump off this worksheet to engage in Socratic dialogue with Tom about his self-blame, and to also encourage him to feel his natural feelings that he had been avoiding.

THERAPIST: Tom, are you OK if I ask you some follow- up questions about these thoughts?

TOM: Sure. Would it really matter if I said no? (Tom and therapist chuckle.)

THERAPIST: Of course I can’t make you talk about this Tom. . . . That said, I do believe you can get better by talking about it. Can you explain to me a bit more about the scene that leads to your conclusion that you murdered her?

TOM: I’m starting to feel sick to my stomach—like I felt at the time when I saw her in the back seat with all that blood and her doll. She was lifeless just like that doll. I really think I might throw up. I am also disgusted and sad. I killed an innocent child. There are so many things I could have done differently not to have taken her life.

[The therapist is aware of the assimilation process in Tom’s use of hindsight bias about the “many things he could have done not to have taken her life.” She stores that informa- tion away for future reference for challenging because she wants to make sure that Tom is feeling as many of his natu- ral emotions as possible about the traumatic event.] THERAPIST: Continue to feel those feelings. Don’t run

away from them. Anything else that you’re feeling? TOM: I feel mad at myself and guilty. THERAPIST: Were you feeling mad at yourself and

guilty at the time? TOM: No. I was horrified. THERAPIST: OK, let’s stay with that feeling. TOM: (Pauses.) I don’t want to feel this anymore. THERAPIST: I know you don’t want to feel this any-

more. You’re doing a great job of not avoiding your feelings here. In order to not feel like this for a long time, you need to feel these absolutely natural feel- ings. Let them run their course. They’ll decrease if you stay with them.

Posttraumatic Stress Disorder 85

After a period in which Tom experienced his feelings related to the situation and allowed them to dissipate, a discussion ensued regarding how hurtful it was to Tom to hear other people’s reaction to the war. He expressed specific frustration with administration and its policy on the war. The therapist gently redirected Tom’s more philosophical discussion of international policy to the effects of the trauma on him. Tom then told a story of how he had shared his traumatic experience with a high school friend. He felt that this person had a negative reaction to him as a result of sharing the story. Tom felt judged and unsupported by this friend. Since this experience with his friend, Tom had refrained from tell- ing others about his combat experience. Using Socratic questioning, the therapist asked Tom if there might be any reason, outside of his actions, that someone might have a negative reaction to hearing about the shooting. Through this exchange, Tom was able to recognize that when others hear about traumatic events, they also are trying to make sense of these experiences in light of their existing belief systems. In other words, others around him might fall prey to the “just world” belief that bad things only happen to bad people. They also might not take into account the entire context in which Tom shot the passengers in the car. This recognition resulted in Tom feeling less angry at his friend for this perceived judgment. He was also somewhat willing to admit that his interpretation of his friend’s reaction might have been skewed by his own judgment of him- self. In fact, later in the therapy, when Tom was able to ask his friend directly about the perceived reaction, the friend indicated that it had been hard for him to hear, but that he had not been judging Tom at all. In actu- ality, he was thinking about the terrible predicament Tom had endured at the time.

The therapist returned to Stuck Points she had heard in the course of reviewing the sheets and Socratic dia- logue. The following dialogue then occurred:

TOM: I’m not sure what the Stuck Points are, but from what you’ve been asking me, I guess you question whether or not I murdered this family.

THERAPIST: That’s true. I think it is worthwhile for us to discuss the differences between blame and respon- sibility. Let’s start with responsibility. From your ac- count, it sounds like you were responsible for shooting the family. It sounds like other people may have been responsible, too, given that you were not the only person who shot at them.

[The therapist stores this fact in her mind to challenge Tom later about the appropriateness of his actions. This also provides a good opportunity to reinforce Tom for perform- ing well in a stressful situation.] THERAPIST: The bottom line is that responsibility is

about your behavior causing a certain outcome. Blame has to do with your intentionality to cause harm. It has to do with your motivations at the time. In this case, did you go into the situation with the motivation and intention to kill a family?

TOM: No, but the outcome was that they were mur- dered.

THERAPIST: Some died. That is true. From what you’ve shared, if we put ourselves back into the situation at the time, it doesn’t seem like it was your intention for them to die. They were coming down the road too fast, not responding to the very clear efforts to warn them to stop. Your own and others’ intentions were to get them to stop at the checkpoint. Your intention at the time did not seem to be to kill them. In fact, wasn’t your intention quite the opposite?

TOM: Yes. (Begins to cry.) THERAPIST: (Pauses until Tom’s crying subsides some-

what.) It doesn’t seem that your intention was to kill them at all. Thus, the word blame is not appropriate. Murder or considering yourself a murderer does not seem accurate in this situation. The reason I’ve ques- tioned the term murder or murderer all along was be- cause it doesn’t seem like your intention was to have to shoot them.

TOM: But why do I feel like I am to blame? THERAPIST: That’s a good question. What’s your best

guess about why that is? TOM: (still crying) If someone dies, someone should

take responsibility. THERAPIST: Do you think it is possible to take respon-

sibility without being to blame? What would be a better word for a situation that is your responsibility, but that you didn’t intend to happen? If a person shot someone but didn’t intend to do that, what would we call that?

TOM: An accident, I guess. THERAPIST: That’s right. In fact, what would you call

shooting a person when you are trying to protect something or someone?

TOM: Self-defense.

86 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: Yes, very good. Weren’t you responsible for guarding the checkpoint?

TOM: Yeah. THERAPIST: So, if you were responsible for guard-

ing that checkpoint, and they continued through, wouldn’t that have put the area at risk?

TOM: Yes, but it was a family—not insurgents. THERAPIST: How did you know that at the time? TOM: There was a woman and child in the car. THERAPIST: Yes—we know how the story ended now.

Did you know that at the time? TOM: No. THERAPIST: So only in hindsight do you know that it

was a family that might have had no bad intention. We actually don’t know the family’s intention, do we? They didn’t heed the several warnings, right?

TOM: Yes. (Pauses.) I hadn’t thought that they would be looking to do something bad with a woman and child in the car.

THERAPIST: We don’t know, and won’t ever know, un- fortunately. However, what we do know is what you knew at the time. What you knew at the time is that they did not heed the warnings, that you were respon- sible for securing the checkpoint, and that you took action when you needed to take action to protect the post. Thinking about those facts of what happened and what you knew at the time, how do you feel?

TOM: Hmm . . . I guess I’d feel less guilty. THERAPIST: You’d feel less guilty. Or, you feel less

guilty? TOM: When I think through it, I do feel less guilty. THERAPIST: There may be points when you start feel-

ing guiltier again. It will be important for you to hold onto the facts of what happened versus going to your automatic interpretation that you’ve had for a while now. Is there any part of it that makes you proud?

TOM: Proud? THERAPIST: Yes. It seems like you did exactly what you

were supposed to do in a stressful situation. Didn’t you show courage under fire?

TOM: It’s hard for me to consider my killing them as courageous.

THERAPIST: Sure. You haven’t been thinking about it in this way for a long time, but it is something to consider.

The therapist’s Socratic dialogue was designed to help Tom consider the entire context in which he was operating. She also began to plant the seed that Tom not only did nothing wrong but he also did what he was supposed to do to protect the checkpoint. Whenever possible, pointing out acts of heroism or courage can be powerful interventions with trauma survivors.

The therapist noted that another of Tom’s sheets contained overaccommodated beliefs about the U.S. military. He had entered the service with a very positive view of the military. Tom had a family history of mili- tary service and believed in service to country and the “rightfulness” of the military. Subsequent to his trau- matic event and military service in Iraq, he developed a negative view of the military that had extended to the Federal government in general. The therapist used this content to introduce the first series of tools to help chal- lenge Tom’s Stuck Points. She also emphasized how he would gradually be taking over as his own therapist, ca- pable of challenging his own patterns of thinking that kept him “stuck.”

THERAPIST: It seems that you have some very strong beliefs about the military and the U.S. government since your service. I’d like to use those beliefs to in- troduce some new material that will be helpful to you in starting to challenge Stuck Points on your own. You’ve done an outstanding job of considering the way that you think and feel about things. You’ve been very open to considering alternative interpreta- tions of things. Starting in this session, I’m going to help you to become your own therapist and to attack your own Stuck Points directly.

TOM: OK. THERAPIST: We’re going to be building your skills over

the next few sessions. The first tool is a sheet called the Challenging Questions Worksheet. Our first step is to identify a single belief you have that may be a Stuck Point. As I mentioned before, I’d like us to use your beliefs about the Federal government now. So, if you were to boil down what you believe about the Federal government or the military, what is it?

TOM: I don’t know. I’m not sure. I guess I’d say that the U.S. military is extremely corrupt.

THERAPIST: Good. That is very clear and to the point. So, let’s go over these questions and answer them as they relate to this belief. The first question you ask yourself is “What’s the evidence for and against this idea?”

Posttraumatic Stress Disorder 87

TOM: The evidence for this is Abu Ghraib. Can you believe that they would do that? I would have also put my own shooting under the “for” list, but I’m beginning to question that.

THERAPIST: What other evidence is there of corrup- tion?

TOM: Oh, and these defense contractors  .  .  . what a scam! That leads me to the current administration and its vested interests in going to war to make money on defense contracting. And, oh, of course, to make money on the oil coming out of these coun- tries!

THERAPIST: OK. Sounds like you have some “for” evi- dence. What about the “against” evidence?

TOM: Well, some of my fellow soldiers were very good. They were very committed in their service and to the mission. I also had mostly good leaders, although some of them were real pigs. Some were really power- hungry a—holes, frankly.

THERAPIST: So, it sounds like you have some pros and cons that support your belief that the U.S. military is completely corrupt. In the process of changing, it is common to have thoughts on both sides. That means that you are considering different alternatives, and are not “stuck” on one way of seeing things. Let’s look at the next one. . . .

The therapist spent the balance of the session going over the list of questions to make sure that Tom un- derstood them. Although most of the questions focused on the issue of corruption in the military, other issues were also brought in to illustrate the meaning of the questions. For example, the therapist introduced the probability questions with the example from Tom’s life in which he believed that he was going to be shot by an insurgent sniper while back home. These questions are best illustrated with regard to issues of safety. The therapist pointed out that perhaps not all of the ques- tions applied to the belief on which Tom was working. The question “Are you thinking in all-or-none terms?” seemed to resonate with Tom the most, because it ap- plied to his belief about the military. He commented that he was applying a few examples of what seemed to be corruption to the entire military. Tom also indicated that his description of the military as “extremely” cor- rupt was consistent with the question “Are you using words or phrases that are extreme or exaggerated?” In- dicative of his grasp of the worksheet, Tom also noticed

that the question “In what ways is your Stuck Point not including all of the information?” applied to his prior view of his behavior as a murder in the traumatic event.

For his practice assignment prior to Session 5, Tom agreed to complete one Challenging Questions Work- sheet each day. He and the therapist brainstormed about potential Stuck Points prior to the end of the session to facilitate practice assignment completion. These Stuck Points included “I don’t deserve to have a family,” “I murdered an innocent family,” and “I am weak because I have PTSD.” Prior to ending the session, the therapist inquired about his reaction to the therapy session. Tom commented that it had been very difficult, but that he felt better than he expected in going into the “nitty- gritty” of what happened. He also noted that there were things he had not considered about the event that were “food for thought.”

Session 5

Tom arrived at Session 5 looking brighter and making more eye contact with the therapist. His self-reported PTSD symptoms were decreased, and he spontaneously noted that he was experiencing less guilt.

THERAPIST: You mentioned that you’re feeling less guilt now. Why is that?

TOM: I’m beginning to realize that I was not the only one there that was trying to stop them. Several of us were trying to get them to stop. There is still some guilt that I was the one who shot them.

THERAPIST: If one of the other guards had shot them, would you blame him or her for the shooting? Would you expect him or her to feel guilty for their behav- ior?

TOM: (Laughs.) I started thinking about that this week. It made me wonder if it was really me who even shot them. As I was writing and thinking about it more, I realized that there is a possibility that another of the guards may have been shooting at the same time.

THERAPIST: What would it mean if they were shooting at the same time?

TOM: If he was shooting at the same time, it means that he thought that shooting at them might be the right thing to do in that situation.

THERAPIST: Might have been the right thing to do? TOM: (smiling) Yeah, I still have questions that we

might have been able to do something else.

88 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: It seems like you’re still trying to “undo” what happened. I’m curious, what else could you have done?

TOM: Not have shot at them. THERAPIST: Then what would have happened? TOM: They might have stopped. (Pauses.) Or I guess

they could have gone through the checkpoint and hurt other people past the checkpoint. I guess they could have also been equipped with a car bomb that could have hurt many other people. That seems hard to believe, though, because of the woman and child in the car.

THERAPIST: It is impossible for us to know their inten- tions, as we discussed before. The bottom line is that you’ve tended to assume that doing something dif- ferent, or doing nothing, would have led to a better outcome.

TOM: That is true. I still feel sad. THERAPIST: Sure you do—that’s natural. I take it as

a good sign that you feel sad. Sadness seems like a very natural and appropriate reaction to what hap- pened—much more consistent with what happened than the guilt and self-blame that you’ve been expe- riencing.

Tom and the therapist discussed how the goal of the therapy was not to forget what had happened, but to have the memory without all of the anxiety, guilt, and other negative emotions attached to it. Tom indicated that he was becoming less afraid and more able to tol- erate his feelings, even when they were intense. Tom acknowledged that talking about his trauma, doing the worksheets, and coming to psychotherapy sessions were becoming easier and that his negative feelings were be- ginning to diminish.

Tom completed Challenging Questions Worksheets about all of the Stuck Points he and the therapist had generated. The therapist reviewed these worksheets to determine whether Tom had used the questions as de- signed. She asked Tom which of the worksheets he had found least helpful. He responded that he had had the most difficulty completing the sheet about deserving to have a family. The therapist then reviewed this sheet in detail with Tom (see Figure 2.2).

THERAPIST: So, I notice that in your answer about the evidence for and against this idea about deserving a family, you included as evidence that you took some

other man’s family. I’m glad to see that you didn’t include the word murder—that’s progress. But, how is that evidence for you not deserving a family?

TOM: It is evidence because I feel like I took someone else’s; therefore, I don’t deserve one for myself. It seems fair.

THERAPIST: Remind me to make sure and look at what you put for the question about confusing feelings and facts. For now, though, help me understand the math of why you don’t deserve your family, and your hap- piness about your family, because of what happened?

TOM: I don’t know—it just seems fair. THERAPIST: Fair? That implies that you did something

bad that requires you to be punished. TOM: As I’ve been thinking about it more, I don’t think

I did something wrong when I really look at it, but it still feels like I did something wrong and that I shouldn’t have something good like a wife and child in my life.

THERAPIST: Maybe we should look at your response to that feelings versus facts question. What did you put in response to the question “In what ways is your Stuck Point based on feelings rather than facts?”

TOM: I wrote, “I’m feeling guilty, like I did something wrong when the truth is that I did what I was sup- posed to do.” I try to remember what we talked about—that part about them not responding to the warnings and my shooting them, which may have prevented something else that was bad. I still feel bad—not as bad as I did—but I still feel like I did something wrong.

[The therapist uses this as an opportunity to talk about the need for practicing new alternative thoughts in order to elicit emotional change.] THERAPIST: You are well on your way, Tom, to recover-

ing. Your head is starting to get it, and your feelings need to catch up. You’ve been thinking about what happened and what you did in a certain way for a while now. You blamed yourself over and over and over again, telling yourself that you did something wrong. You gave yourself a steady diet of that type of thinking, which resulted in you feeling guilty about what happened. It is like a well-worn rut of thinking in your brain that automatically leads you down the path of feeling guilty. What you need to do now is start a new road of more realistic and truthful think- ing about the situation that will eventually be a well-

Posttraumatic Stress Disorder 89

Below is a list of questions to be used in helping you challenge your Stuck Points or problematic beliefs. Not all questions will be appropriate for the belief you choose to challenge. Answer as many questions as you can for the belief you have chosen to challenge below.

Belief: I don’t deserve to have a family.

1. What is the evidence for and against this Stuck Point?

For: I took some other man’s family.

Against: I didn’t want to have to shoot anyone. An “eye for an eye” does not apply here.

2. Is your Stuck Point a habit or based on facts?

It is a habit for me to think this way. The facts are that I didn’t do something wrong to deserve to be punished in this way.

3. In what ways is your Stuck Point not including all of the information?

My interpretation of the original situation has been fairly unrealistic, which is where I get this belief.

4. Does your Stuck Point include all-or-none terms?

N/A

5. Does the Stuck Point include words or phrases that are extreme or exaggerated (e.g., “always,” “forever,” “never,” “need,” “should,” “must,” “can’t,” and “every time”)?

I guess maybe “deserve” could be an extreme word.

6. In what way is your Stuck Point focused on just one piece of the story?

Yes, like #3, I tend to forget what all was going on at the time of my shooting.

7. Where did this Stuck Point come from? Is this a dependable source of information on this Stuck Point?

No, I’m not very reliable these days.

8. How is your Stuck Point confusing something that is possible with something that is likely?

N/A

9. In what ways is your Stuck Point based on feelings rather than facts?

I’m feeling guilty like I did something wrong when the truth is that I did what I was supposed to do.

10. In what ways is this Stuck Point focused on unrelated parts of the story?

Maybe my deserving a family has nothing to do with someone else losing theirs?

FIGURE 2.2. Challenging Questions Worksheet for Tom. Adapted from Resick, Monson, and Chard (2017). Copyright © 2017 The Guilford Press. Adapted by permission.

90 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

worn path. What is the more realistic view of your role in this event?

TOM: (tearfully) I had to shoot at the car, and people died.

THERAPIST: That’s right. And, let’s pretend for a second that you really do believe that thought. If so, what would you feel?

TOM: I’d feel so much lighter. I wouldn’t feel guilty. I’d continue to feel sad about this horrible situation, but I wouldn’t blame myself.

THERAPIST: Let’s take it to the next step. If you didn’t blame yourself and feel guilty, then would you be- lieve that you deserve to be happy with your wife and the baby that will soon be here?

TOM: Sure. THERAPIST: So, Tom, your work is to practice, prac-

tice, practice this new and more accurate way of looking at what happened and your role in it. With practice, your feelings will start matching the truth about what happened and the fact that you are not to blame.

TOM: It is kind of like training to use a weapon. They made us do certain things with our guns over and over and over again, until it was automatic. It was very automatic after a while.

THERAPIST: That’s right. There are other questions on this sheet that might be helpful in convincing you of the truth about this in your practice.

This dialogue illustrates a common occurrence at this stage in the therapy. Tom was starting to experi- ence cognitive change, but his emotional change was lagging. The therapist reinforced the need to practice the new ways of thinking to feel different. It is also important to highlight clients’ gains in changing their thinking, even if their feelings have not changed or are ambivalent. A change in thinking is framed as more than halfway to a change in feeling. In effect, changed thinking involves competing thoughts or learning, and with more repetitions of the new thought, the associ- ated feelings follow and eventually win out.

In the latter portion of this session the therapist in- troduced the Patterns of Problematic Thinking Work- sheet and provided an explanation of how this list was different from the Challenging Questions Worksheet (see Figure 2.3). More specifically, she indicated that the Patterns of Problematic Thinking Worksheet per-

tains to more general patterns of thinking versus chal- lenging individual thoughts that Tom might have. The Patterns of Problematic Thinking Worksheet lists seven types of faulty thinking patterns (e.g., oversimplifying, overgeneralizing, emotional reasoning).

Tom and the therapist went through the list and gen- erated examples for each of the patterns. For example, for “Ignoring important parts of a situation,” the thera- pist pointed out something that Tom had brought up several times during therapy. Initially, Tom had not in- cluded the important information that he and the other guards had attempted to stop the car before shooting at it. She also pointed out that emotional reasoning was similar to confusing a feeling with a fact, which had been a primary focus of the session.

When they got to the item “Overgeneralizing from a single incident,” Tom said he noticed that he was begin- ning to change his thoughts about the government and its leaders. He commented that it had been very power- ful for him to consider that, in a number of instances, his fellow soldiers had operated with integrity and were committed to the mission, and to the safety and protec- tion of others. Tom said spontaneously, “I guess that is also kind of like drawing conclusions when evidence is lacking or even contradictory.” He said that he had started stereotyping after the traumatic event—apply- ing negative attributes and opinions to everyone in the military and the government too broadly. Tom and the therapist discussed how the goal of the therapy was to have a balanced and realistic view of things versus the overly ideal version he had pretrauma or the overly pes- simistic version he had posttrauma. In other words, the goal was to find shades of gray and balance in his think- ing about the government, the military, and their lead- ership. Tom added an example of this thinking: “There are at least some people in government who want to do good for others.”

Tom was given the practice assignment to read over the list in the Patterns of Problematic Thinking Work- sheet and to note examples of times he used each of the problematic thinking patterns.

Session 6

Tom began the session by stating that he was feeling better, and that his wife had also noted a difference in him and was feeling less concerned about the therapy making him worse rather than better. The therapist asked whether Tom had completed his practice assign- ment, the Patterns of Problematic Thinking Work-

Posttraumatic Stress Disorder 91

sheet. He indicated that he had not, but that he had thought about it over the week. He also laughed and said that he had noticed the thinking patterns in his wife and others. The therapist asked Tom to complete some of the sheet in session. At this point in therapy, the therapist was sitting back more as Tom took on the role of challenging his own cognitions. The therapist provided both minimal clarification and additional ex- amples that she had noticed in working with Tom.

In this session, the therapist introduced the Chal- lenging Beliefs Worksheet. She was careful to point out that the worksheet integrated all of the previous work

Tom had done and added a few new elements. The following dialogue illustrates the introduction of this sheet (see Figure 2.4).

THERAPIST: I want to show you the final worksheet that we’re going to be using for the rest of the therapy.

TOM: OK. Wow—that looks complicated! THERAPIST: Actually, you’ve done pretty much ev-

erything on this worksheet already. This worksheet brings together into one place everything that we’ve been working on.

FIGURE 2.3. Patterns of Problematic Thinking Worksheet for Tom. Adapted from Resick, Monson, and Chard (2017). Copyright © 2017 The Guilford Press. Adapted by permission.

Listed below are several different patterns of problematic thinking that people use in different life situations. These patterns often become automatic, habitual thoughts that cause people to engage in self- defeating behavior. Considering your own Stuck Points, or samples from your everyday thinking, find examples for each of these patterns. Write in the Stuck Point or typical thought under the appropriate pattern, and describe how it fits that pattern. Think about how that pattern affects you.

1. Jumping to conclusions or predicting the future.

I tend to jump to the conclusion that I have done something wrong when bad things happen. I assume things are my fault.

2. Exaggerating or minimizing a situation (blowing things way out of proportion or shrinking their importance inappropriately).

I minimize the things that I have done well in the military.

3. Ignoring important parts of a situation.

In the past I have tended to neglect the important aspect that several of us tried to stop the car from going through the checkpoint.

4. Oversimplifying things as “good–bad” or “right–wrong.”

I can sometimes think of all the Iraqis as all bad.

5. Overgeneralizing from a single incident (e.g., a negative event is seen as a never- ending pattern).

I have assumed that because of my traumatic event, I could not be safe with my baby to be born.

6. Mind reading (assuming that people are thinking negatively of you when there is no definite evidence for this).

I assume that everyone thinks I am a terrible person, a murderer, because of what I did.

7. Emotional reasoning (using your emotions as proof—e.g., “I feel fear, so I must be in danger”).

This one is easy—I feel guilty, and there I must be.

92

F IG

U R

E 2

.4 .

C ha

lle ng

in g

Be lie

fs W

or ks

he et

fo r T

om , S

es sio

n 6.

F ro

m R

es ic

k, M

on so

n, a

nd C

ha rd

(2 01

7) . C

op yr

ig ht

© 2

01 7

T he

G ui

lfo rd

P re

ss . R

ep rin

te d

by

pe rm

iss io

n.

A . S

it u

at io

n B

. T h

o u

g h

t/ S

tu ck

P o

in t

D . C

h al

le n

g in

g T

h o

u g

h ts

E . P

ro b

le m

at ic

P at

te rn

s F.

A lt

er n

at iv

e T

h o

u g

h t(

s)

D es

cr ib

e th

e ev

en t,

th ou

gh t,

or b

el ie

f le

ad in

g to

th e

un pl

ea sa

nt

em ot

io n

(s ).

W rit

e th

ou gh

t/ S

tu ck

P oi

nt

re la

te d

to s

itu at

io n

in s

ec tio

n A

. R

at e

yo ur

b el

ie f i

n th

is th

ou gh

t/ S

tu ck

P oi

nt fr

om 0

to 1

0 0

% .

(H ow

m uc

h do

y ou

b el

ie ve

th is

th

ou gh

t? )

U se

C h

al le

n g

in g

Q u

es ti

o n

s to

e xa

m in

e yo

ur

au to

m at

ic th

ou gh

t f ro

m s

ec tio

n B

. C on

si de

r w

he th

er th

e th

ou gh

t i s

ba la

nc ed

a nd

fa ct

ua l,

or

ex tr

em e.

U se

th e

P at

te rn

s o

f P

ro b

le m

at ic

T h

in ki

n g

W

o rk

sh ee

t to

d ec

id e

w he

th er

th

is is

o ne

o f y

ou r

pr ob

le m

at ic

pa

tt er

ns o

f t hi

nk in

g.

W ha

t e ls

e ca

n I s

ay in

st ea

d of

th

e th

ou gh

t i n

se ct

io n

B ?

H ow

el

se c

an I

in te

rp re

t t he

e ve

nt

in st

ea d

of th

is th

ou gh

t? R

at e

yo ur

b el

ie f i

n th

e al

te rn

at iv

e th

ou gh

t( s)

fr om

0 to

1 0

0 %

.

E vi

de nc

e fo

r?

E vi

de nc

e ag

ai ns

t?

H ab

it or

fa ct

?

N ot

in cl

ud in

g al

l i nf

or m

at io

n?

A ll-

or -n

on e?

E xt

re m

e or

e xa

gg er

at ed

?

F oc

us ed

o n

ju st

o ne

p ie

ce ?

S ou

rc e

de pe

nd ab

le ?

C on

fu si

ng p

os si

bl e

w ith

li ke

ly ?

B as

ed o

n fe

el in

gs o

r fa

ct s?

F oc

us ed

o n

un re

la te

d pa

rt s?

Ju m

pi ng

to c

on cl

us io

ns :

E xa

gg er

at in

g or

m in

im iz

in g

:

Ig no

rin g

im po

rt an

t p ar

ts :

O ve

rs im

pl ify

in g

:

O ve

rg en

er al

iz in

g :

M in

d re

ad in

g :

E m

ot io

na l r

ea so

ni ng

:

G . R

e -R

at e

O ld

T h

o u

g h

t/ S

tu ck

P o

in t

R e

-r at

e ho

w m

uc h

yo u

no w

be

lie ve

th e

th ou

gh t/

S tu

ck P

oi nt

in

s ec

tio n

B , f

ro m

0 to

1 0

0 %

.

C . E

m o

ti o

n (s

)

S pe

ci fy

y ou

r em

ot io

n (s

) (s

ad ,

an gr

y, e

tc .)

, a nd

r at

e ho

w

st ro

ng ly

y ou

fe el

e ac

h em

ot io

n fr

om 0

to 1

0 0

% .

H . E

m o

ti o

n (s

)

N ow

w ha

t d o

yo u

fe el

? R

at e

it fr

om 0

to 1

0 0

% .

A t

a st

or e

in un

ifo rm

“T hi

s gu

y ha

s a

ch ip

o n

hi s

sh ou

ld er

b ec

au se

I a

m in

t he

m ili

ta ry

.” (1

0 0 % )

A ng

er (

8 0 % )

Fe ar

( 3 0 % )

H

ab it t

o th

in k

ev er

yo ne

di

sl ik

es m

e be

ca us

e I w

as i n

Ir aq

.

M e

I am

a ss

um in

g th

at h

e is

th in

ki ng

t he

w or

st o

f m

e.

“I d

on ’t k

no w

i f he

h as

a

ch ip

o n

hi s

sh ou

ld er

.” (6

0 % )

“I f he

d oe

s ha

ve a

c hi

p on

hi

s sh

ou ld

er , I do

n’ t

kn ow

w

ha t

it i s

ab ou

t— m

ay be

i t

is n’

t ev

en a

bo ut

m e,

l et

al

on e

ha vi ng

s er

ve d

in Ir

aq .”

(8 0 % )

3 5 %

A ng

er ( 2 0 % )

Fe ar

( 1 5 % )

Posttraumatic Stress Disorder 93

TOM: I’ll take your word for it, Doc. THERAPIST: Remember the A-B-C Worksheets from

way back when? TOM: Yes. THERAPIST: (pointing to first two columns on the Chal-

lenging Beliefs Worksheet) This is A, B, and C. You have in column A the situation, or “Activating Event” that you had on the A-B-C Worksheet. In column B you have “Automatic Thoughts,” which is the “Be- lief/Stuck Point” portion of the A-B-C Worksheet. Last, section C, “Emotions,” is the “Consequence” portion of the A-B-C Worksheet.

TOM: OK. So far, so good. THERAPIST: Section D is where you identify the “Chal-

lenging Questions” from that sheet that apply to the thought or Stuck Point that you’re working on. In section E, you identify the type of “Patterns of Prob- lematic Thinking” that apply to the thought or Stuck Point that you’re working on. Make sense?

TOM: Yes. THERAPIST: So, only section F, “Alternative Thought,”

is new. Here you identify alternative thoughts that you could have about the situation. In other words, we’re looking for alternative statements that you can tell yourself or different interpretations of the event. In sections G and H, you get to see how your belief in your original thoughts may change and how the new thoughts affect your feelings.

TOM: OK. THERAPIST: So, let’s pick a Stuck Point and start using

this Challenging Beliefs Worksheet. What Stuck Point would you like to learn with?

TOM: Well, I still wonder if there are people out in the world who want to hurt me, even if I now realize that no sniper is going to take me out.

THERAPIST: So, let’s pick a specific event—the more specific, the better.

TOM: I was in the grocery store, and I had my uniform on. There was this guy who seemed to have a chip on his shoulder about it—like he hated me or some- thing.

THERAPIST: So, write down the event in Section A. (Pauses.) What was your thought? You’ve already mentioned one of them.

TOM: This guy has a chip on his shoulder about me because I’m in the military.

THERAPIST: Good. How strongly do you believe that thought?

TOM: 100%. THERAPIST: OK, let’s write that next to the thought.

We are now rating how much you believe in your thoughts because you’re going to see at the end how much your thought has changed. What feeling or feelings are associated with that thought?

TOM: Definitely anger. THERAPIST: Makes sense, given your thought. How

much anger from 0 to 100%, with 100% being as much anger as you could possibly imagine having?

TOM: Hmm . . . I’d say 80%. THERAPIST: Any other feelings? You can have more

than one. TOM: I guess when I stop and think about it, there is

some fear there, too. THERAPIST: That makes sense, too. How much fear

from 0 to 100%? TOM: Oh, maybe 30%. It’s not the strongest feeling,

but it’s there, because I’m wondering if he is going to say something or do something.

THERAPIST: Nice job. Let’s move onto the next column that relates to the Challenging Questions Worksheet you’ve already done. Take a look at this list. What questions might apply here?

TOM: I guess I might be confusing a habit with a fact. It seems like it is a habit for me to assume that every- one dislikes me because I was in Iraq. I really don’t know if that is why he seemed to have a chip on his shoulder. I guess I also don’t know for sure if he had a chip on his shoulder. He didn’t say anything to me. (Pauses.) I guess that is also an example of the source of information being unreliable, and that source is me! (Laughs.)

THERAPIST: While you were talking, I was thinking that the same questions applied. You can also pick out other challenging questions that might apply, but usually two or three will do the trick. In the next column, we’re going to refer to the Patterns of Prob- lematic Thinking Worksheet. What might fit here?

TOM: I guess one jumps out—mind reading. THERAPIST: How so? TOM: I’m assuming that he is thinking the worst about

me and about my having served my country. I’m good at that.

94 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: Write that down. You can add others later if something seems to apply. The next column is very important. This is where you start coaching yourself to come up with alternative thoughts or perceptions about the situation. Based on having asked yourself these questions and noticing the problematic think- ing patterns, what other ways might you think about this situation?

TOM: I guess one thing I could say to myself is, “I don’t know if he has a chip on his shoulder.” I could also say, “If he does have a chip on his shoulder, I don’t know what it is about—maybe it isn’t even about me, let alone about my having served in Iraq.”

THERAPIST: Wow! You’re doing great at this. Let’s get those written down. Let’s also add how much you believe those two new thoughts. Below those alterna- tive thoughts is the section that asks you to recon- sider how much you believe your original thoughts over here in section B. How much do you believe them after walking through this process? Before you said 100%.

TOM: Oh, I’d say now it is only about 35%. THERAPIST: That is a big change. You went from 100%

certainty to 35% certainty that he had a chip on his shoulder because you fought in the war.

TOM: I’m a little surprised by that myself. THERAPIST: Let’s take it the final step. How about your

feelings now? Let’s rerate those here. TOM: My anger is way down—I’d say only about 20%.

The anxiety is still there because I really wouldn’t want to have to protect myself, and he might have had a chip on his shoulder at me. It is down a little, though, because I realize I’m not 100% certain he was out to get me. I’d say maybe 15% on fear.

THERAPIST: Do you have questions about what we just did here?

TOM: Not at the moment. I’ll get back to you. THERAPIST: I’m going to ask that you do one of these

sheets on a Stuck Point per day until I see you again. I’m also going to give you some example sheets other patients have done that might be helpful to you.

TOM: OK. Should be interesting. . . .

The therapist cautioned Tom that he should not ex- pect his beliefs and feelings always to change complete- ly in the process of doing the sheet. The old thought would need to be completely dismantled, and the new

thought would need to become more habitual for him to see a more permanent change. The therapist sug- gested that Tom read the sheets he completed over to himself a number of times to facilitate the process. Tom was instructed to complete a Challenging Beliefs Work- sheet each day prior to the next session, taking thoughts off his Stuck Points Log to challenge. The therapist also reminded Tom that he needed to finish the Patterns of Problematic Thinking Worksheet assignment from last session.

Session 7

Tom arrived at the session having completed the Pat- terns of Problematic Thinking Worksheet, as well as two Challenging Beliefs Worksheets. The therapist spent a little time looking at his answers to the Patterns of Problematic Thinking Worksheet, because she did not want to send the message inadvertently that com- pleting the assignments was unimportant. She asked Tom to read the patterns that he had completed at home, as opposed to those in their previous session.

Tom completed only two Challenging Beliefs Work- sheets. Thus, the therapist emphasized how Tom might use this process more generally in his day-to-day life, and highlighted how more practice would lead to more results. She noted that using the process on less emo- tionally distressing topics could actually be very help- ful in getting the process down. It is always easier to learn something when one is not dealing with the most challenging circumstances. She used a military analogy with Tom about learning to load and shoot a gun—best learned in a nonconflict situation, so that it is a more rote behavior when under fire.

The therapist skimmed the two sheets Tom had com- pleted and noticed that he had struggled most coming up with alternative statements related to his wife’s im- pending delivery of their child. The following dialogue ensued (see Figure 2.5):

THERAPIST: I notice that you might have had the most trouble coming up with alternative thoughts about how safe you can be with your wife and your child who is about to be born.

TOM: Yeah, I don’t really like to talk about it. It freaks my wife out. I’m uncomfortable being around my wife, which makes her feel bad, but I’m just afraid I’m going to hurt her or the child.

THERAPIST: Let’s take your first thought because it is

95

F IG

U R

E 2

.5 .

C ha

lle ng

in g

Be lie

fs W

or ks

he et

fo r T

om , S

es sio

n 7.

F ro

m R

es ic

k, M

on so

n, a

nd C

ha rd

(2 01

7) . C

op yr

ig ht

© 2

01 7

T he

G ui

lfo rd

P re

ss . R

ep rin

te d

by

pe rm

iss io

n.

A . S

it u

at io

n B

. T h

o u

g h

t/ S

tu ck

P o

in t

D . C

h al

le n

g in

g T

h o

u g

h ts

E . P

ro b

le m

at ic

P at

te rn

s F.

A lt

er n

at iv

e T

h o

u g

h t(

s)

D es

cr ib

e th

e ev

en t,

th ou

gh t,

or b

el ie

f le

ad in

g to

th e

un pl

ea sa

nt

em ot

io n

(s ).

W rit

e th

ou gh

t/ S

tu ck

P oi

nt

re la

te d

to s

itu at

io n

in s

ec tio

n A

. R

at e

yo ur

b el

ie f i

n th

is th

ou gh

t/ S

tu ck

P oi

nt fr

om 0

to 1

0 0

% .

(H ow

m uc

h do

y ou

b el

ie ve

th is

th

ou gh

t? )

U se

C h

al le

n g

in g

Q u

es ti

o n

s to

e xa

m in

e yo

ur

au to

m at

ic th

ou gh

t f ro

m s

ec tio

n B

. C on

si de

r w

he th

er th

e th

ou gh

t i s

ba la

nc ed

a nd

fa ct

ua l,

or

ex tr

em e.

U se

th e

P at

te rn

s o

f P

ro b

le m

at ic

T h

in ki

n g

W

o rk

sh ee

t to

d ec

id e

w he

th er

th

is is

o ne

o f y

ou r

pr ob

le m

at ic

pa

tt er

ns o

f t hi

nk in

g.

W ha

t e ls

e ca

n I s

ay in

st ea

d of

th

e th

ou gh

t i n

se ct

io n

B ?

H ow

el

se c

an I

in te

rp re

t t he

e ve

nt

in st

ea d

of th

is th

ou gh

t? R

at e

yo ur

b el

ie f i

n th

e al

te rn

at iv

e th

ou gh

t( s)

fr om

0 to

1 0

0 %

.

E vi

de nc

e fo

r?

E vi

de nc

e ag

ai ns

t?

H ab

it or

fa ct

?

N ot

in cl

ud in

g al

l i nf

or m

at io

n?

A ll-

or -n

on e?

E xt

re m

e or

e xa

gg er

at ed

?

F oc

us ed

o n

ju st

o ne

p ie

ce ?

S ou

rc e

de pe

nd ab

le ?

C on

fu si

ng p

os si

bl e

w ith

li ke

ly ?

B as

ed o

n fe

el in

gs o

r fa

ct s?

F oc

us ed

o n

un re

la te

d pa

rt s?

Ju m

pi ng

to c

on cl

us io

ns :

E xa

gg er

at in

g or

m in

im iz

in g

:

Ig no

rin g

im po

rt an

t p ar

ts :

O ve

rs im

pl ify

in g

:

O ve

rg en

er al

iz in

g :

M in

d re

ad in

g :

E m

ot io

na l r

ea so

ni ng

:

G . R

e -R

at e

O ld

T h

o u

g h

t/ S

tu ck

P o

in t

R e

-r at

e ho

w m

uc h

yo u

no w

be

lie ve

th e

th ou

gh t/

S tu

ck P

oi nt

in

s ec

tio n

B , f

ro m

0 to

1 0

0 %

.

C . E

m o

ti o

n (s

)

S pe

ci fy

y ou

r em

ot io

n (s

) (s

ad ,

an gr

y, e

tc .)

, a nd

r at

e ho

w

st ro

ng ly

y ou

fe el

e ac

h em

ot io

n fr

om 0

to 1

0 0

% .

H . E

m o

ti o

n (s

)

N ow

w ha

t d o

yo u

fe el

? R

at e

it fr

om 0

to 1

0 0

% .

B ei

ng a

ro un

d m

y w

ife a

nd ch

ild

“O ut

o f no

w he

re , I’l

l ge

t ph

ys ic al

ly v

io le

nt .”

(8 0 % )

Fe ar

( 8 5 % )

G iv

en m

y hi

st or

y, i t

is a

ct ua

lly a

l ow

p ro

ba bi

lit y

no t

hi gh

.

I am

as

su m

in g

be ca

us e

I sh

ot

on ce

i n

a ce

rt ai

n si tu

at io

n,

I’l l be

v io

le nt

i n

ge ne

ra l.

“I t

is u

nl ik

el y

th at

I ’ll

h ur

t m

y fa

m ily

, an

d ev

en m

or e

un lik

el y

th at

it w

ill b

e su

dd en

a nd

u ne

xp ec

te d.

” (9

5 % )

1 0 %

Fe ar

( <1

0 % )

I’m e

xa gg

er at

in g

th e

lik el

ih oo

d th

at I ’d

b e

vi ol

en t

96 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

kind of general. How is it that you think you’re going to hurt them? Are we talking physically or mentally?

TOM: Oh, physically is what I mean. I don’t know how exactly, but somehow, some way, I guess.

THERAPIST: That makes it a bit more concrete. How do you physically think you’re going to hurt them? Do you think you’ll shoot them, given your trauma history?

TOM: No. Absolutely not. THERAPIST: So, what have you considered in your

mind? TOM: I guess I’m worried that, out of nowhere, I’ll get

physically violent. THERAPIST: OK, now we’re cooking. Let’s write that

down. “Out of nowhere I’ll get physically violent.” I noticed that in section C you didn’t mention any- thing about confusing possibilities with certainties. Safety issues are almost always about gauging prob- abilities. The world is not a completely safe place, and every day we all make calculated risks about our safety based on the probability of bad things happen- ing to us or to someone else. How do you think that question might apply?

TOM: Are you getting at the idea that I’m confusing how likely it is to be?

THERAPIST: Precisely. How do you think that applies here?

TOM: I’m convinced that “somehow, some way” I’m going to hurt my family, so I believe that it is a high potential that it will happen and not a low possibility. I think you think that the possibility I will do that is low. But, I’m still concerned about it.

THERAPIST: Let’s talk about the actual likelihood. How often have you hurt your family physically?

TOM: Never. Are you kidding? THERAPIST: I thought as much, but you made it sound

like it was very likely to happen. I guess that’s part of the problem, right?

TOM: You’re right. THERAPIST: How often have you been physically vio-

lent against anyone? TOM: I haven’t, besides the shooting. And it surely

hasn’t been unexpected. Now that we’re talking through it, it feels a little silly.

THERAPIST: So, it sounds like figuring out the actual probability of this is right where we needed to go.

Given what we’ve talked about, what is an alternative statement you can tell yourself and how much do you believe it?

TOM: It is unlikely that I’ll hurt my family, and even more unlikely that it will be sudden and unexpected given that it has never happened.

THERAPIST: Let’s keep going to see how that might change how you feel. You wrote that you had 85% fear. What is that rating now?

TOM: Less than 10%. There is some fear now that I know I am capable of hurting a family, but like we’ve talked about before—and what I have to remem- ber—is that it occurred in a certain situation and not in my everyday life now as a civilian in my family.

This exchange between Tom and the therapist il- lustrates the hallmark role of probability in assessments and beliefs about safety, the first of the themes that is introduced in this session. It is important to realize that there are some objectively unsafe situations or behav- iors, and these should not be minimized or challenged. If there are unreasonable safety precautions or beliefs, the actual probability of harm should be carefully eval- uated, keeping in mind that 100% safety is rarely, if ever, guaranteed.

The Safety module was then introduced. Safety is the first of five modules (two- to three-page handouts) that also include Trust, Power/Control, Esteem, and Intimacy. The therapist oriented Tom to the format of the module, which included discussion about how beliefs about the self and others in this area can be dis- rupted or seemingly confirmed after a traumatic event, depending on one’s history prior to the traumatic event. The modules describe how these problematic beliefs are manifested emotionally and behaviorally (e.g., not leav- ing one’s home because of the belief that the world is unsafe). It also provides alternative self-statements that are more balanced and realistic in each area.

Tom had felt safe with others before the traumatic event occurred, and this sense of safety about others had been disrupted, as evidenced by his sense that oth- ers around him were out to get him. Pretrauma, Tom had also felt as though he was not a danger to others. Posttrauma, he believed that he could not be safe with others, which specifically manifested in his concerns about being around his pregnant wife. The therapist suggested that Tom complete at least one worksheet on his Stuck Points about others being safe, as well as his being a possible danger to others.

Posttraumatic Stress Disorder 97

Session 8

Tom did an excellent job of completing Challenging Beliefs Worksheets on a daily basis, including ones on the theme of safety. About half of the session was spent on Tom sharing with the therapist about these work- sheets and the two of them collaboratively improving completion of them for Tom’s benefit.

The therapist transitioned the session to introduce the Trust module. Tom noted that he had pretty good trust of himself and others prior to his best friend com- mitting suicide when they were in high school. Tom said that after the experience, he sometimes did not trust his judgments about other people, and that he felt respon- sible for not anticipating his friend’s suicide. The mili- tary traumatic event served to confirm his belief that he could not trust his judgments about others’ intentions. Tom’s concerns about his ability to be safe with his wife and unborn child also dovetailed with the issue of trust. The therapist and Tom went over the information in the Trust module handout, and Tom seemed to reso- nate with all of the potential effects. He reported that he had really been trying to open up with his wife and not avoid her. He noted that they were communicating more, which made both of them more relaxed and com- fortable in the final days of her pregnancy.

The therapist closed the session by assigning daily Challenging Beliefs Worksheets, asking Tom to do at least one on the topic of trust. She reminded him that, like other areas, the goal is to develop balanced alternative thoughts. In the case of trust, she noted that Stuck Points about trust often revolve around making all-or-none judgments, either trusting or not. The goal is to consider trust as multidimensional, with different types of issues resulting in different levels of trust in different situations. Tom also agreed to complete the Trust Star Worksheet, which is designed to help the client identify these different types of trust and levels of each type.

Session 9

Tom arrived at this session having completed a num- ber of Challenging Beliefs Worksheets. Several of them were about trust, including his level of trust of the gov- ernment and trust of himself in being a father. He had also used the worksheets on non-trust-related topics related to his daily life. He commented that the work- sheets had been helpful in working out his thinking be- fore he behaved impulsively or felt miserable.

The therapist praised Tom for completing the work- sheets so well, and asked him whether he felt he could use assistance with any of the worksheets. Tom quickly responded that he wanted to focus on the sheet about fatherhood because he was experiencing so much anxi- ety about his child’s impending birth. In turning their attention to this worksheet, the therapist immediately noticed that Tom had probably struggled with this worksheet, because he had listed so many different types of thoughts that were fueling his anxiety about becoming a father. She used this as an opportunity to fine-tune Tom’s use of the worksheets. The therapist’s choice in thoughts to challenge first also illustrates the prioritization of treatment targets in the therapy. She chose to go after the more directly trauma-relat- ed thoughts that contained remnants of assimilation. Tom’s thoughts about deserving to be happy about starting a family given the death of the woman, fetus, and child suggested that he had not fully accepted the traumatic event and the circumstances surrounding it. Thus, she addressed this thought first (see Figure 2.6).

THERAPIST: Wow, you’ve got lots of thoughts going on in your head about becoming a father, don’t you? I’m going to suggest that we use a different worksheet for each of the clusters of thoughts you’re having on this topic. I think that will make your use of the Chal- lenging Beliefs Worksheet better. It seems that some thoughts are directly related to your traumatic expe- rience, others are specifically related to your wife’s labor and delivery, and still others are related more generally to being a parent. Let’s focus on those that are directly related to your trauma. You wrote that one of your feelings was guilt (85%), and I’m assum- ing that it is related to your thought that it isn’t right that you’re happy with a soon-to-be-born baby given what happened.

TOM: That’s right. If I’m really honest, I still feel guilty that the Iraqi woman was pregnant and getting ready to have a child, and the shooting deprived her of the ability to have that child and be happy, and I’m get- ting ready to have that happiness.

THERAPIST: We’ve talked about this before, but we’ve been more focused on the man and the child in- volved in the situation.

TOM: Yeah, I think the closer my wife gets to delivery, the more I think about the Iraqi woman. I’ve been imagining that she wasn’t part of a potential plot for terrorist activity and was more an innocent partici-

98

F IG

U R

E 2

.6 .

C ha

lle ng

in g

Be lie

fs W

or ks

he et

fo r T

om , S

es sio

n 9.

F ro

m R

es ic

k, M

on so

n, a

nd C

ha rd

(2 01

7) . C

op yr

ig ht

© 2

01 7

T he

G ui

lfo rd

P re

ss . R

ep rin

te d

by

pe rm

iss io

n.

A . S

it u

at io

n B

. T h

o u

g h

t/ S

tu ck

P o

in t

D . C

h al

le n

g in

g T

h o

u g

h ts

E . P

ro b

le m

at ic

P at

te rn

s F.

A lt

er n

at iv

e T

h o

u g

h t(

s)

D es

cr ib

e th

e ev

en t,

th ou

gh t,

or b

el ie

f le

ad in

g to

th e

un pl

ea sa

nt

em ot

io n

(s ).

W rit

e th

ou gh

t/ S

tu ck

P oi

nt

re la

te d

to s

itu at

io n

in s

ec tio

n A

. R

at e

yo ur

b el

ie f i

n th

is th

ou gh

t/ S

tu ck

P oi

nt fr

om 0

to 1

0 0

% .

(H ow

m uc

h do

y ou

b el

ie ve

th is

th

ou gh

t? )

U se

C h

al le

n g

in g

Q u

es ti

o n

s to

e xa

m in

e yo

ur

au to

m at

ic th

ou gh

t f ro

m s

ec tio

n B

. C on

si de

r w

he th

er th

e th

ou gh

t i s

ba la

nc ed

a nd

fa ct

ua l,

or

ex tr

em e.

U se

th e

P at

te rn

s o

f P

ro b

le m

at ic

T h

in ki

n g

W

o rk

sh ee

t to

d ec

id e

w he

th er

th

is is

o ne

o f y

ou r

pr ob

le m

at ic

pa

tt er

ns o

f t hi

nk in

g.

W ha

t e ls

e ca

n I s

ay in

st ea

d of

th

e th

ou gh

t i n

se ct

io n

B ?

H ow

el

se c

an I

in te

rp re

t t he

e ve

nt

in st

ea d

of th

is th

ou gh

t? R

at e

yo ur

b el

ie f i

n th

e al

te rn

at iv

e th

ou gh

t( s)

fr om

0 to

1 0

0 %

.

E vi

de nc

e fo

r?

E vi

de nc

e ag

ai ns

t?

H ab

it or

fa ct

?

N ot

in cl

ud in

g al

l i nf

or m

at io

n?

A ll-

or -n

on e?

E xt

re m

e or

e xa

gg er

at ed

?

F oc

us ed

o n

ju st

o ne

p ie

ce ?

S ou

rc e

de pe

nd ab

le ?

C on

fu si

ng p

os si

bl e

w ith

li ke

ly ?

B as

ed o

n fe

el in

gs o

r fa

ct s?

F oc

us ed

o n

un re

la te

d pa

rt s?

Ju m

pi ng

to c

on cl

us io

ns :

E xa

gg er

at in

g or

m in

im iz

in g

:

Ig no

rin g

im po

rt an

t p ar

ts :

O ve

rs im

pl ify

in g

:

O ve

rg en

er al

iz in

g :

M in

d re

ad in

g :

E m

ot io

na l r

ea so

ni ng

:

G . R

e -R

at e

O ld

T h

o u

g h

t/ S

tu ck

P o

in t

R e

-r at

e ho

w m

uc h

yo u

no w

be

lie ve

th e

th ou

gh t/

S tu

ck P

oi nt

in

s ec

tio n

B , f

ro m

0 to

1 0

0 %

.

C . E

m o

ti o

n (s

)

S pe

ci fy

y ou

r em

ot io

n (s

) (s

ad ,

an gr

y, e

tc .)

, a nd

r at

e ho

w

st ro

ng ly

y ou

fe el

e ac

h em

ot io

n fr

om 0

to 1

0 0

% .

H . E

m o

ti o

n (s

)

N ow

w ha

t d o

yo u

fe el

? R

at e

it fr

om 0

to 1

0 0

% .

K ill

in g

a pr

eg na

nt

Ir aq

i w

om an

an

d he

r so

n.

“I t

is n’

t ri

gh t

th at

I ’m

ha

pp y

w it h

a ba

by o

n th

e w

ay , gi

ve n

w ha

t ha

pp en

ed .”

(8 0 % )

“S he

m ig

ht n

ot h

av e

be en

pa

rt o

f a

te rr

or is t

pl ot

, bu

t ju

st a

p as

se ng

er .”

(5 0 % )

G ui

lt (

8 5 % )

H er

i nt

en ti on

s ar

e no

t re

le va

nt . M

in e

ar e.

I’m t

ry in

g to

f ig

ur e

ou t

w ha

t w

as i n

he r

he ad

.

“M y

in te

nt io

ns a

re w

ha t

m at

te r. I

di dn

’t in

te nd

t o

do

an yt

hi ng

t o

de pr

iv e

so m

eo ne

el se

o f fa

m ily

h ap

pi ne

ss .”

(8 5 % )

1 5 % ( 2 nd

d oe

sn ’t

m at

te r)

G ui

lt ( 5 % )

H ap

py ( 1 0 % )

Posttraumatic Stress Disorder 99

pant. Then, I go back and forth, thinking that she might have actually been involved and didn’t care that she was pregnant. Or maybe it was just an ac- cident, and they truly didn’t understand that they needed to stop. Uggghhhh, it is exhausting.

THERAPIST: And we’ll never know. If your friend were saying all of this to you, what would be your response to him?

TOM: I’d be telling him to quit beating himself up and feeling guilty.

THERAPIST: Easier said than done. Anything else? Maybe it would help to look at the Challenging Questions and Patterns of Problematic Thinking Worksheets. I’m wondering if you are focusing on unrelated parts of the story—item 10 on the Chal- lenging Questions Worksheet.

TOM: Hmm . . . what is unrelated in this case? THERAPIST: How relevant are her intentions to deserv-

ing to be happy yourself about having a child? TOM: (Pauses.) I’m going to have to think about that

for a second. THERAPIST: Aren’t your intentions in that situation

what is relevant? Were your intentions at that time to deprive her of the right to bear her child and live happily ever after?

TOM: No, not at all. THERAPIST: So, why guilt? What did you do wrong

that you should be punished about? TOM: Oh, wow. I hadn’t thought of that. Her inten-

tions are irrelevant. It only makes me crazy to try to get in her head. I guess that would be mind reading, now wouldn’t it?

THERAPIST: Very good—a different spin on mind reading. So, what is the alternative, more balanced and realistic thought?

TOM: My intentions are what matter. I didn’t intend for her to lose her own or her baby’s life.

THERAPIST: Go on . . . do you have a right to experi- ence happiness?

TOM: I guess I do. It just feels weird. THERAPIST: Sure—it feels different. It is different than

what you’ve been thinking about it for a while. I’m curious—what would you feel if you said to yourself, “I did not intentionally do anything to deprive some- one else of family happiness. I deserve to be happy in becoming a father.”

TOM: I’d feel less guilty for sure, and even happy. THERAPIST: Let’s get this all written down. Now you

have the job of holding on to these new insights and practicing them. Read over this worksheet every day until you see me again. I’d also like you to take these other thoughts on your original Challenging Beliefs Worksheet about this topic and put them on separate worksheets and work through them. Can you com- mit to doing that?

TOM: Yes, I already feel better. THERAPIST: This is an exciting time—you’ve got to

continue to work on this, so that you can have the enjoyment you deserve!

At this point, the therapist introduced the Power/ Control module. Tom admitted that prior to the trau- matic event, he was someone who liked to be in control. He did not like unpredictability, and he noticed that this tendency had gotten especially bad after his friend’s suicide. The military lifestyle seemed to be congruent with this tendency. Tom indicated that he had not had authority issues prior to the traumatic event, but he had noticed himself questioning authority much more since his military trauma. As with previous sessions, Tom was given the practice assignment to complete Challenging Beliefs Worksheets every day prior to the next session, and at least one was assigned on power/control.

Session 10

Tom began the session by saying that his wife had gone to her obstetrician the previous day, and that her labor would be induced in 1 week if she did not naturally go into labor before then. Tom indicated that the last session had been very good in helping him to become happier about his child’s impending birth, and that he had read the Challenging Questions Worksheet about deserving to be happy several times since the last ses- sion. He believed it more and more. He stated that he was still having some anxiety about becoming a father, and about everything going OK with his wife’s labor and delivery. The therapist normalized some of Tom’s anxiety, stressing how it was very natural for a first-time father, and Tom was able to recognize the typicality of this anxiety in others he had witnessed becoming par- ents.

Tom stated that since reading the Power/Control module after the last session, he had started to realize that not everyone in authority over him had wielded

100 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

their authority malevolently. This was very important in light of Tom’s preexisting history of desiring to exert control; he had directly confronted his illusion of con- trol. The therapist and Tom went over this worksheet.

Tom went on to describe how his belief that he could and should have control over everything had resulted in low self-esteem. In general, when things did not go as he desired, Tom felt as though he was a failure for not controlling the outcome. This belief structure led him to think that he should have been able to control his friend and stop him from committing suicide. It also led him to believe that he should have been able to create a positive outcome in the military traumatic event. This discussion served as a natural segue to the next topic—esteem. Tom admitted that he had become someone who thrived too much on accomplishment. This had affected his self-esteem and was especially rel- evant to his belief that he had not accomplished his goal in the military because he had to be taken from the field after the traumatic event at the checkpoint.

After reviewing the Esteem module, the therapist asked Tom to complete Challenging Beliefs Worksheets on his remaining Stuck Points, as well as any Stuck Points relating to esteem. He was also given two other assignments: to practice giving and receiving compli- ments every day, and to do one nice thing for himself every day that was not contingent on “achieving” some- thing. These assignments were to help him with his self- and other-esteem.

Session 11

Tom completed a worksheet on self-esteem related to his belief that he had not achieved his goal within the military. The therapist and Tom went over this work- sheet, and both noted that he had made significant progress by using the worksheet to change the way he thought and felt about himself. He asserted that he was beginning to see that people are much more than their professional accomplishments. They also have other activities and relationships with their families, friends, and themselves.

The therapist inquired about the assignment of giv- ing and receiving compliments. Tom replied that it had gone well, even though it felt a bit awkward and forced. He was even able to notice that when he gave compli- ments and was more positive toward other people, he seemed to get more positive responses back from them. The therapist noticed that several of the compliments were to his wife, and she pointed out that Tom seemed

more connected to his wife. He said that he was ac- tually beginning to feel glimmers of excitement about the birth of their child. He reported that he was still feeling some anxiety about becoming a father, and about how the labor and delivery would go, but that the anxiety was less and more manageable. When the therapist asked about Tom receiving compliments, he reported more difficulties. She asked what Tom typi- cally did when he received compliments, and it became clear that he often deflected or minimized them. Cor- respondingly, Tom also said that he had only done one nice thing for himself since the last session, and that it had felt uncomfortable. This pattern seemed to fit with Tom’s overall schema of being unworthy and un- deserving. The following dialogue ensued between the therapist and Tom:

THERAPIST: It seems like you have a hard time letting someone be nice to you and being nice to yourself.

TOM: Yes. THERAPIST: Why do you think that is? TOM: I don’t know. (Pauses.) I don’t like it. It feels like

they shouldn’t be nice to me, and I shouldn’t be nice to me.

THERAPIST: Hmm  .  .  . I wonder if there is anything “off” about that thinking? What do you think?

TOM: As I hear myself say it, it sounds a little weird. It sounds like I don’t deserve to have nice things for me. Kind of like not deserving to have a family . . .

THERAPIST: This seems like a larger tendency in your life—one of those problematic thinking patterns. What pattern do you hear in your thinking? Look at the worksheet if you want to.

TOM: Maybe emotional reasoning. I feel like I don’t de- serve it; therefore, I must not deserve it. That seems like the best one. Maybe I’m also drawing a conclu- sion when the evidence is lacking.

THERAPIST: I agree. Given how much you seem to fol- low this pattern of thinking, I’m betting it has been around for a while—maybe even before the shooting occurred in Iraq.

TOM: It has. I think it had to do with my dad, his alco- holism, and not being close to me. As a kid, I always thought I had done something wrong, or that I was so bad that he didn’t want to be around me.

THERAPIST: Now, with adult eyes, what do you think about your dad not being close to you?

Posttraumatic Stress Disorder 101

TOM: I figure that he drank for a reason, and that it might have been me and my other brothers and sis- ters.

THERAPIST: Why do you assume that he drank because of you kids?

TOM: I don’t know. I figure it was stressful having four kids.

THERAPIST: It probably was at times, but as you hear yourself talk about this, what is amiss in how you’ve made sense of his drinking and being close to you?

TOM: I’ve known other people who had four kids and didn’t have drinking problems. There were a lot of big families where I grew up. Plus, I know that he and my mom had money problems when we were young, and that they fought a lot.

THERAPIST: So, again, why then do you assume it was you who caused his drinking and alienation?

TOM: When we talk about it, I guess I see that it might not have been me alone.

THERAPIST: Or not even you at all. Everybody has a choice about how they handle their stress, and it seems that he was distant from everyone, not just you.

TOM: True. It still feels that way. THERAPIST: There seems to be a well-worn path in your

brain that when something goes wrong, you blame yourself. The next step is that you deserve to be pun- ished, or at least you don’t deserve anything good. I don’t think this tendency is going to change over- night. You’re going to need to work hard at talking to yourself more rationally to change how you feel. For that new path to get worn, you’re going to have to walk down it a number of times. Pretty soon, the path will be more worn and automatic. It will take some effort, but you can change the way you auto- matically feel. I’d like you to do a Challenging Be- liefs Worksheet about what we’ve just talked about. Once we get a good one about it, you can read and refer to it as part of forging that new path. Can you do that?

TOM: Yes. I think it would be good.

This exchange regarding Tom’s dad dovetailed nicely with the final module, Intimacy. The therapist noted that people tend to think of intimacy as it relates to romantic relationships, and especially in terms of sexual intimacy. She stressed that there are all kinds of intima-

cy with different people. In essence, intimacy relates to how close and open we feel with other people. She went on to discuss the notion of self-intimacy, or how well we take care of, support, and soothe ourselves. In other words, it reflects how good a relationship we have with ourselves. Tom admitted that he struggled with being close to other people, which had most obviously mani- fested in the work he had done relative to his wife and unborn child. As noted earlier, Tom also struggled with doing nice things and taking good care of himself. Both of these areas seemed to be affected by Tom’s underly- ing schema that he was undeserving and unworthy.

The therapist assigned daily Challenging Beliefs Worksheets, continuation of the behavioral assign- ments, and requested that Tom do worksheets on being nice to himself and being close to his wife. In addition, she asked Tom to write a final Impact Statement, spe- cifically about his understanding of the trauma now, after all the work he had done. The therapist asked him to write about his current thoughts/beliefs in the areas of safety, trust, power/control, esteem, and intimacy.

Session 12

The day after Session 11, Tom left a message indicat- ing that his wife had delivered a healthy baby girl. He indicated in his voice-mail message that he felt happy and relieved. He went on about how beautiful the baby was, how well his wife had done in labor and delivery, and how he had enjoyed holding his daughter in his arms the first time. The 12th session was delayed a bit because of the baby’s arrival.

Tom’s wife and new daughter accompanied him to the final session. The therapist spent some time admir- ing Tom’s new baby and congratulating his wife be- fore starting the final session. Tom seemed genuinely proud and happy about his daughter, and noted that becoming a father had been more natural than he had anticipated. He commented that he had been worried that he would not want to hold the infant for fear of hurting her or because he would do something wrong. Instead, he found it almost “instinctual” to hold her, and that soothing her had come more naturally than he expected. Tom seemed surprised about how natural his role as a father had come.

The therapist inquired about how the assignments had gone. Tom said that he had not done as much as he had hoped given the baby’s arrival, but that he had done worksheets about his father and about being close to his wife. The therapist looked over these worksheets,

102 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

which Tom had done very well. She asked Tom about how helpful they had been, and he reported that they had been very helpful. He added that he was still strug- gling about his father, but that he was beginning to think that it was not all about him, which had made him feel better about himself and less guilty in general. He mentioned that he was considering writing a let- ter to his father about his daughter’s arrival, and that he was thinking about asking his father about why he drank and distanced himself from his family. The therapist reinforced Tom for considering this and for not blindly making assumptions about his role in his father’s drinking. However, she also attempted to inoc- ulate Tom to the possibility that his father could blame him or his siblings for his alcoholism (given that she did not know his father or his history), and that this did not necessarily mean that it was true. She reminded him that he needed to consider the source of information, and that any good detective would get multiple reports. Tom seemed to like the idea of getting more informa- tion from others, mentioning that he and his siblings had never really talked about his belief that they were to blame for their father’s alcoholism.

Tom also shared that he better understood the idea of having intimacy, without sex, in his relationship with his wife. He said that since the birth of their child, he felt closer to his wife and had generally been more open and present to her. The therapist asked him about doing nice things for himself, and Tom laughed and said that he was more open to that but was finding less time to do it with a new baby.

The therapist then asked Tom to read the final Im- pact Statement about the meaning of the event for him after the work that he had done. He read:

“There is no doubt that this traumatic event has deep- ly impacted me. My thoughts about myself, others, and the world were changed. When I started thera- py, I believed that I was a murderer. I blamed myself completely. Now, I believe that I shot a family, but I did not murder them. I realize that I and others around me had to do what we did at the time, and that we chose to shoot because we had to. I will never know what that man, or maybe even the family, was trying to do by going through that checkpoint, but I know now that I had no choice but to shoot to stop them. Regarding safety, I used to think that there were people out to get me, but now I realize that the probability of that is slim. I still feel a little anxious about me, my wife, and now my daughter, getting

hurt, but not by a sniper. That seems unlikely. Now I worry about the stuff that everyone worries about— like crazy drivers, illness, or some accident. About safety, I used to worry that I was going to go ‘off ’ and hurt my family. I don’t believe that I will do that, because I’ve never done that before and basically this trauma messed with my head about how likely I would be to hurt someone unless I had to. I’m trust- ing myself more in terms of the decisions I make, and I have some more faith and trust in my government now that I realize I really needed to shoot in that situation. I think I may always struggle with wanting to have power and control over things, but I’m work- ing on not having control over everything. The fact is, I don’t have control, even though I like to think that I do. My self-esteem is improving. I have to re- member that not every bad thing that happens is my fault, and that I deserve to be happy even if I don’t fully believe it yet. One of the biggest things that seems to be changing is that I’m enjoying being close to my wife and my new daughter. I used to avoid my wife, because I thought I didn’t deserve to be happy and that I might hurt her. Slowly I’m realizing that it is not very likely that I’ll hurt my wife or my new daughter, or at least hurt them intentionally. My wife seems much happier now. I want to hold on to this time in my life and provide a good life for my daugh- ter and wife. I’m happy to know that my daughter is not going to know someone who thought that snipers were out to get him, and who was anxious, avoiding everything and everyone. It sounds silly, but I’m kind of glad that I went through this because I think I’m going to be a better dad and person because of it.”

Tom was a bit teary as he finished reading. The ther- apist asked Tom whether he remembered what he wrote the first time. Tom said no, so the therapist read to him his first Impact Statement. She pointed out that Tom had come a long way, and he agreed. The therapist and Tom reviewed the whole therapy process, what they had covered, and the Stuck Points that Tom had challenged. Tom said that he was going to continue using the work- sheets, because they had been so helpful in making him slow down to think about things instead of just react- ing. They did some relapse planning, and the therapist asked Tom what he could do if he sensed that he was struggling with PTSD or depressive symptoms, or sec- ond-guessing his new ways of thinking. He mentioned that he was going to share the materials with his wife, because she was very good at helping him to “get his

Posttraumatic Stress Disorder 103

head on straight.” He also included on his list a review of the materials he had completed during the course of therapy. The therapy session ended with a discussion of Tom’s goal to write his father a letter and to increase his contact with his siblings. He was planning to use these contacts to discover more about the reasons his father was alcoholic and had seemed to abandon the family. Tom also shared his goals about the type of father and husband he hoped to be, and what his professional fu- ture held as he left the military. The therapist congratu- lated Tom on his willingness to do the hard work to recover from what happened to him and wished him the best with his family and future. Tom expressed his appreciation for the therapy.

REFERENCES

American Psychiatric Association. (2013). Diagnostic and sta- tistical manual of mental disorders (5th ed.). Arlington, VA: Author.

American Psychological Association. (2017). Clinical Practice Guideline for the Treatment of PTSD. Washington, DC: Author.

Atwoli, L., Stein, D. J., Koenen, K., & McLaughlin, K. A. (2015). Epidemiology of posttraumatic stress disorder: Prevalence, correlates and consequences. Current Opinion in Psychiatry, 28, 307–311.

Becker, J. V., Skinner, L. J., Abel, G. G., Axelrod, R., & Cichon, J. (1984). Sexual problems of sexual assault survi- vors. Women and Health, 9, 5–20.

Blain, L. M., Galovski, T. E., & Robinson, T. (2010). Gender differences in recovery from posttraumatic stress disor- der: A critical review. Aggression and Violent Behavior, 15, 463–474.

Blanchard, E. B., Hickling, E. J., Buckley, T. C., & Taylor, A. E. (1996). Psychophysiology of posttraumatic stress dis- order related to motor vehicle accidents: Replication and extension. Journal of Consulting and Clinical Psychology, 64, 742–751.

Blanchard, E. B., Hickling, E. J., Devinei, T., Veazey, C. H., Galovski, T. E., & Mundy, E. (2003). A controlled evalu- ation of cognitive behavioral therapy for posttraumatic stress in motor vehicle accident survivors. Behaviour Re- search and Therapy, 41, 79–96.

Bleiberg, K. L., & Markowitz, J. C. (2019). Interpersonal psy- chotherapy for PTSD: Treating trauma without exposure. Journal of Psychotherapy Integration, 29, 15–22.

Bowen, G. R., & Lambert, J. A. (1986). Systematic desensiti- zation therapy with post-traumatic stress disorder cases. In C. R. Figley (Ed.), Trauma and its wake: Vol. II. Traumatic stress theory, research, and intervention (pp. 280–291). New York: Brunner/Mazel.

Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual rep- resentation theory of posttraumatic stress disorder. Psycho- logical Review, 103, 670–686.

Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images in psychological disorders charac- teristics, neural mechanisms, and treatment implications. Psychological Review, 117, 210–232.

Brom, D., Kleber, R. J., & Defares, P. B. (1989). Brief psy- chotherapy for PTSD. Journal of Consulting and Clinical Psychology, 57, 607–612.

Carlson, E. B., Smith, S. R., Palmieri, P. A., Dalenberg, C. J., Ruzek, J. I., Kimerling, R., et al. (2011). Development and validation of a brief self-report of trauma exposure: The Trauma History Screen. Psychological Assessment, 23, 463–477.

Chemtob, C., Roitblat, H. L., Hamada, R. S., Carlson, J. G., & Twentyman, C. T. (1988). A cognitive action theory of post-traumatic stress disorder. Journal of Anxiety Disorders, 2, 253–275.

Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clin- ical Psychology, 70, 1067–1074.

Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., et al. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128–141.

Dalgleish, T. (2004). Cognitive approaches to posttraumatic stress disorder: The evolution of multirepresentational theorizing. Psychological Bulletin, 130, 228–260.

Department of Veterans Affairs & Department of Defense. (2017). VA/DoD clinical practice guideline for the manage- ment of posttraumatic stress disorder and acute stress disorder. Washington, DC: Author.

Dillon, K. H., LoSavio, S. T., Henry, T. R., Murphy, R. A., & Resick, P. A. (2019). The impact of military status on cognitive processing therapy outcomes in the community. Journal of Traumatic Stress, 32, 330–336.

Dohrenwend, B. P., Turner, J. B., Turse, N. A., Adams, B. G., Koenen, K. C., & Marshall, R. (2006). The psychological risks of Vietnam for U.S. veterans: A revisit with new data and methods. Science, 313, 979–982.

Dursa, E. K., Reinhard, M. J., Barth, S. K., & Schneider- man, A. I. (2014). OEF/OIF-era veterans in a large pop- ulation-based cohort. Journal of Traumatic Stress, 27, 542–549.

Ehlers, A., & Clark, D. M. (2000). A cognitive model of post- traumatic stress disorder. Behaviour Research and Therapy, 38, 319–345.

Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fen- nell, M., Herbert, C., et al. (2003). A randomized con- trolled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for posttrau-

104 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

matic stress disorder. Archives of General Psychiatry, 60, 1024–1032.

Elbogen, E. B., Johnson, S. C., Wagner, H. R., Sullivan, C., Taft, C. T., & Beckham, J. C. (2014). Violent behaviour and post-traumatic stress disorder in US Iraq and Afghani- stan veterans. British Journal of Psychiatry, 204, 368–375.

Farmer, C. C., Mitchell, K. S., Parker-Guilbert, K., & Ga- lovski, T. E. (2017). Fidelity to the cognitive processing therapy protocol: Evaluation of critical elements. Behavior Therapy, 48, 195–206.

First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2016). User’s guide for the Structured Clinical Interview for DSM-5 Disorders: Clinician Version (SCID-5-CD). Arling- ton, VA: American Psychiatric Press.

Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67, 194–200.

Foa, E. B., Hembree, E. A., Cahill, S. E., Rauch, S. A. M., Riggs, D. S., Feeny, N. C., et al. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at aca- demic and community clinics. Journal of Consulting and Clinical Psychology, 73, 953–964.

Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure for PTSD: Emotional processing of traumatic experiences: Therapist guide (2nd ed.). New York: Oxford University Press.

Foa, E. B., McLean, C. P., Zang, Y., Zhong, J., Powers, M. B. Kauffman, B. Y., et al. (2016). Psychometric properties of the Posttraumatic Diagnostic Scale for DSM-5 (PDS-5). Psychological Assessment, 28, 1166–1171.

Foa, E. B., Rothbaum, B., Riggs, D., & Murdock, T. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychol- ogy, 59, 715–723.

Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). Behav- ioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy, 20, 155–176.

Forbes, D., Bisson, J. I., Monson, C. M., & Berliner, L. A. (2021). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (3rd ed.). New York: Guilford Press.

Frost, N. D., Laska, K. M., & Wampold, B. E. (2014). The evidence for present-centered therapy as a treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 27, 1–8.

Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., et al. (2015). The prevalence of posttraumatic stress disorder in Operation Enduring Free- dom/Operation Iraqi Freedom (OEF/OIF) veterans: A meta-analysis. Journal of Anxiety Disorders, 31, 98–107.

Gobin, R. L., Mackintosh, M. A., Willis, E., Allard, C. B., Kloezeman, K., & Morland, L. A. (2018). Predictors of differential PTSD treatment outcomes between veteran and civilian women after cognitive processing therapy. Psychological Trauma: Theory, Research, Practice and Policy, 10, 173–182.

Goodson, J., Helstrom, A., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Powers, M. B. (2011). Treatment of posttraumatic stress disorder in U.S. combat veterans: A  meta-analytic review. Psychological Reports, 109, 573– 599.

Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, 7–17.

Held, P., Klassen, B. J., Brennan, M. B., & Zalta, A. K. (2018). Using prolonged exposure and cognitive process- ing therapy to treat veterans with moral injury-based PTSD: Two case examples. Cognitive and Behavioral Prac- tice, 25, 377–390.

Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deploy- ment to Iraq or Afghanistan. Journal of the American Medi- cal Association, 295, 1023–1032.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cot- ting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13–22.

Holder, N., Holliday, R., Williams, R., Mullen, K., & Surís, A. (2018). A preliminary examination of the role of psy- chotherapist fidelity on outcomes of cognitive processing therapy during an RCT for military sexual trauma-related PTSD. Cognitive Behaviour Therapy, 47, 76–89.

Holmes, M. R., & St. Lawrence, J. S. (1983). Treatment of rape-induced trauma: Proposed behavioral conceptualiza- tion and review of the literature. Clinical Psychology Re- view, 3, 417–433.

Hooper, L., Stockton, P., Krupnick, J., & Green, B. (2011). Development, use and psychometric properties of the Trauma History Questionnaire. Journal of Loss and Trau- ma, 16, 258–283

Horowitz, M. J. (1986). Stress response syndromes (2nd ed.). New York: Jason Aronson.

Jackson, S., Baity, M. R., Bobb, K., Swick, D., & Giorgio, J. (2019). Stress inoculation training outcomes among vet- erans with PTSD and TBI. Psychological Trauma: Theory, Research, Practice and Policy, 11, 842–850.

Janoff-Bulman, R. (1985). The aftermath of victimization: Rebuilding shattered assumptions. In C. R. Figley (Ed.), Trauma and its wake: Vol. I. The study and treatment of posttraumatic stress disorder (pp. 15–35). New York: Brun- ner/Mazel.

Posttraumatic Stress Disorder 105

Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: Free Press.

Keane, T. M., Kolb, L. C., Kaloupek, D. G., Orr, S. P., Blanchard, E. B., Thomas, R. G., et al. (1998). Utility of psychophysiology measurement in the diagnosis of post- traumatic stress disorder: Results from a Department of Veteran’s Affairs cooperative study. Journal of Consulting and Clinical Psychology, 66, 914–923.

Keane, T. M., Zimering, R. T., & Caddell, J. M. (1985). A behavioral formulation of posttraumatic stress disorder. Behavior Therapist, 8, 9–12.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the Na- tional Comorbidity Survey Replication. Archives of Gen- eral Psychiatry, 62, 593–602.

Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comor- bidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psy- chiatry, 62, 617–627.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nel- son, C. B. (1995). Posttraumatic stress disorder in the Na- tional Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060.

Kilpatrick, D. G., & Amick, A. E. (1985). Rape trauma. In M. Hersen & C. Last (Eds.), Behavior therapy casebook (pp. 86–103). New York: Springer.

Kilpatrick, D. G., Resnick, H. S., & Freedy, J. R. (1991). The Potential Stressful Events Interview. Unpublished instrument, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC.

Kilpatrick, D. G., Saunders, B. E., Veronen, L. J., Best, C. L., & Von, J. M. (1987). Criminal victimization: Lifetime prevalence, reporting to police, and psychological impact. Crime and Delinquency, 33, 479–489.

Kilpatrick, D. G., Veronen, L. J., & Best, C. L. (1985). Fac- tors predicting psychological distress among rape victims. In C. R. Figley (Ed.), Trauma and its wake: Vol. I. The study and treatment of posttraumatic stress disorder (pp. 114–141). New York: Brunner/Mazel.

Kilpatrick, D. G., Veronen, L. J., & Resick, P. A. (1982). Psychological sequelae to rape: Assessment and treatment strategies. In D. M. Doleys, R. L. Meredith, & A. R. Ciminero (Eds.), Behavioral medicine: Assessment and treat- ment strategies (pp. 473–497). New York: Plenum Press.

Koenen, K. C., Ratanatharathorn, A., Ng, L., McLaughlin K. A., Bromet, E. J., Stein D. J., et al. (2017). Posttrau- matic stress disorder in the World Mental Health Surveys. Psychological Medicine, 47, 2260–2274.

Kothgassner, O. D., Goreis, A., Kafka, J. X., Van Eickels, R. L., Plener, P. L., & Felnhofer, A. (2019). Virtual reality ex- posure therapy for posttraumatic stress disorder (PTSD): A meta-analysis. European Journal of Psychotraumatology, 10, 1–5.

Kubany, E. S., Haynes, S. N., Leisen, M. B., Owens, J. A., Kaplan, A. S., Watson, S. B., et al. (2000). Development and preliminary validation of a brief broad-spectrum mea- sure of trauma exposure: The Traumatic Life Events Ques- tionnaire. Psychological Assessment, 12, 210–224.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., et al. (1990). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.

Lang, P. J. (1968). Fear reduction and fear behavior: Problems in treating a construct. In J. M. Schlien (Ed.), Research in psychotherapy (pp.  90–102). Washington, DC: American Psychological Association.

Lang, P. J. (1977). Imagery in therapy: An information pro- cessing analysis of fear. Behavior Therapy, 8, 862–886.

Liebman, R. E., Whitfield, K., Sijercic, I., Ennis, N., & Monson, C. M. (2020). Harnessing the healing power of relationships in trauma recovery: A review of cognitive- behavioral conjoint therapy for PTSD. Current Treatment Options in Psychiatry, 7, 203–220.

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and interven- tion strategy. Clinical Psychology Review, 29, 695–706.

Mahoney, M. J., & Lyddon, W. J. (1988). Recent develop- ments in cognitive approaches to counseling and psycho- therapy. Counseling Psychologist, 16, 190–234.

Markowitz, J. C., Petkova, E., Neria, Y., Van Meter, P. E., Zhao, Y., Hembree, E., et al. (2015). Is exposure neces- sary?: A randomized clinical trial of interpersonal psycho- therapy for PTSD. American Journal of Psychiatry, 172, 430–440.

Marmar, C. R., Schlenger, W., Henn-Haase, C., Quian, M., Purchia, E., Li, M., et al. (2015). Course of posttraumatic stress disorder 40 years after the Vietnam War: Findings from the National Vietnam Veterans Longitudinal Study. JAMA Psychiatry, 72, 875–881.

Marques, L., Valentine, S. E., Kaysen, D., Mackintosh, M. A., Dixon De Silva, L. E., Ahles, E. M., et al. (2019). Pro- vider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. Journal of Consulting and Clinical Psychology, 87, 357–369.

McCann, I. L., & Pearlman, L. A. (1990). Vicarious trauma- tization: A framework for understanding the psychologi- cal effects of working with victims. Journal of Traumatic Stress, 3, 131–149.

McFall, M., Fontana, A., Raskind, M., & Rosenheck, R. (1999). Analysis of violent behavior in Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder. Journal of Traumatic Stress, 12, 501–517.

Meichenbaum, D. H. (1985). Stress inoculation training. El- msford, NY: Pergamon Press.

Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavior-

106 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

al conjoint therapy for posttraumatic stress disorder: Harness- ing the healing power of relationships. New York: Guilford Press.

Monson, C. M., Fredman, S. J., & Dekel, R. (2010). Post- traumatic stress disorder in an interpersonal context. In J. G. Beck (Ed.), Interpersonal processes in the anxiety dis- orders: Implications for understanding psychopathology and treatment (pp. 179–208). Washington, DC: American Psy- chological Association.

Monson, C. M., Gradus, J. L., Young-Xu, Y., Schnurr, P. P., Price, J. A., & Schumm, J. A. (2008). Change in posttrau- matic stress disorder symptoms: Do clinicians and patients agree? Psychological Assessment, 20, 131–138.

Moring, J. C., Dondanville, K. A., Fina, B. A., Hassija, C., Chard, K., Monson, C. M., et al. (2020, May 13). Cogni- tive processing therapy for posttraumatic stress disorder via telehealth: Practical considerations during the COVID-19 pandemic. Journal of Traumatic Stress, 10. [Epub ahead of print]

Morland, L. A., Mackintosh, M. A., Rosen, C. S., Willis, E., Resick, P., Chard, K., et al. (2015). Telemedicine versus in-person delivery of cognitive processing therapy for post- traumatic stress disorder: A randomized noninferiority trial. Depression and Anxiety, 32, 811–820.

Mowrer, O. H. (1947). On the dual nature of learning—a re-interpretation of “conditioning” and “problem-solving.” Harvard Educational Review, 14, 102–148.

National Institute for Health and Care Excellence. (2018). Post-traumatic stress disorder: NICE Guidelines. Re- trieved from www.nice.org.uk/guidance/ng116.

Nelson Goff, B. S., & Smith, D. B. (2005). Systemic traumat- ic stress: The couple adaptation to traumatic stress model. Journal of Marital and Family Therapy, 31, 145–157.

Norris, F. H. (1992). Epidemiology of trauma: Frequency and impact of different potentially traumatic events on differ- ent demographic groups. Journal of Consulting and Clinical Psychology, 60, 409–418.

Orr, S. P., Lasko, N. B., Metzger, L. J., Berry, N. J., Ahern, C. E., & Pitman, R. K. (1998). Psychophysiologic assess- ment of women with posttraumatic stress disorder result- ing from childhood sexual abuse. Journal of Consulting and Clinical Psychology, 66, 906–913.

Ostacher, M. J., & Cifu, A. S. (2019). Management of post- traumatic stress disorder. Journal of the American Medical Association, 321, 200–201.

Panagioti, M., Gooding, P. A., & Tarrier, N. (2012). A meta- analysis of the association between posttraumatic stress disorder and suicidality: The role of comorbid depression. Comprehensive Psychiatry, 53, 915–930.

Phoenix Australia Centre for Posttraumatic Mental Health. (2013). Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder. Melbourne, Aus- tralia: Author.

Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant,

B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Sur- vey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25, 456–465.

Pitman, R. K., Orr, S. P., Forgue, D. F., & Altman, B. (1990). Psychophysiologic responses to combat imagery of Viet- nam veterans with posttraumatic stress disorder versus other anxiety disorders. Journal of Abnormal Psychology, 99, 49–54.

Pitman, R. K., Rasmusson, A. M., Koenen, K. C., Shin, L. M., Orr, S. P., Gilbertson, M. W., et al. (2012). Biologi- cal studies of posttraumatic stress disorder. Nature Reviews Neuroscience, 13, 769–787.

Prins, A., Bovin, M. J., Smolenski, D. J., Marx, B. P., Ki- merling, R., Jenkins-Guarnieri, M. A., et al. (2016). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and evaluation within a Veteran primary care sample. Journal of General Internal Medicine, 31, 1206–1211.

Resick, P. A., Galovski, T. E., Uhlmansiek, M. O., Scher, C. D., Clum, G., & Young-Xu, Y. (2008). A randomized clin- ical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clini- cal Psychology, 76, 243–258.

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cogni- tive processing therapy for PTSD: A comprehensive manual. New York: Guilford Press.

Resick, P. A., & Schnicke, M. K. (1992). Cognitive process- ing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60, 748–756.

Resick, P. A., & Schnicke, M. K. (1993). Cognitive process- ing therapy for rape victims: A treatment manual. Newbury Park, CA: SAGE.

Resick, P. A., Suvak, M. K., Johnides, B. D., Mitchell, K. S., & Iverson, K. M. (2012). The impact of dissociation on PTSD treatment with cognitive processing therapy. De- pression and Anxiety, 29, 718–730.

Resick, P. A., Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Yarvis, J. S., Peterson, A. L., et al. (2017). Effect of group vs individual cognitive processing therapy in active- duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 74, 28–36.

Resick, P. A., Wachen, J. S., Mintz, J., Young-McCaughan, S., Roache, J. D., Borah, A. M., et al. (2015). A random- ized clinical trial of group cognitive processing therapy compared with group present-centered therapy for PTSD among active duty military personnel. Journal of Consult- ing and Clinical Psychology, 83, 1058–1068.

Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., & Best, C. L. (1993). Prevalence of civilian trauma and posttraumatic stress disorder in a representative national

Posttraumatic Stress Disorder 107

sample of women. Journal of Consulting and Clinical Psy- chology, 61, 984–991.

Roberts, N. P., Roberts, P. A., Jones, N., & Bisson, J. I. (2016). Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder. Cochrane Database of Systematic Reviews, 4, CD010204.

Rothbaum, B. O., Hodges, L. F., Ready, D., Graap, K., & Alarcon, R. (2001). Virtual reality exposure therapy for Vietnam veterans with PTSD. Journal of Clinical Psychia- try, 62, 617–622.

Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative ex- posure therapy: A short term treatment for traumatic stress disorders (2nd ed.). Cambridge, MA: Hogrefe.

Schnurr, P. P., Friedman, M. J., Foy, D. W., Shea, M. T., Hsieh, F. Y., Lavori, P. W., et al. (2003). Randomized trial of trauma-focused group therapy for posttraumatic stress disorder: Results from a Department of Veterans Affairs Cooperative Study. Archives of General Psychiatry, 60, 481–489.

Schnurr, P. P., Spiro, A., III, Vielhauer, M. J., Findler, M. N., & Hamblen, J. L. (2002). Trauma in the lives of older men: Findings from the Normative Aging Study. Journal of Clinical Geropsychology, 8, 175–187.

Schnyder, U., & Cloitre, M. (2015). Evidence based treatments for trauma-related psychological disorders: A practice guide for clinicians. Cham, Switzerland: Springer International.

Shalev, A. Y., Orr, S. P., & Pitman, R. K. (1992). Psycho- physiologic response during script-driven imagery as an outcome measure in posttraumatic stress disorder. Journal of Clinical Psychiatry, 53, 324–326.

Shapiro, F. (2018). Eye movement desensitization and reprocess- ing (EMDR) therapy: Basic principles, protocols, and proce- dures (3rd ed.). New York: Guilford Press.

Sloan, D. M., & Marx, B. P. (2019). Written exposure therapy for PTSD: A brief treatment approach for mental health pro- fessionals. New York: American Psychological Association.

Stanley, I. H., Rogers, M. L., Hanson, J. E., Guiterrez, P. M., & Joiner, T. E. (2019). PTSD symptom clusters and suicide attempts among high-risk military service mem-

bers: A three-month prospective investigation. Journal of Consulting and Clinical Psychology, 87, 67–78.

Street, A. E., Gradus, J. L., Vogt, D. S., Giasson, H. L., & Resick, P. A. (2013). Gender differences among veterans deployed in support of the wars in Afghanistan and Iraq. Journal of General Internal Medicine, 28, 556–562.

Taft, C. T., Watkins, L. E., Stafford, J., Street, A. E., & Mon- son, C. M. (2011). Posttraumatic stress disorder and in- timate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79, 22–33.

Tarrier, N., Pilgrim, H., Sommerfield, C., Faragher, B., Reynolds, M., Graham, E., et al. (1999). A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67, 13–18.

Wade, D., Varker, T., Kartal, D., Hetrick, S., O’Donnell, M., & Forbes, D. (2016). Gender difference in outcomes following trauma-focused interventions for posttraumatic stress disorder: Systematic review and meta-analysis. Psy- chological Trauma: Theory, Research, Practice and Policy, 8, 356–364.

Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the ef- ficacy of treatments for posttraumatic stress disorder. Jour- nal of Clinical Psychiatry, 74, 541–550.

Weathers, F., Bovin, M., Sloan, D., Schnurr, D., Schnurr, P., Kaloupek, D., et al. (2018). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and ini- tial psychometric evaluation in military veterans. Psycho- logical Assessment, 30, 383–395.

Weathers, F. W., Litz, B., Keane, K. M., Palmieri, P. A., Marx, B., & Schnurr, P. P. (2013). PTSD Checklist–5. Washington, DC: U.S. Veterans Affairs National Center for Posttraumatic Stress Disorder.

Zalta, A. K., Gillihan, S. J., Fisher, A. J., Mintz, J., McLean, C. P., Yehuda, R., et al. (2014). Change in negative cogni- tions associated with PTSD predicts symptom reduction in prolonged exposure. Journal of Consulting and Clinical Psychology, 82, 171–175.

108

Many people are very shy and somewhat inhibited. For this reason, the suffering associated with social anxiety disorder is often minimized as a common trait in the population that does not require a heavy artillery of formalized treatment interventions (either drugs or psychological treatments). Noth- ing could be further from the truth. For members of a very large segment of the population with de- bilitating social anxiety (over 12% and increasing), at some point in their lives, the seemingly simple process of interacting with people or forming relationships provokes overwhelming terror and is often avoided. The effects on career and quality of life can be devastating. As is increasingly true of our new generation of psychological interventions, cognitive-behavioral approaches have proven to be significantly better than equally credible but less focused psychological interventions, and its effects are increasingly powerful over time. This chapter by Aderka and Hofmann is new to this edition and illustrates a newer cognitive-behavioral approach called “process-based therapy” (PBT) as applied to social anxiety disorder. PBT goes beyond the static DSM approach to diagnosis and more stan- dardized treatment by emphasizing a very idiographic or individual approach to assessment and treatment in the specific context of the patient, along with continual processing and feedback. Thus, treatment may end up looking relatively different from one patient to the next in both content and se- quence. This approach is illustrated in the assessment and treatment of “Mark,” which demonstrates nicely the maturity and clinical sophistication of this remarkable approach to social anxiety. —D. H. B.

We have all felt social anxiety at some point in our lives. Whether it is presenting in front of others,

being on a date, talking in a group, going to a party, or being observed while we are completing a task, so- cial anxiety is ubiquitous and is a natural response in many social situations. However, for some people, so- cial anxiety is so severe that it can lead to substantial impairment in many aspects of daily life. Individuals with social anxiety disorder (SAD) typically fear and avoid situations in which others can evaluate them. In these situations, they fear that they will act in a way (or show anxiety symptoms) that will be embarrassing

or humiliating. Thus, individuals with SAD typically avoid anxiety-provoking social situations or endure them with substantial distress. However, it is important to note that social anxiety is a culture-related experi- ence (Hofmann, Asnaani, & Hinton, 2010) ranging from normative social anxiety that causes little distress or impairment to severe social anxiety and avoidance that can significantly impair one’s ability to function in important areas of life.

SAD is one of the most common psychological dis- orders, and a large epidemiological study conducted in the United States (National Comorbidity Survey Repli-

C H A P T E R 3

social Anxiety A Process‑Based Treatment Approach

Idan M. Aderka Stefan G. Hofmann

Social Anxiety 109

cation Study) found a lifetime prevalence rate of 12.1% for the disorder (Kessler, Chiu, Demler, & Walters, 2005). In a review of community studies from around the world, Furmark (2002) concluded that the preva- lence of SAD is 7–13% in Western countries.

Impairment in SAD can affect all facets of daily life, including relationships, work, and studies (Aderka et al., 2012). Compared to individuals without SAD, those with the disorder are more likely to drop out of school prematurely (Stein & Kean, 2000), to have lower educational attainment (Katzelnick & Greist, 2001; Wittchen, Stein, & Kessler, 1999), to hold jobs below their level of qualification (Katzelnick & Greist, 2001), to have lower income and to be unemployed (Lecru- bier et al., 2000), and even when employed, tend to miss eight times more work days (Wittchen, Fuetsch, Sonntag, Müller, & Liebowitz, 2000). Individuals with SAD report poor quality of life (Alonso et al., 2004), are more likely to attempt suicide (Wunderlich, Bronisch, & Wittchen, 1998), and are more likely to have alcohol and nicotine dependence (Wittchen et al., 1999).

A number of important gender differences exist in SAD. First, women are more likely to have SAD, and this has been replicated in studies across the world (for reviews, see Asher, Asnaani, & Aderka, 2017; Fehm, Pelissolo, Furmark, & Wittchen, 2005; Furmark, 2002). This gender difference in prevalence is greatest among adolescents and seems to diminish along the course of life. In addition to having greater prevalence, women also report greater clinical severity, as indicat- ed by more severe symptoms (Asher & Aderka, 2018), higher levels of social fears (Crome, Baillie, & Taylor, 2012), and a greater number of social fears (Xu et al., 2012). As is true for all anxiety disorders, SAD is more disabling in women than in men, particularly among White women and to some extent also among Hispanic women (McLean, Asnaani, Litz, & Hofmann, 2011). Interestingly, whereas women are more likely to suffer from SAD and demonstrate greater clinical severity, men with the disorder may seek treatment to a greater extent (Asher, Hermesh, Gur, Marom, & Aderka, 2019).

PSYCHOLOGICAL THERAPIES FOR SAD

Researchers have examined the efficacy of many psy- chological treatments for SAD including (but not lim- ited to) cognitive and behavioral treatments, acceptance and commitment therapy (ACT), interpersonal psy- chotherapy (IPT), mindfulness training, attention bias

modification, interpretation training, psychodynamic therapy, and social skills training. A large number of treatment formats have also been examined, includ- ing individual therapy, group therapy, virtual reality exposure treatment, Internet-delivered treatment, and computerized administration (i.e., for attention-bias modification). While a comprehensive and exhaustive review of each of these therapies and treatment formats is beyond the scope of this chapter, we present a general overview of the treatment outcome literature for SAD, with a focus on cognitive-behavioral therapy (CBT), ACT, and other evidence-supported and process-based interventions (e.g., Hofmann & Hayes, 2018).

CBT is the most widely researched treatment for SAD. In a meta-analysis of randomized controlled tri- als for SAD (Carpenter et al., 2018), the authors found a mean controlled effect size of 0.41 of CBT as compared to a placebo condition. Importantly, CBT for SAD has also been found to be effective under less-controlled, real-world conditions (Stewart & Chambless, 2009). Finally, the efficacy of CBT has been demonstrated meta-analytically in individual therapy (Aderka, 2009; Carpenter et al., 2018; Mayo-Wilson et al., 2014), in group therapy (e.g., Wersebe, Sijbrandij, & Cuijpers, 2013), in virtual reality exposure treatment (e.g., Carl et al., 2019; Chesham, Malouff, & Schutte, 2018) and in Internet-delivered treatments (e.g., Kampmann, Em- melkamp, & Morina, 2016).

ACT has also been found to be effective in treating SAD. In a review of studies examining ACT for SAD, moderate to large effect sizes were found across 10 stud- ies (Swain, Hancock, Hainsworth, & Bowman, 2013). Moreover, in a relatively recent trial, ACT was found to be comparable to CBT on most outcome measures of SAD (Craske et al., 2014). ACT was also found to be efficacious in group formats (Kocovski, Fleming, Haw- ley, Huta, & Antony, 2013) and as an Internet-delivered treatment (Ivanova et al., 2016), and was found to be effective in naturalistic settings (Dalrymple & Herbert, 2007).

A number of studies have examined IPT for the treatment of SAD. Lipsitz et al. (2008) examined 70 individuals with SAD who were treated with either IPT or supportive therapy. They found that IPT resulted in significant improvement during treatment. However, IPT was not significantly superior to supportive ther- apy in that study. In another study, Borge et al. (2008) examined 80 individuals with chronic and severe SAD in a residential setting who received either CBT or IPT. They found that both treatments were effective

110 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

and found no differences between the two treatments. Finally, Stangier, Schramm, Heidenreich, Berger, and Clark (2011) randomized 117 individuals with SAD to wait list, cognitive therapy, and IPT. They found that both cognitive therapy and IPT outperformed wait-list. However, CBT was found to be significantly more ef- ficacious than IPT. More recently, Dagöö et al. (2014) examined Internet-delivered versions of CBT and IPT. They found that CBT significantly outperformed IPT in this medium of administration. Thus, most studies find IPT to be an effective treatment for SAD, but in most studies CBT results in superior outcomes.

Mindfulness-based stress reduction (MBSR) was also examined as a treatment for SAD. In a random- ized controlled trial, Goldin et al. (2016) examined the effect of MBSR, CBT, and wait-list on 108 individuals with SAD. They found that CBT and MBSR resulted in similar improvements in social anxiety symptoms and in most additional outcome measures. In contrast, Koszycki, Benger, Shlik, and Bradwejn (2007), who examined CBT and MBSR, found that whereas both treatments improved social anxiety, CBT resulted in better outcomes. Thus, mindfulness may be an effec- tive treatment for SAD, but more studies are required in order to draw firm conclusions on the effect of mind- fulness on social anxiety symptoms.

A PSYCHOLOGICAL MODEL OF SOCIAL ANXIETY

Hofmann (2007) developed an integrated CBT model describing the process by which social anxiety is main- tained and exacerbated. Before we describe the model, it is important to consider that the experience of social anxiety and SAD is heterogeneous (Hofmann, Hein- richs, & Moscovitch, 2004) and not all of the main- tenance factors in the model play an important role for each individual. Rather, it is more likely that some of the maintenance factors are more salient for some individuals than for others. Therefore, an idiographic approach assessing which maintaining processes are relevant for each individual and in different contexts is needed in order to tailor interventions to particular clients (Hayes et al., 2019; Hofmann & Hayes, 2018).

Core Social Anxiety‑Provoking Process

The model describes a circular process that maintains or exacerbates social anxiety (see Figure 3.1). Accord- ing to the model, socially anxious individuals have a

strong desire to make a favorable impression on others but have doubt and uncertainty about their ability to do so (Clark & Wells, 1995; Leary, 2010; Trower & Gil- bert, 1989). This can also be understood as a discrep- ancy between perceived social standards and perceived social abilities (Alden, Bieling, & Wallace, 1994). More specifically, socially anxious individuals perceive social standards to be high while perceiving their own social abilities to be low (Moscovitch, Orr, Rowa, Reimer, & Antony, 2009). This discrepancy results in social ap- prehension regarding one’s performance in social situa- tions and regarding the ability to make a favorable im- pression on others.

Importantly, social standards do not necessarily need to be high to create social apprehension. Research has shown that social apprehension might also arise when standards are ambiguous or poorly defined. For in- stance, Moscovitch and Hofmann (2007) examined individuals with SAD and nonanxious controls who were exposed to cues indicating that standards for per- formance were high, low, or ambiguous prior to being asked to perform a socially threatening task. The results showed that individuals with SAD rated their perfor- mance as being worse in the high and even more so in the ambiguous standards conditions. No group dif- ference in appraisal was observed in the low standards condition. Thus, when standards are poorly defined or ambiguous, individuals with SAD perceive their social abilities as lower and experience enhanced social appre- hension.

Self‑Focused Attention

Social apprehension can lead to heightened self-focused attention, in which individuals shift their attention in- ward and engage in a process of detailed monitoring and observation of themselves (Hirsch, Clark, Mathews, & Williams, 2003). This shift in attention has a number of negative consequences that can enhance anxiety. First, physiological symptoms are perceived as more salient when attention is directed to them. Thus, so- cially anxious individuals become more aware of their anxiety-related physiological symptoms (e.g., blushing, trembling, sweating) and the symptoms are perceived as more salient, thus increasing anxiety (“What if some- one would notice my blushing/trembling/sweating?”). Second, under conditions of high self-focused attention, socially anxious individuals experience spontaneous, re- current, and excessively negative self-images that they believe to be accurate at the time they occur (Hack-

Social Anxiety 111

mann, Surawy, & Clark, 1998; Hackmann, Clark, & McManus, 2000; Hofmann & Heinrichs, 2003). These negative images can also exacerbate anxiety. Third, self-focused attention can lead to reduced externally fo- cused attention and can lead socially anxious individu- als to miss important positive cues from others during social interactions (e.g., someone smiling).

Cognitive and Emotional Processes Enhanced by Self‑Focused Attention

Self-focused attention experienced in socially threaten- ing situations can also spark or enhance a number of additional cognitive and emotional processes. One such process is negative self-perception, in which cognitions about the inferiority, inadequacy, or flaws of the self are experienced more saliently (Beck & Emery, 1985;

Clark & Wells, 1995; Rapee & Heimberg, 1997). An- other such cognitive process is perceived poor social skills, in which socially anxious individuals underestimate their skills, abilities, and actual performance in social situations (e.g., Rapee & Lim, 1992). A third cognitive process is high estimated social cost, in which the conse- quences of one’s inability to meet social standards are perceived as catastrophic or disastrous. Consistently, socially anxious individuals believe that negative so- cial events are more likely to occur than positive social events (Lucock & Salkovskis, 1988), and assume that most people are inherently critical of others and are likely to evaluate them negatively (Leary & Kowalski, 1995). The fourth process enhanced by self-focused at- tention is low perceived emotional control. Specifically, socially anxious individuals believe that they have little control over their emotional response in threatening so-

Social Apprehension

Heightened Self- Focused Attention

High Estimated Social Cost

Low Perceived Emotional Control

Perceived Poor Social Skills

Postevent Rumination

Negative Self- Perception

Anticipation of Social Mishap

Avoidance and Safety Behaviors

High Perceived Social Standards and Poorly Defined Social Goals

FIGURE 3.1. A psychological model of social anxiety. Copyright © 2007 Stefan G. Hofmann. Used by permission.

112 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

cial situations and that this lack of control can be easily noticed by other people.

Emotional Processes

Whereas the model developed by Hofmann (2007) focused specifically on emotional control, more recent theoretical thinking (e.g., Hofmann, 2014), as well as empirical studies (e.g., Kashdan & Steger, 2006; Kash- dan et al., 2013), have identified a number of emotional processes related to social anxiety and SAD. Thus, in this chapter, we present an update and expansion of the Hofmann (2007) model based on theoretical models and empirical studies of emotion in social anxiety and SAD. Specifically, we focus on three emotional pro- cesses: emotion differentiation, experiential avoidance, and emotion regulation. All three emotional processes can be viewed as contributing to the lack of control over emotions associated with social anxiety and SAD.

Emotion differentiation is defined as the degree to which a person is able to classify felt experiences into discrete emotion categories (Kashdan & Farmer, 2014). It also refers to the level of specificity with which peo- ple distinguish between their emotional states (Erbas, Ceulemans, Koval, & Kuppens, 2015). A number of re- searchers (e.g., Boden, Thompson, Dizén, Berenbaum, & Baker, 2013; Kashdan, Barrett, & McKnight, 2015) have proposed that effective emotion regulation is large- ly dependent on knowledge of experienced emotions that are targeted for regulation. Put differently, it is harder to regulate or control emotions one cannot name or differentiate as a distinct state. Individuals with SAD have been found to have difficulties differentiating be- tween negative (but not positive) emotions (Kashdan & Farmer, 2014) and this can contribute to low perceived emotional control about anxiety and other negative emotions experienced in social situations.

Experiential avoidance reflects efforts to control or avoid unpleasant internal events, such as distressing emotions, negative thoughts, and unwanted physical sensations (Hayes, Wilson, Gifford, Follette, & Stro- sahl, 1996). Experiential avoidance can lead to low perceived emotional control, because when emotions are avoided, they become more difficult to regulate or influence. In addition, experiential avoidance may re- sult in paradoxical effects and increase the experience of the emotion one is trying to avoid (e.g., Campbell-Sills, Barlow, Brown, & Hofmann, 2006; Gross & Levenson, 1997). This can result in a flood of negative emotions that are then more difficult to control. In two examina-

tions of individuals with and without SAD using expe- rience sampling, Kashdan et al. (2013, 2014; Study 1) found that compared to healthy controls, individuals with SAD reported greater use of experiential avoidance in their daily, face-to-face interactions, and this associa- tion could not be attributed to comorbid anxiety and depressive disorders. Moreover, the experiential avoid- ance–social anxiety association was greater for individ- uals with SAD compared to healthy controls (Kashdan et al., 2014, Study 1). Finally, Dalrymple and Herbert (2007), examined individuals with SAD who under- went ACT. Results showed that treatment resulted in reductions in both experiential avoidance and SAD symptoms. Moreover, changes in experiential avoid- ance predicted subsequent changes in SAD symptoms along the course of therapy.

Emotion regulation can also contribute to low per- ceived emotional control. Specifically, individuals with SAD have been found to rely excessively on expressive suppression, which is associated with negative social and emotional consequences, and to use cognitive reappraisal ineffectively, thus inhibiting the potential positive emo- tional benefits of this strategy (see Dryman & Heim- berg, 2018, for a review). These difficulties in regulating emotions may lead to low perceived emotional control.

Avoidance and Safety Behaviors

Avoidance and safety behaviors constitute a central part in the model, as they create a feedback loop that maintains anxiety. Whereas the term avoidance reflects avoidance of certain anxiety-provoking situations be- fore they occur (this is similar to the concept of situ- ation selection in emotion regulation models; Gross, 1998), safety behaviors reflect any attempt to reduce anxiety or avoid it within social situations (this mirrors the concept of situation modification in emotion regu- lation models). Both forms of avoidance are the result of anxiety and serve as potentially maladaptive strategies to regulate anxiety, and both forms of avoidance inad- vertently increase anxiety in the long term, thus cre- ating the maintaining feedback loop. Adopting safety behaviors in social situations has been found to lead to diverse negative effects for socially anxious individuals, such as impaired performance (Rowa et al., 2015), in- creased momentary anxiety (for a review, see Piccirillo, Taylor Dryman, & Heimberg, 2016), and even feelings of inauthenticity and interpersonal rejection, which further fuel future anxiety (Plasencia, Taylor, & Alden, 2016; Taylor & Alden, 2010).

Social Anxiety 113

Postevent Processing

Postevent processing refers to a process that follows stress- ful social situations. During postevent processing, so- cially anxious individuals mentally review the social interaction in detail, with a focus on anxious feelings and negative self-perceptions. This process of focusing on negative aspects typically leads socially anxious in- dividuals to recall the interaction as being more nega- tive than it actually was and results in elevated anxiety regarding future situations. For example, Abbott and Rapee (2004) found that compared to individuals with- out social anxiety, individuals with SAD had a more negative appraisal of an impromptu speech task imme- diately following the task. In addition, whereas indi- viduals with SAD maintained their negative appraisal through the week following the task and engaged in more rumination and postevent processing, individuals without social anxiety developed a more positive atti- tude about their performance along the week.

PROCESS‑BASED THERAPY OF SOCIAL ANXIETY

The treatment described in this chapter is based on a process-based approach (Hayes & Hofmann, 2018; Hofmann & Hayes, 2018). Rather than have a predeter- mined structure to treatment, with certain sessions in- cluding specific interventions in a particular order, the process-based approach strives to provide therapists and clients with more flexibility. The approach describes a wide range of possible interventions that can be applied flexibly based on an idiographic analysis that is tailored to the client and to a particular context. For instance, some individuals with SAD have very salient negative self-perceptions and perceptions of poor social skills, and these may be treated by cognitive reappraisal and modifying core beliefs, whereas others’ social anxiety may have a strong emotional component, with difficul- ty differentiating between negative emotions and a fear of anxiety and related emotions, and these are better treated by psychoeducation on emotions, working on emotion differentiation, and cultivating psychological acceptance. Even for the same individual, salient fac- tors may vary between contexts. For instance, socially anxious individuals may be extremely concerned with physiological symptoms and the possibility that oth- ers will notice and judge them negatively when giving a presentation in front of a class, but be much more

concerned with their appearance and poor social skills (“I’ll say something stupid, or boring”) when on a date. Thus, a careful idiographic analysis that considers the individual and context represents an important first step in the selection and implementation of any inter- vention in this treatment.

Based on the large interpersonal diversity and diver- sity in contexts, interventions to consider can include contingency management, stimulus control, shaping, self-management, arousal reduction, coping and emo- tion regulation, problem solving, exposure strategies, behavioral activation, interpersonal skills, cognitive reappraisal, modifying core beliefs, cognitive defusion, cultivating psychological acceptance, values choice and clarification, mindfulness practice, enhancing motiva- tion, and crisis management (for a detailed description of these interventions, see Hayes & Hofmann, 2018). In this chapter we focus on three of these interventions that we consider especially relevant to most individuals with SAD and high social anxiety: cognitive restructur- ing, exposures and behavioral experiments, and emo- tion differentiation and regulation.

Stages of PBT of Social Anxiety

PBT of social anxiety includes a three-stage process that is repeated throughout treatment: contextual id- iographic assessment, intervention, and processing and feedback. It begins with a contextual idiographic as- sessment that identifies a target for intervention. This assessment is intended to be collaborative process in which both client and therapist examine a particular context or situation and use the client’s unique knowl- edge of him/herself and the therapist’s unique knowl- edge of psychology (e.g., the model described earlier) to formulate a shared understanding of the process occur- ring in that particular context and to identify targets for intervention. For instance, sometimes clients share that they have stressful situations in their immediate future, such as a party, a presentation, or a date, and these situ- ations become the focus of inquiry. Other times, the therapist can suggest a possible context based on his/ her familiarity with the client. However, this process of generating a shared understanding of the situation and choosing a target for intervention is always collabora- tive. Many times, the process also includes drawing a schematic of the relevant processes (i.e., drawing a sim- plified version of the model that is person- and context- specific). This contextual model or schematic captures the joint understanding of client and therapist, and it

114 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

is important that clients feel that the model is a good representation of their experience.

Once a collaborative understanding has emerged, and a target for intervention is identified, we enter the intervention stage, which includes choosing, planning, and implementing an intervention. For instance, if the model identified an important safety behavior in a certain context (e.g., rehearsing topics for conversation before a date), then planning an exposure while drop- ping the safety behavior represents a valid option (e.g., asking questions based on what the partner said rath- er than preplanned topics). However, for every target identified, there are usually multiple potential interven- tions. For instance, cognitive reappraisal focusing on rehearsing topics may also be an option, as well as strat- egies cultivating acceptance of the anxiety experienced due to the uncertainty of not knowing the topics of conversation before an actual conversation takes place. Choosing an intervention is also a collaborative process that takes into account context, client preferences and values, and therapist experience and knowledge.

After an intervention is chosen and implemented, processing the intervention and eliciting feedback can take place. Processing the intervention includes discuss- ing the client’s experiences during the intervention. It may also include discussing what was learned as a result of the intervention, or what went wrong and prevented meaningful learning. Finally, receiving feedback on the intervention is essential in order to decide whether to adapt or change the intervention and conduct it again (e.g., if something went wrong, was misunderstood, was not properly planned), whether to choose a different in- tervention for the same target, or whether to move on to a different context or therapeutic target. Thus, elicit- ing feedback provides essential information that can in- form the next cycle, beginning with idiographic assess- ment (i.e., the second cycle of idiographic assessment will include information about the client’s experiences and processing of the first intervention).

To summarize, the PBT manual for social anxiety operates differently than some manuals. Whereas man- uals typically arrange content and interventions along sessions (e.g., first, three sessions of cognitive restruc- turing, followed by six sessions of exposure exercises), PBT flexibly includes any content or intervention based on a contextual idiographic assessment. One way to fa- cilitate and guide contextual idiographic assessment is by using a functional-analytic network based on the ex- tended evolutionary meta-model (EEMM; Hayes et al., 2019). This is by no means the only way to conduct or

organize a contextual idiographic assessment; rather, it represents a specific comprehensive assessment scheme that considers the potential contribution of various di- mensions and levels to the particular problem space of a given individual.

The EEMM (Figure 3.2) utilizes a number of dimen- sions to describe target problems. Specifically, problems can be described as having one or more of the following facets or existing on one or more of the following di- mensions: affective, cognitive, attentional, self-related, motivational, and overt behavioral. For each of these dimensions, problems can involve variation, selection, retention, and context issues. For instance, if a client has a negative automatic thought every time he/she talks to a particular person at the office, this problem can be conceptualized as belonging to the cognitive dimension and involving low variation (i.e., the client has access to this thought but not to other, alternative thoughts) and a strong context component (a particu- lar person at the office). Potential interventions could target variation (e.g., developing alternative thoughts) and facilitate selection of appropriate and helpful ways of thinking. Applying such interventions in a way that takes context into account (e.g., applying them at the office) and maximizes retention (e.g., applying them with other people in the office first and with the target person later) is also important. Specific treatment strat- egies for target problems are discussed below.

Cognitive Reappraisal

Cognitive reappraisal refers to the process of changing the meaning of a stimulus or situation, in order to alter emotional responses (Gross, 1998). This process can in- clude helping clients to adopt new perspectives; to think about themselves, others, their lives, and everyday situ- ations in different ways; and to consider multiple view- points on important issues. Cognitive reappraisal can be divided into three stages: identifying maladaptive thinking, evaluating maladaptive thinking, and modi- fying maladaptive thinking (Wenzel, 2018).

Identifying maladaptive thinking, the first stage of cognitive reappraisal, typically involves identifying a context or situation in which clients recently expe- rienced high levels of negative affect and asking them questions to elicit their thoughts. Clinicians can ask questions such as “What was going through your mind during the situation?” or “What were you thinking about when X happened?” Whereas these may seem like easy questions to answer, not all clients find it

Social Anxiety 115

easy to verbally describe their thoughts. When eliciting thoughts is difficult for clients, therapists can ask them to guess their own thoughts, or to guess what some- one else may have been thinking in a similar situation. Therapists can also suggest several possible thoughts and see whether clients identify with one or more of these thoughts.

Identifying maladaptive thinking can be seen as the basis for later stages of cognitive reappraisal, but it can also have therapeutic value in and of itself. Specifi- cally, the process of identifying maladaptive thoughts increases awareness of internal psychological processes and facilitates a connection with one’s experiences. This can serve to reduce experiential avoidance and increase one’s ability to fully experience the present moment.

Once thoughts are identified, and clients and therapists become familiar with clients’ maladaptive thoughts, a process of evaluation can begin. In evaluat- ing maladaptive thoughts, it is important for therapists to refrain from adopting an overly challenging, criti- cal, or superior stance. Rather, joining clients from a position of curiosity, while attempting to facilitate discovery of additional information and examination of additional possible points of view, usually leads to

better results. The idea is to evaluate thoughts together and learn more about them. Questions that facilitate this evaluation may include “What is the evidence for and against this thought?”; “What additional explana- tions exist?”; “What is the best, the worst, and the most realistic things that can happen?”; “What would you tell a friend or family member if they were in a similar situation?”; “What are the consequences of focusing on this thought versus thinking differently or focusing on something else?” This list of questions is by no means exhaustive, but it can serve as an example of possible questions that may spark a process of jointly discover- ing more about clients’ thoughts and becoming familiar with additional perspectives.

Modifying maladaptive thinking, the third and final stage of cognitive reappraisal, refers to a collaborative process in which clients (with therapist guidance) de- velop alternative, more balanced thoughts using the discoveries made in the evaluation stage. The goal of this stage is not to remove maladaptive thoughts, re- place maladaptive thoughts, or discard thoughts that are “wrong.” Rather, the goal is to incorporate new in- formation into existing thoughts to create a more bal- anced or a multifaceted way of thinking.

FIGURE 3.2. The extended evolutionary meta-model (EEMM) for organizing target problems and identifying appropriate interventions. Copyright © 2019 Steven C. Hayes and Stefan G. Hofmann. Used by permission.

116 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

For instance, a male client of one of the authors (I. M. A.) was anxious about an upcoming date. He identified a number of maladaptive thoughts related to his anticipatory anxiety, but a central and representa- tive thoughts was “I’ll mess it up. She’ll hate me and won’t want to see me anymore.” During the evaluation stage, the therapist asked the client whether this chain of events is bound to happen and represents 100% of all possible scenarios. When the client replied negatively, it sparked a discussion of alternative scenarios for the date. Incorporating these scenarios with the original thought, the client was able to develop the following perspective: “It is absolutely possible that I will mess it up, that she’ll hate me and never want to see me again. In fact, it is an integral part of any date. However, it is also possible that things won’t be that bad. We could get along, she may like me, and we could see each other again. It’s also possible I won’t like her and won’t want to keep seeing her. Actually, I won’t really know until we go on the date.” This type of flexible and multi- faceted thinking retains the original thought but views it as a single outcome among many possible outcomes, while accepting the inherent uncertainty when meeting someone new.

To summarize, cognitive reappraisal is a process of collaboratively identifying, evaluating, and modifying maladaptive thoughts. As mentioned earlier, a number of maladaptive thoughts can play an important role in maintaining social anxiety (e.g., negative self-percep- tions and perceived poor social skills). The process of cognitive reappraisal can be used to target these ele- ments (or additional thoughts pertaining to anticipa- tory anxiety, postevent processing, and other sections of the model).

Exposure and Behavioral Experiments

Exposure is a collaborative process in which the client (with the therapist’s guidance) chooses to systematically enter situations or approach stimuli that provoke fear, anxiety, or other negative emotions. This definition highlights three important characteristics of exposure. First, it is a collaborative process. Thus, effective ex- posures are not “prescriptions” administered to clients by therapists. Rather, choosing exposures and planning them is part of a collaborative discussion in which goals, rules, and definitions of success are discussed and mu- tually agreed upon. Second, the client makes an explicit choice to enter situations or approach stimuli. Thus, client agency and volition are extremely important in

exposure and represent the approach behavior required to facilitate new learning. Third, exposure is systematic and includes planning, gradual progression, and appro- priate repetition. Exposure can be divided into three stages: establishing the rationale for exposure, choos- ing and planning exposures, and processing exposures (after their completion).

Establishing the rationale for exposure is extremely important, as clients are unlikely to engage in expo- sures without a clear and compelling rationale. As PBT aims to enhance flexibility and use individually tailored interventions based on idiographic assessment, we pro- vide three possible rationales for exposure that can be presented to different clients with different character- istics. The first is the behavioral rationale for exposure that is centered on habituation. According to this ratio- nale, repeated exposure to anxiety-provoking situations results in habituation, and emotional experiences and reactions to these situations gradually decline with re- peated exposures. The second rationale is the cognitive rationale for exposure, centered on creating cognitive change or achieving new learning as a result of expo- sure. Exposures with this rationale are typically referred to as behavioral experiments. This rationale is based on the idea that without exposure, clients do not test their thoughts and beliefs about themselves, others, or anxi- ety (or only do so only in a philosophical or theoretical way). However, during exposure, clients can test beliefs and use their real-world experience to guide new learn- ing and facilitate cognitive change. This rationale is also similar to the concept of collaborative empiricism, in which therapist and client design experiments (i.e., ex- posures) to test beliefs. The third rationale for exposure, the emotional rationale, focuses on fully experiencing emotions and cultivating acceptance of these emotions (i.e., reducing experiential avoidance). According to this rationale, exposure is used to approach emotions that are typically avoided, and to experience these emo- tions without fighting them or avoiding them. Such an experience reduces fear of emotions, and enhances acceptance and tolerance of emotions. These rationales can be used separately or in combination to facilitate discussions with clients on exposure.

Choosing and planning exposures is the second stage of this intervention. To facilitate appropriate selection of exposures, a hierarchy can be jointly established to guide decision making. In a hierarchy, situations or po- tential exposures are organized by level of anxiety or difficulty. When selecting exposures, we typically rec- ommend starting with situations that elicit 30–40% of

Social Anxiety 117

the maximum anxiety and gradually increase levels of anxiety in subsequent exposures based on client prog- ress. An alternative strategy for selecting exposures is to choose situations that not only provoke anxiety that is clearly experienced (or situations that the client per- ceives as significantly difficult), but also exposures that the client feels he/she can complete. Exposures that are perceived as both difficult and possible are typically chosen.

Once an exposure has been chosen, planning can begin. As we described in the model, individuals with SAD typically have ambiguous standards or poorly de- fined goals in social situations. Thus, when planning exposures, goals must be clearly defined to prevent pathological maintaining processes from undermining the intervention. Goals need to be objectively defined and must include behaviors that are under the cli- ent’s control. Having a 15-minute conversation with a stranger is an example of a poorly defined goal, because it not specific and involves other people who are not under the client’s control. However, initiating a conver- sation with an employee at the supermarket and asking two questions is a much better goal, because it is more clearly defined and under the client’s control. Goals must be individually tailored to specific clients, con- texts, and the particular thoughts or beliefs that need to be examined. When planning exposures, eliciting predictions from clients can be very helpful (e.g., “The anxiety will last for hours”, “Everyone will be mean to me the entire time”). Eliciting predictions that are clear and objectively defined can facilitate cognitive change by being juxtaposed with actual outcomes when pro- cessing completed exposures.

The final stage of exposure includes the processing of completed exposures. If the goals for the exposure are met, therapists should praise clients and highlight cli- ents’ achievement, accomplishment, and success (e.g., “You’ve just done something that you’ve avoided for so long! I’m sure it was tempting to skip this exposure and find an excuse not to do it, but you chose to take the hard way, and this is quite an accomplishment”). While devoting time to bolster clients’ sense of achievement may be easily overlooked in therapy, recent research clearly demonstrates its centrality in treatment. For in- stance, in one of the largest treatment studies, which in- cluded over 90,000 sessions, therapist praise was found to be the best predictor of therapeutic outcomes in CBT (Ewbank et al., 2019). Along these lines, increases in self-efficacy as a result of completing exposures were found to predict improvement from exposure therapy

(Jones & Menzies, 2000). If exposure goals are not met, therapist and client should discuss the exposure to un- derstand what might have gone wrong and decide on alterations to be made for future exposures (e.g., reduc- ing the difficulty level of the next exposure, changing goals, or selecting a different context).

Another important part in the processing of expo- sures is discussing the meaning of the exposure, and what was learned in the exposure. Important questions to ask clients include “What have you learned from completing this exposure?” and “What do you know now that you didn’t know before?” Discussing the out- comes of exposure and the new learning that occurred are important to facilitate consolidation of cognitive change.

To summarize, the exposure is one of the most ef- fective interventions for social anxiety. The rationale for exposures should be discussed, and clients need to “buy-in” before exposures can be implemented. Expo- sures are then systematically planned and executed; fi- nally, exposures are processed after they are completed in order to enhance client self-efficacy, to elicit feed- back and gather information to be used in future inter- ventions, and to consolidate new learning.

Enhancing Emotional Processes

Individuals with SAD and socially anxious individu- als display a reduced capacity to differentiate between negative emotions. This is important, as it is almost im- possible to regulate emotions or accept emotions one cannot differentiate. Thus, for some socially anxious individuals, work on emotion differentiation may be a prerequisite for work on emotion regulation and emo- tional acceptance.

Work on emotion differentiation can utilize a num- ber of tools or techniques. First, psychoeducation on emotions is extremely important, not only psychoedu- cation on emotions in general, their function, and their patterns of experience (as is done in many treatments), but also psychoeducation on discrete emotions, their definitions, and the differences between them. For in- stance, discussing the differences between shame and guilt, anger and frustration, and despair and loneliness, and delineating the contexts in which these emotions are experienced and the cognitions associated with them provides a good foundation for emotion differ- entiation. Another important tool in facilitating emo- tion differentiation is an Emotion Log, in which clients monitor and record emotions during the week. This log

118 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

(which also includes context/situation and thoughts) can help clients recognize different emotions and is also discussed and processed in therapy to further enhance learning. A third tool for enhancing emotion differen- tiation is reading vignettes and guessing others’ emo- tions. For clients who find it difficult to identify their own emotions, practicing emotion identification and differentiation using vignettes of others may be a help- ful alternative.

Once clients become better at identifying and nam- ing their emotions, and better at differentiating be- tween them, work on emotional regulation or emo- tional acceptance can begin. One way to help clients improve their emotion regulation capabilities is to prac- tice cognitive reappraisal (see the previous section) in multiple contexts, and for multiple emotions (Aldao & Plate, 2018). This is important, as regulating certain emotions may be more difficult than others for a par- ticular client and context. For example, even if socially anxious clients experience heightened levels of anxiety, practicing reappraisal when experiencing anger, guilt, loneliness, or shame may prove very valuable. Practicing reappraisal in different contexts (e.g., within the ses- sion, at home alone, with close others, with strangers, and at work) is also very helpful for enhancing clients’ capacity to regulate their emotions.

Another emotional skill that can be viewed as com- plementary to emotion regulation is emotional accep- tance (Forsyth & Ritzert, 2018). Emotional acceptance reflects a focus on accepting emotions as they are and adopting an intentionally open, receptive, flexible, and nonjudgmental posture with respect to moment-to- moment experience (Hayes, Strosahl, & Wilson, 2012). Practicing mindfulness of one’s emotions is an excel- lent way to facilitate emotional acceptance. In mindful- ness exercises, clients practice observing their emotions, along with the physical sensations that accompany them, in a nonjudgmental and curious way. Mindful- ness helps clients experience their emotions as they are, without trying to change or alter them, and without struggling with them or avoiding them. Another set of exercises that facilitate emotional acceptance is defu- sion exercises. In these exercises, the focus is on creat- ing distance between internal stimuli, such as thoughts and emotions, and the self. When we are “fused” with our emotions, these emotions determine our behavior without additional input. Thus, defusion strives to cre- ate distance between emotions and the self, so that val- ues and other considerations can also guide behavior. When experiencing emotions in this way, there is no

need to fight them, avoid them, or alter them in any way. Rather, one can experience these emotions as they are, and still make decisions and behave according to one’s values. Thus, defusion can help facilitate emo- tional acceptance.

While in no way an exhaustive list, cognitive reap- praisal, exposure, and behavioral experiments and emo- tion-focused interventions represent important inter- ventions to consider when treating social anxiety. PBT includes the flexible implementation of these interven- tions based on repeated contextual idiographic assess- ment conducted throughout treatment. The following case study exemplifies the use of these strategies.

CASE STUDY

Presenting Problem

“Mark,” a 25-year-old man, sought treatment due to intense anxiety he experienced in interpersonal interac- tions. Mark reported that he was constantly concerned about saying something strange, odd, silly, or irrelevant and fearing that other people would judge him, think negatively of him, and ultimately decide to keep their distance. Mark described one-on-one conversations as particularly distressing and mentioned that he rarely shared personal information about himself, as well as thoughts and feelings, with others in an attempt to keep conversations as brief as possible. He described himself as insecure and his voice as too soft. Interacting with women was intimidating and anxiety provoking to Mark, and he shared that he had never been in a romantic relationship, and in fact had never been on a date. Mark said that there was a girl in college who had shown romantic interest in him, but he felt he could not handle the anxiety of meeting her, being on a date, and disclosing personal information about himself, and he ultimately decided to avoid her. When reflecting on this, Mark said he both wanted the relationship but was even more terrified of it, which led to his decision to withdraw.

History

Mark, the youngest of three siblings, described his re- lationship with his parents as close and caring. Mark was raised in a Jewish household and felt that religion was an important part of his life. At school, Mark ex- celled academically and never had any behavior prob- lems. However, some interpersonal difficulties emerged

Social Anxiety 119

as early as elementary school. Mark did not like talk- ing in front of the class and refrained from answering questions even when he knew the correct answers. He had a few close friends (two or three) but always found it difficult to form new relationships, and he typically avoided parties and other social events in his teens. After graduating from high school, Mark studied soft- ware engineering in college. He reported experiencing substantial test anxiety that was compounded by the competitive atmosphere in college. Specifically, he had trouble sleeping before tests and found it difficult to concentrate while studying or while taking some of the tests. Despite this anxiety, Mark did well academically and graduated with good grades. Socially, Mark avoid- ed parties and many social activities. He said that such parties (with alcohol or drugs) were inconsistent with his religious values, but, in fact, he also avoided other social activities he was interested in (e.g., writing class). Mark made some friends during college, but he viewed these connections as superficial and did not keep in touch after graduating. Instead, he remained in touch with his childhood friends, with whom he felt more comfortable. After graduation, Mark began to work at a software company and rented a small apartment. Mark’s childhood friends were all in romantic relation- ships, and some were engaged to be married. To Mark, this, as well as his difficulties forming new relationships at work, indicated that something was clearly “wrong” with him. As time went by, he felt increasingly isolated and began to think that his social anxiety would never go away, and would prevent him from living a full, sat- isfying life. He decided to seek psychological treatment.

Pretreatment Assessment

Mark underwent a structured diagnostic interview: the Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5; Brown & Barlow, 2014). Mark met criteria for primary SAD, with a clinician severity rating of 5 (on a scale of 0–8, with 4 being the clinical cutoff), and also met criteria for comorbid major depressive dis- order, with a clinical severity rating of 4. Mark com- pleted a number of self-report measures, including the Liebowitz Social Anxiety Scale—Self-Report version (LSAS-SR; Liebowitz, 1987), the Social Phobia Inven- tory (SPIN; Connor et al., 2000), the Social Anxiety Questionnaire (SAQ; Caballo, Arias, Salazar, Irurtia, & Hofmann, 2015), the Social Thoughts and Beliefs Scale (STABS; Turner, Johnson, Beidel, Heiser, & Lyd- iard, 2003), the Beck Depression Inventory–II (BDI-II;

Beck, Steer, & Brown, 1996), and the Sheehan Disabil- ity Scale (SDS; Sheehan, 1983).

Mark’s total score on the LSAS-SR was 72. This score is above the cutoff of 60, which indicates clini- cal levels of severity (Rytwinski et al., 2009). Similarly, Mark’s score on the SPIN was 39, which is above the clinical cutoff of 20 (Connor et al., 2000) and repre- sents moderate to high levels of clinically significant social anxiety. Finally, Mark’s score on the SAQ was 110, which is above the clinical cutoff of 89 for men (Caballo et al., 2015). Importantly, the LSAS-SR focus- es on 24 commonly encountered social situations (e.g., going to a party) and assesses anxiety and avoidance for each of these situations. In contrast, the SPIN ex- amines symptoms of social anxiety in general, without necessarily referring to a particular situation (e.g., fear of criticism or blushing in general). Thus, these mea- sures can be seen as complementary, with the LSAS-SR being highly contextualized but focused only on symp- toms of anxiety and avoidance, whereas the SPIN is less contextualized but includes many additional symptoms (e.g., physiological and cognitive symptoms). Finally, a unique aspect or advantage of the SAQ over both the LSAS-SR and SPIN is having separate empirically de- rived cutoffs for men and women. This is extremely im- portant, as gender differences play an important role in social anxiety (Asher et al., 2017). Thus, the SAQ can be viewed as more gender-sensitive.

Mark’s score on the STABS (a measure of social anx- iety-related cognitions) was 50, which is above the clini- cal cutoff of 40 (Turner et al., 2003). Mark’s score on the BDI-II was 21, which indicated a moderate level of depression. He did not endorse any suicidal thoughts. His scores on the SDS were 6 for work, 9 for social life, and 4 for home. This indicates a moderate impairment at work, a marked impairment in social life, and a mild impairment in family life or home responsibilities.

Establishing the Therapeutic Alliance and Identifying Treatment Goals

Establishing a strong therapeutic alliance is important in every treatment, and creating a strong science of the therapeutic relationship is an important aspect of pro- cess-based therapies (Hofmann & Hayes, 2018). The therapeutic alliance has been shown to predict treat- ment outcome above and beyond therapeutic orienta- tions (for a meta-analysis, see Flückiger, Del, Wampold, & Horvath, 2018), and this predictive utility may hold even when symptom improvement is taken into ac-

120 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

count (e.g., Zilcha-Mano, Dinger, McCarthy, & Bar- ber, 2014). The therapeutic alliance has three impor- tant facets: bond, goals and tasks (Bordin, 1979). Bond refers to the emotional connection between therapist and patient (e.g., the extent to which both members of the therapeutic dyad like, respect, and trust one an- other). Goals refers to agreement on the goals in therapy (or the therapeutic focus at any given point in therapy), and tasks refers to agreement on the actions needed to achieve these goals (e.g., the interventions used, the roles of the therapist and patient in these interventions). A strong therapeutic alliance can facilitate many of the interventions in treatment (e.g., exposure is likely to be facilitated when trust exists in the therapeutic dyad) and may also be beneficial in and of itself (having a strong alliance with the therapist may serve as a positive implicit model for other relationships in the patient’s life). For a detailed discussion of these two potential contributions of the therapeutic alliance to cognitive and behavioral interventions see Persons (2008).

During the first session, the therapist asked Mark a number of open-ended questions about the reasons that led him to seek treatment, and about his main areas of difficulty. This is typically a good way to help cli- ents to talk and share their thoughts and feelings, and can generally lead to good rapport. However, Mark’s replies were very brief, and it seemed that he had a hard time elaborating and disclosing personal information. He would typically respond with two or three brief sen- tences, then become anxious over the ensuing silence. The therapist quickly adjusted and began to take a more active role in the session. Specifically, the thera- pist began asking questions that were more specific and helped guide Mark through the story (“And what hap- pened then?”; “How did you feel when this happened?”; “What was going through your mind?”; Did anything else happen before this occurred?”). In addition, the therapist decided not to focus solely on Mark’s expe- rience during the session but also to begin discussing certain aspects of the model described earlier and to examine whether Mark felt those aspects were relevant to him or resonated with him. This type of back-and- forth helped the conversation flow more smoothly, and helped to foster an atmosphere of curiosity about what the therapist and treatment had to offer.

Over the next few sessions, the therapist focused on facilitating a strong therapeutic alliance by discuss- ing and agreeing on goals and priorities, and broadly discussing what would be required to meet these goals (i.e., addressing the tasks facet). Specifically, Mark and

the therapist discussed Mark’s depression and social anxiety and how to prioritize these issues. The therapist asked Mark what he wanted to focus on in treatment, and whether he viewed depression or social anxiety as his bigger concern. The therapist also used the “magic wand” metaphor and asked Mark whether he believed his social anxiety would remain if the therapist were able to use a wand to magically remove the depression, and whether he believed his depression would remain if the therapist were able to magically remove the so- cial anxiety. Mark replied that his social anxiety would probably remain if the depression were removed, but that he would not be depressed if his social anxiety ceased to be an issue. As a result of this collaborative decision-making process, Mark and the therapist col- laboratively decided that addressing social anxiety would be their priority in treatment. Once this decision was made, the therapist and Mark began to discuss vari- ous contexts in which Mark felt impaired by his social anxiety and began to prioritize these contexts. Mark and the therapist decided that despite the fact that ro- mantic relations represented the context in which Mark felt most impaired, they would initially focus on other, less impaired contexts (i.e., work) to begin practicing skills. Then, they would target the more difficult con- texts using the skills acquired and the lessons learned from work-related contexts.

Once goals and overarching strategy were set, the therapist shared his thoughts on the interventions that would likely be helpful. He told Mark that they would probably spend some of their time in therapy examin- ing Mark’s thoughts, and getting to know them. He also added that they might devote time to discussing and developing new ways of thinking about social situa- tions and about Mark’s experience and behavior in such situations. Finally, the therapist noted that the idea that thoughts are merely thoughts, and do not always ad- equately represent the world or ourselves, might also be explored. This would mean developing a different way of thinking about thoughts or of relating to them. The therapist also discussed the importance of exposure to social situations. He initiated a discussion of avoidance and anxiety, and the relationship between them, and also guided Mark in examining his previous behavior problems (which included a fair amount of avoidance) and their long-term consequences. The therapist then suggested that the approach in treatment could be one that strives to engage in previously avoided situations to reduce anxiety in the long term by experiencing it in the short term. Finally, the therapist said that they might

Social Anxiety 121

adopt a focus on feelings in some sessions. Emotion- focused interventions could help Mark get to know his own emotions (and emotions in general) to a greater extent. In this approach, feeling emotions and describ- ing the experience would be goals even if the feelings were unpleasant. These discussions served a number of goals: (1) to prepare Mark for future interventions; (2) to involve Mark in decisions regarding potential in- terventions as part of a collaborative process; and (3) to receive Mark’s input and thoughts regarding these interventions (such input can facilitate clinical decision making further along the course of treatment).

In addition to working on the therapeutic alliance and reaching agreement on goals and tasks (as well as cultivating an atmosphere of collaboration), Mark and the therapist began to conduct contextual idiographic assessment. Specifically, they reviewed three possible work-related situations and drew a model for each situ- ation or context (based on the general model of SAD presented earlier; i.e., Hofmann, 2007). These situa- tions included asking a coworker for help, asking Mark’s boss for a day off in person (rather than via e-mail), and initiating a conversation with someone at work he does not know (or has not spoken to before). These were all situations Mark had indicated were difficult and anxi- ety provoking for him, and through the contextual id- iographic assessment, Mark and the therapist were able to learn much about the processes occurring in these contexts, the similarities between them, and the unique aspects of each one. For instance, while negative self- perception played a role in all three contexts, perceived poor social skills and anticipation of mishap were es- pecially pertinent when initiating a conversation with someone at work he did not know. Mark’s thoughts for that situation were “I wouldn’t know what to say”; “I’m not good at making small-talk”; “I’ll say something awkward or irrelevant”; “He/she will not want to talk to me.” Safety behaviors were also different for each context. Mark and the therapist were able to identify specific safety behaviors Mark might use when asking for help (e.g., beginning the request with an apology or a lengthy explanation of the reasons for asking help), when requesting a day off in person (e.g., not making eye contact with his boss), and when initiating small- talk with someone for the first time (e.g., rehearsing topics for conversation in advance). Using contextual idiographic assessment, Mark and the therapist were able to enhance their understanding of Mark’s social anxiety and the processes maintaining it in each of these contexts. Figure 3.3 is a schematic of the model

drawn during one of these sessions (based on a dynamic network approach; Hofmann, Curtiss, & Hayes, 2020).

Cognitive Restructuring

During contextual idiographic assessment, Mark and the therapist were able to identify a large number of negative automatic thoughts Mark experienced dur- ing social situations at work. Mark seemed to learn this skill quickly and was able to formulate his thoughts and put them into words with relative ease. He also made several statements that suggested he was able to view these thoughts as irrational—at least in the context of therapy. For instance, in the discussion about asking his boss for a day off, Mark said he was worried that his boss would be upset with him for the request, or angry because it might cause delays in Mark’s work. After identifying that thought, Mark immediately went on to say that he knows days off are part of his job, that his coworkers take days off regularly, and that this does not seem to have any negative effect on their productivity or on their relationships with the boss. Mark’s ability to easily identify negative automatic thoughts, as well as his ability to view them as inaccurate or exaggerated, suggested to the therapist that using cognitive restruc- turing in this context was likely to be helpful.

To facilitate cognitive restructuring, the therapist used a technique that differentiates between Mark and his social anxiety, and creates some distance or defu- sion between the two (e.g., Barrera, Szafranski, Rat- cliff, Garnaat, & Norton, 2016; Kocovski, Fleming, & Rector, 2009; Kross, Gard, Deldin, Clifton, & Ayduk, 2012). In this way, negative automatic thoughts are at- tributed to social anxiety, whereas the more rational view is attributed to the self (i.e., Mark). This implicitly helps Mark identify with more rational alternatives and creates an alliance between Mark and the therapist in their joint effort to deal with (the distanced or defused) social anxiety. In addition, thinking of social anxiety as an entity that is (in part) distinct from Mark has the advantage of facilitating discourse between Mark and his social anxiety.

THERAPIST: What do you think would go through your mind if you were to ask your boss for a day off in person?

MARK: I think I would be worried that he would be disappointed or mad that I was taking time off. That maybe it would delay some of the things I am cur- rently working on.

122 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: I can completely understand. By taking some time off, you are concerned that your boss would think you are abandoning some of your work or your responsibilities. Do you think you could write those thoughts down and formulate them the same way we did with those previous thoughts?

MARK: Sure. (writing and reading aloud) “My boss will be disappointed or mad at me for taking time off.” (looking at the text) I mean, I know it doesn’t make any sense. Everyone can take time off, and my co- workers do it all the time, and everything is just fine. It’s just when I need to do it, I get anxious.

THERAPIST: I think you are saying something impor- tant here. You know that, realistically, there is noth- ing wrong with asking for time off. Yet when you do, it’s as if the social anxiety is telling you that it is wrong. That your boss will be mad at you or disap- pointed in you. And that makes you start to waver. You get anxious.

MARK: I’ve never thought of it in that way before. THERAPIST: That sounds like a good sign to me. We’re

here to see if we can think about things differently. What do you think you could say back to the social

anxiety after it says that your boss would be disap- pointed or mad?

MARK: Well, exactly what I said before—that other people do it all the time and it’s fine.

THERAPIST: Those are great replies! Is there anything else you can say back?

MARK: I’m not sure. THERAPIST: What about thinking about previous times

you asked for time off? Did your boss ever express disappointment or anger?

MARK: No. He was always perfectly fine with things. THERAPIST: So you could probably reply to the social

anxiety that in all previous instances, things went smoothly.

MARK: That’s right. (taking some time to think) I could also say that my boss takes time off, too. In fact, he was gone for quite a while recently.

THERAPIST: Great job! I like where you’re going with this. What do you think you would tell a friend who came to you with such an issue? How would you sug- gest the friend think about it, or what should he/she say to his/her social anxiety?

FIGURE 3.3. Dynamic network model for Mark. Thicker arrows represent stronger connections between model compo- nents.

Asking for a Day Off Feeling

Anxious

Negative Automatic Thoughts

“He’ll refuse my request”

Safety Behaviors

Apologize in Advance

Self-Efficacy Diminished

Social Anxiety 123

MARK: That the friend shouldn’t care too much about what the boss thinks. He/she can take a day off if he/ she wants to, that he/she is entitled to days off, even if the boss doesn’t like it.

THERAPIST: That sounds great. So we have a number of possible replies to the social anxiety in this situation if it tries to stress you out again. How does that feel?

MARK: It feels pretty good. I think I was so busy being anxious, I never thought I could answer back and change things.

THERAPIST: You’re absolutely right. When we think differently, we often feel differently as well. I think you just experienced that.

Mark responded very well to cognitive restructuring in work contexts. With the therapist’s guidance, he was able to develop alternative thoughts (i.e., replies to his social anxiety) and use them. Mark felt empowered by this skill, and his ability to distance himself from his so- cial anxiety and “talk back” to it helped him feel more confident and increased his self-efficacy.

Exposure and Behavioral Experiments

Encouraged by Mark’s success with cognitive restruc- turing, Mark and the therapist turned their attention to exposures/behavioral experiments at work. They began planning such exposures, with an emphasis on defin- ing goals in a precise, objective, and clearly defined way (because ambiguous goals have been shown to increase and maintain social anxiety; e.g., Moscovitch & Hof- mann, 2007), as well as ensuring that goals always re- main within Mark’s control and do not include others’ responses or Mark’s own anxiety. For instance, the goal of having a conversation when everyone else responds positively or displays interest is clearly out of our control and therefore not a helpful goal in exposure. Similarly, having a conversation while experiencing no anxiety or minimal anxiety is also not particularly helpful as a goal, as it involves emotions that are not under our di- rect or explicit control. In addition, it might convey the (inaccurate) message that anxiety is “bad” and should be reduced as much as possible (as opposed to anxiety being a natural human emotion that needs to be expe- rienced in full, yet does not always have to dictate our actions).

While planning exposures, Mark and the therapist recorded their decisions and other important informa- tion by creating an exposure form (in Mark’s handwrit-

ing). An example of this form for the exposure of initi- ating a conversation with a coworker appears in Figure 3.4. This form includes both a planning section that is completed with the therapist in the session before the exposure takes place, and a processing section that is completed with the therapist in the following session.

THERAPIST: As we did for the previous exposures, we are only setting goals that are under your control. This way, success or failure depends solely (or as much as possible) on you.

MARK: I remember. But how can we do that when it is a conversation with someone else? Don’t things always depend on the other person?

THERAPIST: That is an excellent question. Just like you said, when we have a conversation with someone else, the conversation always depends on the other per- son. However, in an exposure we can set goals that only depend on your behavior. For example, we can decide that the first goal is to initiate the conversa- tion. So the goal would be to make sure you are the one that approaches and begins talking, rather than being the one who responds to something someone else says. Another goal could be asking two ques- tions. Meeting the goal doesn’t depend on whether the other person answers or the way he/she responds. It just has to do with you asking the questions. Even if someone is in a hurry, you can usually get to ask a couple of questions. For example, asking how the person’s weekend was, and if he/she is in a rush and can’t talk right now, you can still ask when would be a good time to chat. So even in this worst-case sce- nario, it is possible to ask two questions.

MARK: I understand. But it would be pretty terrible if someone responded that way. I am sure it wouldn’t feel like success. That’s probably the worst thing that could happen. It means that just like I thought, peo- ple don’t want to talk to me because I’m weird and I don’t know how to have a conversation.

THERAPIST: I completely understand. If your goal is to have a conversation with someone, then not being able to do so would feel like a failure. But in our case, we are interested in something else. You can’t control other people, and you’re right that you could poten- tially experience rejection. However, I am suggesting that success in our case is being able to risk being re- jected. Rejection can happen. We’ve all been rejected, and I know it feels terrible and none of us like it, but

124 CliniCal Handbook of PsyCHologiCal disorders

FIGURE 3.4. Exposure form (planning and processing sections).

Exposure 3: Initiating conversation with a coworker with whom I have never spoken before Exposure Planning Time and place Monday morning (before lunch time) at work

Goals 1. Initiate conversation with Jack, a coworker of mine.

2. Ask Jack at least two open-ended questions.

3. Do not do anything to end the conversation.

Things that may appear to be goals but are not 1. Jack’s responses (Even if Jack answers briefly, shows little interest, can’t talk when I initiate the

conversation, ignores me, or says something mean—my success depends only on my three goals.)

2. My experience of anxiety and other emotions (My anxiety and emotions are not under my direct control, so they can’t define my success. Even if I get very anxious, I can succeed if I meet my three goals. In fact, if I meet goals while being extremely anxious, it can even be considered a bigger success.)

Safety behaviors 1. Not making eye contact (I am dropping this safety behavior.)

2. Rehearsing topics or questions for conversation (Is OK for now, but I will drop this next time.)

Negative automatic thoughts (or predictions) 1. I will say something stupid or weird.

2. Jack will not want to talk to me.

Alternative thoughts 1. It’s possible I’ll say something stupid, but most of the time I say things that are fine.

2. Even if I say something stupid and Jack will not want to talk to me, I will feel bad for a couple of days, but the feeling will go away and it’s not the end of the world.

Exposure Processing What actually happened? Jack was really nice. We talked for a few minutes and things were fine. We also started saying hello in the mornings after our talk.

What have I learned from this exposure? Things aren’t always as bad as they are in my thoughts. I can do things even if I’m anxious.

Social Anxiety 125

it’s out of our control. But being able to risk rejection is extremely important, and that’s what we are prac- ticing here. Taking a risk instead of avoiding things in the first place, that is success.

MARK: Risking rejection  .  .  . (mulling it over) That’s very different from what I’ve always done, isn’t it? It’s not easy.

THERAPIST: Absolutely. It’s very hard, and may require mustering all our strength, but it can also be very helpful.

MARK: So I just walk up to someone and start asking questions?

THERAPIST: In a way. We will plan it, get all the details right, and make sure that you are able to benefit the most from doing this. Let’s start with who the per- son will be. Do you have someone in mind? Someone from work that you haven’t really spoken to?

MARK: Well, there is this one person. His office is down the hall from mine. He seems nice, but I’ve never really talked to him.

THERAPIST: So definitely a possibility. What’s his name?

MARK: Jack. THERAPIST: Anyone else you think we should consider?

Maybe a woman from the office? MARK: (looking terrified) No, no. That’s much harder.

I’ll probably freeze and won’t be able to talk at all. THERAPIST: OK, so it sounds like we’ll be starting with

a man, and then see how things go and what the next steps can be. When would be a good time to approach someone and start talking?

Mark and the therapist then went on to discuss and record all the details of the exposure (see Figure 3.4). In our experience, the more time devoted to agreeing on all the relevant details, to discussing possible scenarios, to addressing others’ possible responses and Mark’s anxiety (and how they are unrelated to success in the exposure), and the more individually tailored the ex- posure is, the better the results. Thus, especially in the first exposures, spending a substantial amount of time preparing for exposures can be very helpful.

Over a number of sessions, Mark and the therapist planned and executed a series of exposures at work. After every exposure, the therapist devoted time to pro- cess Mark’s experience during the exposure, to praise him for conducting the exposure and meeting his goals,

and to discuss what Mark learned from the exposure and how that changes his perceptions of himself, his anxiety, and others (see Figure 3.4 for an example). Mark reported substantial improvements at work: His anxiety dropped, alternative thoughts began emerging, and Mark’s belief in them grew, and he was able to ex- pand his behavioral repertoire by initiating conversa- tions with coworkers, asking for help, and joining oth- ers for lunch. Mark reported that he felt much better at work, that he was more comfortable, and less anxious.

Strategies Focusing on Emotional Processes

Despite Mark’s improvement at work, his difficulties in romantic relationships remained unchanged for the most part. Thus, there was little generalization of new learning from work contexts to social life/romantic re- lations contexts. Mark and the therapist conducted an- other contextualized idiographic assessment to increase their understanding of this context and the potential challenges and barriers to change that may be present. This analysis provided a wealth of important informa- tion.

First, Mark shared an experience of being completely overwhelmed by his emotions, “freezing up,” not being able to talk or move, and just feeling terrified of what was happening to him. The feeling was so aversive that even thinking about it or imagining it made Mark want to escape it and talk about something else. This strong, overwhelming, and paralyzing emotional response was not present in work contexts and represented a unique aspect of the context of romantic relations. When the therapist discussed this feeling with Mark and referred to it as anxiety, Mark replied that it felt like “much more” than anxiety. The therapist inquired about this feeling, but Mark only said that the feeling was some sort of wave of emotion that came crashing down on him. Mark would frequently talk about the intensity of the emotions and their overwhelming nature, but his descriptions were always broad and general, and lacked emotional granularity or specificity. For Mark, the con- text of romantic relations included a strong component of lack of control over emotions that was related to dif- ficulty differentiating between emotions, regulating emotions, and experiential avoidance. The therapist believed that the emotional barrage that Mark was feel- ing represented a core component maintaining Mark’s social anxiety in romantic relations.

A second factor that arose during this contextual idiographic assessment involved Mark’s values and,

126 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

in particular, his religion and spirituality. Both values (Hayes et al., 2012), and religion and spirituality in particular (Rosmarin, Pargament, & Mahoney, 2009; Rosmarin, Auerbach, Bigda-Peyton, Björgvinsson, & Levendusky, 2011), can play an important role in psy- chotherapy. Specifically, during the contextual idio- graphic assessment, the therapist suggested that as part of the strategy in treatment, Mark could create a profile on a dating site, write women he was interested in meet- ing, and work toward dating. Mark’s reply made it clear that this suggestion was not aligned with his values. He replied that in his community, dating was typically ar- ranged by family members or acquaintances who would introduce single individuals for this purpose. Mark said that he preferred meeting women this way and that he viewed dating sites as being “only for sex.”

Following the contextual idiographic assessment, it was clear to the therapist that an exposure-based strat- egy would be a poor fit for Mark in this context, despite being successful in other contexts. Mark’s emotional response was too substantial and was likely to interfere with developing the sense of self-efficacy needed in ex- posures. Moreover, relying on others to arrange dates meant that this was not under Mark’s direct control, and that the number of potential dates may be limit- ed. PBT is ideal for these situations, because it allows flexibility in the use of therapeutic interventions rather than adherence to a strict session-based protocol. Using the information gathered from contextual idiographic assessment, Mark and the therapist decided to dedicate the next sessions to emotion-focused interventions.

As a first step, Mark and the therapist engaged in psychoeducation on emotions. This psychoeducation included a discussion of emotions in general, their function, and their patterns of experience, as is done in many treatments for anxiety. Importantly, the therapist emphasized that emotions represent a natural part of human experience, that emotions change quite rapidly, and that they provide important information for us about ourselves and others. While this information can and should be used to inform daily decisions, it should not be relied upon solely, and other factors (e.g., think- ing rationally, values) should also contribute to our decision-making process. This balance, or reliance on multiple sources of information (including emotions) was discussed as a healthy way to make decisions in our lives. Thus, Mark and the therapist began discussing two goals for the emotion-focused interventions: (1) to experience emotions as fully and completely as possible

(without fighting them or avoiding them) and (2) to base decisions on multiple considerations including not only emotions but also values, future goals, and rational thinking.

In addition to this common form of psychoeduca- tion, Mark and the therapist began to focus on discrete emotions to increase familiarity with them, and facili- tate differentiation and granularity. A greater focus was given to negative emotions, as individuals with SAD have been shown to have impaired differentiation of negative but not positive emotions (Kashdan & Farmer, 2014). Specifically, Mark and the therapist discussed anxiety, frustration, envy, guilt, embarrassment, shame, anger, loneliness, sadness, and despair. They described these emotions, defined them, and discussed the con- texts that commonly lead to these emotions, as well as associated thoughts, bodily sensations, and metaphors for these emotions.

For instance, when discussing envy, they described and defined it as an emotion arising when someone else possesses something (either material or immaterial) that we desire yet do not perceive ourselves to have. We can envy others for having more money than we do, for their appearance, for certain traits that they possess (whereas we do not), and so forth. They also discussed a number of facts about this emotion (derived from research in psychology). For instance, that the more similarity ex- ists between the envied individual and the self (in ev- erything but the desired feature) the greater the envy (Smith & Kim, 2007). Similarly, the more central the desired trait or feature is to one’s self-esteem, the greater the envy (Smith & Kim, 2007). Finally, they talked about how, sometimes, envy can be associated with a desire “to become” the other person and sometimes it can be associated with thoughts of harming the other person to reduce the perceived discrepancy between the self and the envied individual (van de Ven, Zeelenberg, & Pieters, 2009). When discussing envy, Mark noted that the Bible included a number of stories about this emotion, such as Joseph’s story (his brothers envied him, wronged him, and were ultimately punished for it). This was an important moment in therapy, because Mark was able to connect the content discussed in the sessions with his values, religious beliefs, and spiritual- ity. The therapist and Mark discussed how the broth- ers were punished not for experiencing the emotion in the first place, but for acting on it and harming some- one else. This contributed to the distinction between experiencing emotions (which is viewed as a natural

Social Anxiety 127

part of human experience) and acting solely based on these emotions, without considering the consequences (which may lead to adverse outcomes).

After Mark and the therapist concluded their discus- sion of discrete emotions, they began to practice identi- fying these emotions and differentiating between them. The therapist described hypothetical daily scenarios that were likely to evoke certain emotions, and Mark was tasked with identifying the emotions. Mark and the therapist then discussed these scenarios and how Mark was able to determine the likely emotion experienced by the protagonist. Then, the therapist asked Mark to describe a situation in which he felt that particular emo- tion. This enhanced Mark’s ability to identify emotions and differentiate between them, with regard to others’ behavior and to himself. Mark was encouraged to iden- tify three situations during the week in which he saw other people behave or speak in way that suggested they were experiencing a certain emotion, as well as three situations in which he experienced an emotion (three different emotions). Mark logged these situations, de- scribed them, and brought the log in to the following session for processing.

In the final step of the work on identifying and dif- ferentiating between emotions, Mark began to differen- tiate and disentangle the lump of emotions he felt when interacting with women, and especially in romantic contexts. Mark imagined previous interactions he had with women at the office and at school, and identified his emotional response. Mark was able to see that he did experience not only anxiety in these situations (“She’ll think I’m weird and won’t want to talk to me”) but also frustration (“Why do I always feel like this when I talk to women?”), shame (“I hope she won’t see how anx- ious I am”), envy (“How come everyone else can do this so easily but I can’t?”), and despair (“I’m a lost cause. I’ll never be able to have a normal relationship with a woman”). This represented a significant improvement in Mark’s ability to identify and differentiate between his emotions, and he began seeing his emotional re- sponse as a number of different emotions rather than as a nameless lump of overwhelming emotional experi- ence.

The therapist and Mark also conducted two in-ses- sion exposures. Specifically, the therapist invited two fe- male therapists (one in each session) to conduct “getting acquainted” conversations with Mark. Mark’s goals in these interactions were (1) to feel his emotions as fully as possible, without fighting them or avoiding them;

(2) to continue to interaction regardless of emotional reactions; and (3) following the interaction, to identify, discuss, and process his emotional experience with the therapist. While these can be considered exposures, it is important to note that the rationale for using these interventions was not to facilitate habituation of emo- tional responses, nor was it to examine beliefs or pre- dictions Mark had about himself and/or others in such situations. The sole focus was on experiencing emotions and processing them in a way that enhanced Mark’s emotional vocabulary and reduces fear and avoidance of these emotions (i.e., reduces experiential avoidance).

Mark was extremely anxious about these conversa- tions, and the therapist reminded him that these were opportunities to practice date-like situations, to experi- ence the associated emotions, to get to know them bet- ter, and to make sure they did not solely control Mark’s behavior. The therapist told Mark that, in a way, he was gradually owning more and more of his emotional space rather than avoiding it and leaving the emotions to run rampant. Mark benefited greatly from these exposures and was able to complete the interactions despite being highly distressed. Mark learned that he could talk to women while being distressed and did not necessarily need to avoid his emotions or run from them. More- over, feedback from interaction partners that his inner turmoil was less visible to others than he perceived was also valuable to Mark, as it helped him realize that the presence of his emotions did not mean that conversa- tions needed to be avoided.

In the last portion of Mark’s therapy, he began to go on dates (for the first time in his life). Mark quickly found that dates were not necessarily the terrifying en- counters he had feared and were more akin to everyday conversations. In one of these sessions, Mark compared dating to a job interview that, while being stressful, did not need to be overwhelming. Mark was surprised at first that women showed interest in him, but he gradu- ally became more confident as this process continued. At this point in therapy, the therapist focused on pro- cessing these dates with Mark, on Mark learning new things about himself and others in a dating context, and on helping Mark both disclose information so that his dates could get to know him and do his best to get to know his dating partners.

Whereas therapy did not conclude with Mark in a ro- mantic relationship, he was able to date several women (one for a period of 4 weeks) and felt that his anxiety and impairment were greatly reduced. Mark suggested

128 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

that he could continue on his own, and that he had overcome the barriers that made dating a herculean task for him. He felt his next challenge was to find a partner with whom he felt he had a good fit.

At termination, Mark’s scores on self-report measures were 35 on the LSAS, 12 on the SPIN, 80 on the SAQ, 20 on the STABS, and 6 on the BDI-II. He reported that his impairment was 3 for work, 4 for social life, and 2 for home. These scores reflect substantial improve- ment, and symptom levels were below clinical levels.

PREDICTORS OF TREATMENT SUCCESS

A number of predictors of success (and failure) have been addressed throughout this chapter (e.g., the thera- peutic alliance). In addition to such predictors, we would like to emphasize the importance of client mo- tivation and client preferences, and their relationship with the process-based model we described.

Clients who are not motivated to change, or who experience high levels of ambivalence toward change, are at higher risk for treatment failure in any treat- ment (Miller & Rollnick, 2012). Thus, using contex- tual idiographic assessment to assess client motivation is important and can inform therapeutic interventions. For some clients, evoking motivation and reducing bar- riers for change is extremely important and may be a prerequisite for the success of other empirically based processes. Motivation-focused strategies (e.g., motiva- tional interviewing; Miller & Rollnick, 2012) should be utilized and prioritized in such cases.

Client preferences regarding interventions should also be taken into consideration. This was true for Mark in the case presented in this chapter, and it has also been empirically supported across contexts and treat- ments (see Lindhiem, Bennett, Trentacosta, & McLear, 2014, for a meta-analysis). Client preferences should be assessed during contextual idiographic assessment and used to inform treatment decisions. Interventions that are perceived by clients as inappropriate, insufficient, irrelevant, or inferior to other options are unlikely to be successful. In such cases, conducting an in-depth discussion with clients regarding the intervention and its rationale is important, but if clients do not “buy-in,” alternative interventions should be used by therapists. Typically, multiple interventions can be used to achieve any particular goal or therapeutic target. This allows therapists the flexibility needed to tailor treatment to particular clients and their preferences.

SUMMARY

In this chapter, we have described PBT and how it can be applied to the treatment of social anxiety. We believe that this treatment offers flexibility to clients and thera- pists and can be used to provide individually tailored, empirically supported interventions that can reduce so- cial anxiety and its associated impairment and improve quality of life among individuals with social anxiety and SAD.

REFERENCES

Abbott, M. J., & Rapee, R. M. (2004). Post-event rumina- tion and negative self-appraisal in social phobia before and after treatment. Journal of Abnormal Psychology, 113(1), 136–144.

Aderka, I. M. (2009). Factors affecting treatment efficacy in social phobia: The use of video feedback and individual vs. group formats. Journal of Anxiety Disorders, 23, 12–17.

Aderka, I. M., Hofmann, S. G., Nickerson, A., Hermesh, H., Gilboa-Schechtman, E., & Marom, S. (2012). Functional impairment in social anxiety disorder. Journal of Anxiety Disorders, 26(3), 393–400.

Aldao, A., & Plate, A. J. (2018). Coping and emotion regu- lation. In S. C. Hayes & S. G. Hofmann (Eds.), Process- based CBT: The science and core clinical competencies of cognitive-behavioral therapy (pp. 261–272). Oakland, CA: New Harbinger.

Alden, L. E., Bieling, P. J., & Wallace, S. T. (1994). Perfec- tionism in an interpersonal context: A self-regulation anal- ysis of dysphoria and social anxiety. Cognitive Therapy and Research, 18(4), 297–316.

Alonso, J., Angermeyer, M. C., Bernert, S., Bruffaerts, R., Brugha, T. S., Bryson, H., et al. (2004). Disability and quality of life impact of mental disorders in Europe: Re- sults from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica, 109(Suppl. 420), 38–46.

Asher, M., & Aderka, I. M. (2018). Gender differences in so- cial anxiety disorder. Journal of Clinical Psychology, 74(10), 1730–1741.

Asher, M., Asnaani, A., & Aderka, I. M. (2017). Gender dif- ferences in social anxiety disorder: A review. Clinical Psy- chology Review, 56, 1–12.

Asher, M., Hermesh, H., Gur, S., Marom, S., & Aderka, I. M. (2019). Do men and women arrive, stay, and respond differently to cognitive behavior group therapy for so- cial  anxiety disorder? Journal of Anxiety Disorders, 64, 64–70.

Barrera, T. L., Szafranski, D. D., Ratcliff, C. G., Garnaat, S. L., & Norton, P. J. (2016). An experimental comparison of techniques: Cognitive defusion, cognitive restructuring,

Social Anxiety 129

and in-vivo exposure for social anxiety. Behavioural and Cognitive Psychotherapy, 44(2), 249–254.

Beck, A. T., & Emery, G. (1985). Anxiety disorders and pho- bias: A cognitive perspective. New York: Basic Books.

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depres- sion Inventory–II manual. San Antonio, TX: Psychological Corporation.

Boden, M. T., Thompson, R. J., Dizén, M., Berenbaum, H., & Baker, J. P. (2013). Are emotional clarity and emotion differentiation related? Cognition and Emotion, 27(6), 961–978.

Bordin, E. S. (1979). The generalizability of the psychoana- lytic concept of the working alliance. Psychotherapy: Theo- ry, Research and Practice, 16(3), 252–260.

Borge, F.-M., Hoffart, A., Sexton, H., Clark, D. M., Mar- kowitz, J. C., & McManus, F. (2008). Residential cogni- tive therapy versus residential interpersonal therapy for so- cial phobia: A randomized clinical trial. Journal of Anxiety Disorders, 22(6), 991–1010.

Brown, T. A., & Barlow, D. H. (2014). Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5L)—Life- time Version: Client Interview Schedule 5—Copy Set. New York: Oxford University Press.

Caballo, V. E., Arias, B., Salazar, I. C., Irurtia, M. J., & Hof- mann, S. G. (2015). Psychometric properties of an inno- vative self-report measure: The Social Anxiety Question- naire for adults. Psychological Assessment, 27(3), 997–1012.

Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hof- mann, S. G. (2006). Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders. Behaviour Research and Therapy, 44(9), 1251–1263.

Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Roth- baum, B., Emmelkamp, P., et al. (2019). Virtual reality ex- posure therapy for anxiety and related disorders: A meta- analysis of randomized controlled trials. Journal of Anxiety Disorders, 61, 27–36.

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A. J., & Hofmann, S. G. (2018). Cogni- tive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35(6), 502–514.

Chesham, R. K., Malouff, J. M., & Schutte, N. S. (2018). Meta-analysis of the efficacy of virtual reality exposure therapy for social anxiety. Behaviour Change, 35(3), 152– 166.

Clark, D. M., & Wells, A. (1995). A cognitive model of so- cial phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69–93). New York: Guilford Press.

Connor, K. M., Davidson, J. R. T., Churchill, L. E., Sher- wood, A., Foa, E., & Weisler, R. H. (2000). Psychometric properties of the Social Phobia Inventory (SPIN): New self- rating scale. British Journal of Psychiatry, 176, 379–386.

Craske, M. G., Niles, A. N., Burklund, L. J., Wolitzky-Taylor, K. B., Vilardaga, J. C. P., Arch, J. J., et al. (2014). Ran- domized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social pho- bia: Outcomes and moderators. Journal of Consulting and Clinical Psychology, 82(6), 1034–1048.

Crome, E., Baillie, A., & Taylor, A. (2012). Are male and female responses to social phobia diagnostic criteria com- parable? International Journal of Methods in Psychiatric Re- search, 21(3), 222–231.

Dagöö, J., Asplund, R. P., Bsenko, H. A., Hjerling, S., Holm- berg, A., Westh, S., et al. (2014). Cognitive behavior therapy versus interpersonal psychotherapy for social anxi- ety disorder delivered via smartphone and computer: A randomized controlled trial. Journal of Anxiety Disorders, 28(4), 410–417.

Dalrymple, K. L., & Herbert, J. D. (2007). Acceptance and commitment therapy for generalized social anxiety disor- der: A pilot study. Behavior Modification, 31(5), 543–568.

Dryman, M. T., & Heimberg, R. G. (2018). Emotion regula- tion in social anxiety and depression: A systematic review of expressive suppression and cognitive reappraisal. Clini- cal Psychology Review, 65, 17–42.

Erbas, Y., Ceulemans, E., Koval, P., & Kuppens, P. (2015). The role of valence focus and appraisal overlap in emotion differentiation. Emotion, 15(3), 373–382.

Ewbank, M. P., Cummins, R., Tablan, V., Bateup, S., Ca- tarino, A., Martin, A. J., et al. (2019). Quantifying the association between psychotherapy content and clinical outcomes using deep learning. JAMA Psychiatry, 77(1), 35–43.

Fehm, L., Pelissolo, A., Furmark, T., & Wittchen, H.-U. (2005). Size and burden of social phobia in Europe. Euro- pean Neuropsychopharmacology, 15(4), 453–462.

Flückiger, C., Del, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta- analytic synthesis. Psychotherapy, 55(4), 316–340.

Forsyth, J. P., & Ritzert, T. R. (2018). Enhancing psychologi- cal acceptance. In S. C. Hayes & S. G. Hofmann (Eds.), Process-based CBT: The science and core clinical competencies of cognitive-behavioral therapy (pp.  363–374). Oakland, CA: New Harbinger.

Furmark, T. (2002). Social phobia: Overview of community surveys. Acta Psychiatrica Scandinavica, 105, 84–93.

Goldin, P. R., Morrison, A., Jazaieri, H., Brozovich, F., Heimberg, R., & Gross, J. J. (2016). Group CBT versus MBSR for social anxiety disorder: A randomized con- trolled trial. Journal of Consulting and Clinical Psychology, 84(5), 427–437.

Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2(3), 271–299.

Gross, J. J., & Levenson, R. W. (1997). Hiding feelings: The acute effects of inhibiting negative and positive emotion. Journal of Abnormal Psychology, 106(1), 95–103.

130 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Hackmann, A., Clark, D. M., & McManus, F. (2000). Re- current images and early memories in social phobia. Be- haviour Research and Therapy, 38(6), 601–610.

Hackmann, A., Surawy, C., & Clark, D. M. (1998). Seeing yourself through others’ eyes: A study of spontaneously oc- curring images in social phobia. Behavioural and Cognitive Psychotherapy, 26(1), 3–12.

Hayes, S. C., & Hofmann, S. G. (Eds.). (2018). Process-based CBT: The science and core clinical competencies of cognitive- behavioral therapy. Oakland, CA: New Harbinger.

Hayes, S. C., Hofmann, S. G., Stanton, C. E., Carpenter, J. K., Sanford, B. T., Curtiss, J. E., et al. (2019). The role of the individual in the coming era of process-based therapy. Behaviour Research and Therapy, 117, 40–53.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Ac- ceptance and commitment therapy (2nd ed.). New York: Guilford Press.

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychol- ogy, 64(6), 1152–1168.

Hirsch, C. R., Clark, D. M., Mathews, A., & Williams, R. (2003). Self-images play a causal role in social phobia. Be- haviour Research and Therapy, 41(8), 909–921.

Hofmann, S. G. (2007). Cognitive factors that maintain so- cial anxiety disorder: A comprehensive model and its treat- ment implications. Cognitive Behaviour Therapy, 36(4), 193–209.

Hofmann, S. G. (2014). Interpersonal emotion regulation model of mood and anxiety disorders. Cognitive Therapy and Research, 38(5), 483–492.

Hofmann, S. G., Asnaani, A., & Hinton, D. E. (2010). Cul- tural aspects in social anxiety and social anxiety disorder. Depression and Anxiety, 27(12), 1117–1127.

Hofmann, S. G., Curtiss, J. E., & Hayes, S. C. (2020). Be- yond linear mediation: Toward a dynamic network ap- proach to study treatment processes. Clinical Psychology Review, 76, Article 101824.

Hofmann, S. G., & Hayes, S. C. (2018). The future of inter- vention science: Process-based therapy. Clinical Psychologi- cal Science, 7(1), 37–50.

Hofmann, S. G., & Heinrichs, N. (2003). Differential effect of mirror manipulation on self-perception in social phobia subtypes. Cognitive Therapy and Research, 27(2), 131–142.

Hofmann, S. G., Heinrichs, N., & Moscovitch, D. A. (2004). The nature and expression of social phobia: Toward a new classification. Clinical Psychology Review, 24(7), 769–797.

Ivanova, E., Lindner, P., Ly, K. H., Dahlin, M., Vernmark, K., Andersson, G., et al. (2016). Guided and unguided ac- ceptance and commitment therapy for social anxiety dis- order and/or panic disorder provided via the Internet and a smartphone application: A randomized controlled trial. Journal of Anxiety Disorders, 44, 27–35.

Jones, M. K., & Menzies, R. G. (2000). Danger expectan- cies, self-efficacy and insight in spider phobia. Behaviour Research and Therapy, 38(6), 585–600.

Kampmann, I. L., Emmelkamp, P. M. G., & Morina, N. (2016). Meta-analysis of technology-assisted interventions for social anxiety disorder. Journal of Anxiety Disorders, 42, 71–84.

Kashdan, T. B., Barrett, L. F., & McKnight, P. E. (2015). Unpacking emotion differentiation. Current Directions in Psychological Science, 24(1), 10–16.

Kashdan, T. B., & Farmer, A. S. (2014). Differentiating emo- tions across contexts: Comparing adults with and without social anxiety disorder using random, social interaction, and daily experience sampling. Emotion, 14(3), 629–638.

Kashdan, T. B., Farmer, A. S., Adams, L. M., Ferssizidis, P., McKnight, P. E., & Nezlek, J. B. (2013). Distinguishing healthy adults from people with social anxiety disorder: Evidence for the value of experiential avoidance and posi- tive emotions in everyday social interactions. Journal of Abnormal Psychology, 122(3), 645–655.

Kashdan, T. B., Goodman, F. R., Machell, K. A., Kleiman, E. M., Monfort, S. S., Ciarrochi, J., et al. (2014). A contex- tual approach to experiential avoidance and social anxiety: Evidence from an experimental interaction and daily in- teractions of people with social anxiety disorder. Emotion, 14(4), 769–781.

Kashdan, T. B., & Steger, M. F. (2006). Expanding the to- pography of social anxiety: An experience-sampling assess- ment of positive emotions, positive events, and emotion suppression. Psychological Science, 17(2), 120–128.

Katzelnick, D. J., & Greist, J. H. (2001). Social anxiety disor- der: An unrecognized problem in primary care. Journal of Clinical Psychiatry, 62(Suppl. 1), 11–16.

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627.

Kocovski, N. L., Fleming, J. E., Hawley, L. L., Huta, V., & Antony, M. M. (2013). Mindfulness and acceptance-based group therapy versus traditional cognitive behavioral group therapy for social anxiety disorder: A randomized controlled trial. Behaviour Research and Therapy, 51(12), 889–898.

Kocovski, N. L., Fleming, J. E., & Rector, N. A. (2009). Mindfulness and acceptance-based group therapy for so- cial anxiety disorder: An open trial. Cognitive and Behav- ioral Practice, 16(3), 276–289.

Koszycki, D., Benger, M., Shlik, J., & Bradwejn, J. (2007). Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behaviour Research and Therapy, 45(10), 2518–2526.

Kross, E., Gard, D., Deldin, P., Clifton, J., & Ayduk, O. (2012). “Asking why” from a distance: Its cognitive and

Social Anxiety 131

emotional consequences for people with major depressive disorder. Journal of Abnormal Psychology, 121(3), 559–569.

Leary, M. R. (2010). Social anxiety as an early warning sys- tem: A refinement and extension of the self-presentation theory of social anxiety. In S. G. Hofmann & P. M. Di- Bartolo (Eds.), Social anxiety: Clinical, developmental, and social perspectives (pp. 471–486). London: Elsevier.

Leary, M. R., & Kowalski, R. M. (1995). The self-presenta- tion model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 94–112). New York: Guilford Press.

Lecrubier, Y., Wittchen, H. U., Faravelli, C., Bobes, J., Patel, A., & Knapp, M. (2000). A European perspective on social anxiety disorder. European Psychiatry, 15(1), 5–16.

Liebowitz, M. R. (1987). Social phobia. Modern Problems of Pharmacopsychiatry, 22, 141–173.

Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clini- cal Psychology Review, 34(6), 506–517.

Lipsitz, J. D., Gur, M., Vermes, D., Petkova, E., Cheng, J., Miller, N., et al. (2008). A randomized trial of interper- sonal therapy versus supportive therapy for social anxiety disorder. Depression and Anxiety, 25(6), 542–553.

Lucock, M. P., & Salkovskis, P. M. (1988). Cognitive factors in social anxiety and its treatment. Behaviour Research and Therapy, 26(4), 297–302.

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., et al. (2014). Psychological and phar- macological interventions for social anxiety disorder in adults: A systematic review and network meta-analysis. Lancet Psychiatry, 1(5), 368–376.

McLean, C. P., Asnaani, A., Litz, B. T., & Hofmann, S. G. (2011). Gender differences in anxiety disorders: Preva- lence, course of illness, comorbidity and burden of illness. Journal of Psychiatric Research, 45(8), 1027–1035.

Miller, W. R., & Rollnick, S. (2012). Motivational interview- ing: Helping people change. New York: Guilford Press.

Moscovitch, D. A., & Hofmann, S. G. (2007). When am- biguity hurts: Social standards moderate self-appraisals in generalized social phobia. Behaviour Research and Therapy, 45(5), 1039–1052.

Moscovitch, D. A., Orr, E., Rowa, K., Reimer, S. G., & Ant- ony, M. M. (2009). In the absence of rose-colored glasses: Ratings of self-attributes and their differential certainty and importance across multiple dimensions in social pho- bia. Behaviour Research and Therapy, 47(1), 66–70.

Persons, J. B. (2008). The case formulation approach to cogni- tive-behavior therapy. New York: Guilford Press.

Piccirillo, M. L., Taylor Dryman, M., & Heimberg, R. G. (2016). Safety behaviors in adults with social anxiety: Review and future directions. Behavior Therapy, 47(5), 675–687.

Plasencia, M. L., Taylor, C. T., & Alden, L. E. (2016). Un- masking one’s true self facilitates positive relational out- comes. Clinical Psychological Science, 4(6), 1002–1014.

Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behav- ioral model of anxiety in social phobia. Behaviour Research and Therapy, 35(8), 741–756.

Rapee, R. M., & Lim, L. (1992). Discrepancy between self- and observer ratings of performance in social phobics. Journal of Abnormal Psychology, 101(4), 728–731.

Rosmarin, D. H., Auerbach, R. P., Bigda-Peyton, J. S., Björgvinsson, T., & Levendusky, P. G. (2011). Integrating spirituality into cognitive behavioral therapy in an acute psychiatric setting: A pilot study. Journal of Cognitive Psy- chotherapy, 25(4), 287–303.

Rosmarin, D. H., Pargament, K. I., & Mahoney, A. (2009). The role of religiousness in anxiety, depression, and happi- ness in a Jewish community sample: A preliminary investi- gation. Mental Health, Religion and Culture, 12(2), 97–113.

Rowa, K., Paulitzki, J. R., Ierullo, M. D., Chiang, B., Antony, M. M., McCabe, R. E., et al. (2015). A false sense of securi- ty: Safety behaviors erode objective speech performance in individuals with social anxiety disorder. Behavior Therapy, 46(3), 304–314.

Rytwinski, N. K., Fresco, D. M., Heimberg, R. G., Coles, M. E., Liebowitz, M. R., Cissell, S., et al. (2009). Screening for social anxiety disorder with the self-report version of the Liebowitz Social Anxiety Scale. Depression and Anxi- ety, 26, 34–38.

Sheehan, D. V. (1983). The anxiety disease. New York: Scrib- ner & Sons.

Smith, R. H., & Kim, S. H. (2007). Comprehending envy. Psychological Bulletin, 133(1), 46–64.

Stangier, U., Schramm, E., Heidenreich, T., Berger, M., & Clark, D. M. (2011). Cognitive therapy vs interpersonal psychotherapy in social anxiety disorder: A randomized controlled trial. Archives of General Psychiatry, 68(7), 692–700.

Stein, M. B., & Kean, Y. M. (2000). Disability and quality of life in social phobia: Epidemiologic findings. American Journal of Psychiatry, 157(10), 1606–1613.

Stewart, R. E., & Chambless, D. L. (2009). Cognitive- behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77(4), 595–606.

Swain, J., Hancock, K., Hainsworth, C., & Bowman, J. (2013). Acceptance and commitment therapy in the treat- ment of anxiety: A systematic review. Clinical Psychology Review, 33(8), 965–978.

Taylor, C. T., & Alden, L. E. (2010). Safety behaviors and judgmental biases in social anxiety disorder. Behaviour Re- search and Therapy, 48(3), 226–237.

Trower, P., & Gilbert, P. (1989). New theoretical conceptions of social anxiety and social phobia. Clinical Psychology Re- view, 9(1), 19–35.

132 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Turner, S. M., Johnson, M. R., Beidel, D. C., Heiser, N. A., & Lydiard, R. B. (2003). The Social Thoughts and Beliefs Scale: A new inventory for assessing cognitions in social phobia. Psychological Assessment, 15(3), 384–391.

van de Ven, N., Zeelenberg, M., & Pieters, R. (2009). Level- ing up and down: The experiences of benign and malicious envy. Emotion, 9(3), 419–429.

Wenzel, A. (2018). Cognitive reappraisal. In S. C. Hayes & S. G. Hofmann (Eds.), Process-based CBT: The science and core clinical competencies of cognitive-behavioral therapy (pp. 325–338). Oakland, CA: New Harbinger.

Wersebe, H., Sijbrandij, M., & Cuijpers, P. (2013). Psycho- logical group-treatments of social anxiety disorder: A me- ta-analysis. PLOS ONE, 8(11), e79034.

Wittchen, H. U., Fuetsch, M., Sonntag, H., Müller, N., & Liebowitz, M. (2000). Disability and quality of life in pure and comorbid social phobia: Findings from a controlled study. European Psychiatry, 15(1), 46–58.

Wittchen, H. U., Stein, M. B., & Kessler, R. C. (1999). Social fears and social phobia in a community sample of adolescents and young adults: Prevalence, risk fac- tors and co-morbidity. Psychological Medicine, 29(2), 309–323.

Wunderlich, U., Bronisch, T., & Wittchen, H. U. (1998). Co- morbidity patterns in adolescents and young adults with sucide attempts. European Archives of Psychiatry and Clini- cal Neuroscience, 248(2), 87–95.

Xu, Y., Schneier, F., Heimberg, R. G., Princisvalle, K., Li- ebowitz, M. R., Wang, S., et al. (2012). Gender differences in social anxiety disorder: Results from the national epide- miologic sample on alcohol and related conditions. Journal of Anxiety Disorders, 26(1), 12–19.

Zilcha-Mano, S., Dinger, U., McCarthy, K. S., & Barber, J. P. (2014). Does alliance predict symptoms throughout treat- ment, or is it the other way around? Journal of Consulting and Clinical Psychology, 82(6), 931–935.

133

It will not take the reader long to see that successful therapy for obsessive–compulsive disorder (OCD) is markedly different in both structure and content from the usual therapeutic approaches. For this reason, regrettably, few therapists feel self-efficacious enough to undertake this therapy, yet this approach is clearly the treatment of choice for the most beneficial short- and long-term effects in OCD according to clinical trials. The information provided in this detailed chapter should be sufficient for any reasonably well-trained mental health professional to undertake this treatment, particularly if few other options are available. The suffering involved with OCD can be extraordinary, and even imperfect attempts at therapy can relieve much of this suffering. This chapter describes the detailed conduct of intensive daily sessions involving both imaginal and direct in vivo practice. Also noticeable is the ingenuity required of therapists (e.g., “Where do you find dead animals?”). The importance of involving significant others continues a theme first described by Craske, Wolitzky-Taylor, and Barlow in Chapter 1 of this volume, in which spouses/partners or other people close to the individual with the problem become an important and integral part of treatment. Finally, this chapter contains an up-to- date review of the current status of psychological and pharmacological approaches to OCD. —D. H. B.

Advances in cognitive-behavioral and pharmaco- logical treatments in the last four decades have

improved the prognosis for patients with obsessive– compulsive disorder (OCD). In this chapter we first discuss diagnostic and theoretical issues of OCD and review the available treatments, then describe assess- ment procedures and illustrate in detail how to imple- ment intensive cognitive-behavioral treatment (CBT) involving exposure and ritual prevention (EX/RP) for OCD. Throughout the chapter, we use case material to illustrate interactions that occur between therapist and patient to demonstrate the process that occurs during treatment.

DEFINITION

According to the 11th edition of the International Clas- sification of Diseases (ICD-11; World Health Organiza- tion, 2021), OCD is characterized by recurrent obses- sions and/or compulsions that interfere substantially with daily functioning (Stein et al., 2016). Common obsessions are repeated thoughts about causing harm to others, contamination, and doubting whether one locked the front door. Common compulsions include handwashing, checking, and counting. OCD is cat- egorized among obsessive–compulsive and related dis- orders (e.g., Stein et al., 2010, 2016), which highlight

C H A P T E R 4

Obsessive–Compulsive Disorder

Martin E. Franklin Edna B. Foa

134 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

the formal and functional similarity between OCD and several other disorders that involve intense anxi- ety and associated compulsions (e.g., body dysmorphic disorder [BDD]), as well as those involving repetitive behaviors that appear to be driven by appetitive urges (e.g., trichotillomania [hair pulling], excoriation [skin picking] disorder; Stein et al., 2016).

The functional link between obsessions and compul- sions is emphasized: Obsessions are defined as thoughts, images, or impulses that cause marked anxiety or dis- tress, and compulsions are defined as overt (behavioral) or covert (mental) actions that are performed in an at- tempt to reduce the distress brought on by obsessions or according to rigid rules. This modification was sup- ported by findings from a large field trial on OCD, in which over 90% of participants reported that the aim of their compulsions was either to prevent harm associated with their obsessions or to reduce obsessional distress (Foa et al., 1995).

Data from that same large field study also indicated that the vast majority (over 90%) of individuals with OCD manifest both obsessions and behavioral rituals. When mental rituals are also included, only 2% of the sample report “pure” obsessions (Foa et al., 1995). Be- havioral rituals (e.g., handwashing) are equivalent to mental rituals (e.g., silently repeating special prayers) in their functional relationship to obsessions: Both serve to reduce obsessional distress, to prevent feared harm, or to restore safety. Thus, whereas all obsessions are in- deed mental events, compulsions can be either mental or behavioral. Identification of mental rituals is an espe- cially important aspect of treatment planning, because obsessions and compulsions are addressed via different techniques. For example, we once treated a patient who described himself as a “pure obsessional,” who would ex- perience intrusive and unwanted images of harm com- ing to his girlfriend by an animal attack. The patient would quickly and intentionally insert his own image into the scene to become the victim of the animal maul- ing, thereby reducing his distress and, in his estimation, reducing the likelihood that some future harm would come to his girlfriend. The substitution of his own image into the scene constituted a mental ritual, and the success of imaginal exposure exercises required that the patient refrain from this form of compulsion.

Increased consensus about a continuum of insight in individuals with OCD (e.g., Foa et al., 1995; Insel & Akiskal, 1986) led to designation of a subtype of OCD “with poor insight” to include individuals who

indeed have obsessions and compulsions but fail to rec- ognize their senselessness (Stein et al., 2016), although clinicians had difficulty applying a three-level insight qualifier ( fair-to-good insight, poor insight, no insight) to OCD case vignettes (Kogan et al., 2020). Individuals are classified as having good or fair insight, poor in- sight, or absent insight/delusional beliefs, reflecting an even greater recognition of a continuum of insight in OCD (Leckman et al., 2010). Clinically, it is impor- tant to evaluate the degree of insight prior to initiating CBT, because fixed belief about the consequences of re- fraining from compulsions and avoidance behaviors has been found to be associated with attenuated treatment outcome (e.g., Foa, Abramowitz, Franklin, & Kozak, 1999; Neziroglu, Stevens, Yaryura-Tobias, & McKay, 2000; Visser et al., 2017).

To be diagnosed with OCD, obsessions and/or com- pulsions must be found to be of sufficient severity to cause marked distress, be time-consuming, and inter- fere with daily functioning. If another Axis I disorder is present, the obsessions and compulsions cannot be restricted to the content of that disorder (e.g., preoc- cupation with food in the presence of eating disorders).

PREVALENCE AND COURSE

Once thought to be an extremely rare disorder, the 12-month prevalence of OCD was estimated at 1.0% in the National Comorbidity Survey Replication in- volving over 9,000 adult participants in the United States (Kessler et al., 2005). Epidemiological studies with children and adolescents suggest similar lifetime prevalence rates in these samples (e.g., Dalsgaard et al., 2020; Flament et al., 1988; Valleni-Basille et al., 1994). Slightly more than half of adults suffering from OCD are female (Rasmussen & Tsuang, 1986), whereas a 2:1 male to female ratio has been observed in several pedi- atric clinical samples (e.g., Hanna, 1995; Swedo, Rapo- port, Leonard, Lenane, & Cheslow, 1989). Age of onset typically ranges from early adolescence to young adult- hood, with earlier onset in males; modal onset is ages 13–15 in males, and ages 20–24 in females (Rasmus- sen & Eisen, 1990). However, cases of OCD have been documented in children as young as age 2 (Rapoport, Swedo, & Leonard, 1992).

Development of the disorder is usually gradual, but acute onset has been reported in some cases. Although chronic waxing and waning of symptoms are typical,

Obsessive–Compulsive Disorder 135

episodic and deteriorating courses have been observed in about 10% of patients (Rasmussen & Eisen, 1989). In some cases of pediatric OCD and tic disorders, onset is very sudden and associated with streptococcal infection; treatment of the infection is associated with substantial reduction of symptoms, but recurrence of infection is again associated with symptom exacerbation (Swedo et al., 1998). Presentation of OCD in these cases, which is much more typical in males than in females, came to be known as “pediatric autoimmune neuropsychiatric dis- orders associated with streptococcal infection” (PAN- DAS) and has more recently been revised and broad- ened under the umbrella term “pediatric autoimmune neuropsychiatric syndrome” (PANS; Swedo, Leckman, & Rose, 2012); the prevalence of PANDAS or PANS has yet to be determined. OCD is frequently associ- ated with impairments in general functioning, such as disruption of gainful employment (Koran, 2000; Leon, Portera, & Weissman, 1995; Torres et al., 2006) and interpersonal relationship difficulties (Emmelkamp, de Haan, & Hoogduin, 1990; Riggs, Hiss, & Foa, 1992; Torres et al., 2006). Adolescents identified as having OCD (Flament et al., 1988) reported in a subsequent follow-up study that they had withdrawn socially to prevent contamination and to conserve energy for ob- sessive–compulsive behaviors (Flament et al., 1990). Many individuals with OCD suffer for years before seeking treatment (e.g., García-Soriano, Rufer, Del- signore, & Weidt, 2014). In one study, individuals first presented for psychiatric treatment over 7 years after the onset of significant symptoms (Rasmussen & Tsu- ang, 1986). The disorder may cause severe impairment in functioning that results in job loss and disruption of marital and other interpersonal relationships. Marital distress is reported by approximately 50% of married individuals seeking treatment for OCD (Emmelkamp et al., 1990; Riggs et al., 1992).

COMORBIDITY

Convergent epidemiological and clinical data indicate that OCD rarely occurs in isolation: Although the rates of comorbidity differ across studies due to selec- tion of population and methodology, comorbidity is generally high. For example, Weissman and colleagues (1994) found that 49% of individuals diagnosed with OCD suffered from a comorbid anxiety disorder and 27% from comorbid major depressive disorder (MDD).

Among studies conducted specifically within anxiety clinics, there is great variability, but comorbid condi- tions are generally common (for a review, see Ledley, Pai, & Franklin, 2007). In the largest of the studies conducted in the context of an anxiety clinic, Brown, Campbell, Lehman, Grisham, and Mancill (2001) found that 57% of 77 adults with a principal diagnosis of OCD had a current comorbid Axis I condition; the rate rose to 86% for lifetime comorbid Axis I condi- tions. Notably, when OCD co-occurs with other anxi- ety disorders, it is typically the principal diagnosis (e.g., the diagnosis of greatest severity; see Antony, Downie, & Swinson, 1998). It also appears to be the case that MDD onset tends to follow that of OCD, suggesting that depression might be a response to OCD symptoms (Bellodi, Sciuto, Diaferia, Ronchi, & Smeraldi, 1992; Diniz et al., 2004).

The data are equivocal with respect to the influence of comorbidity on OCD presentation. In one study, Denys, Tenney, van Megen, de Geus, and Westenberg (2004) found that comorbidity did not influence OCD symptom severity, whereas others (Angst, 1993; Tukel, Polat, Ozdemir, Aksut, & Turksov, 2002) found a rela- tionship between comorbidity and OCD symptom se- verity. A more consistent finding is that comorbidity is associated with poorer quality of life, particularly in the case of comorbid depression (Lochner & Stein, 2003; Masellis, Rector, & Richter, 2003).

With respect to the effect of comorbid anxiety and depression on treatment outcome, the influence of de- pression has received more empirical attention to date. Some studies have found that higher levels of depres- sion at pretreatment are related to poorer outcome (e.g., Keijsers, Hoogduin, & Schaap, 1994; Steketee, Chamb- less, & Tran, 2001), whereas others have found little or no effect (Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002; O’Sullivan, Noshirvani, Marks, Monteiro, & Lelliott, 1991; Steketee, Eisen, Dyck, Warshaw, & Rasmussen, 1999). Some have suggested that, more specifically, the severity of the comorbid depression might influence its effects on OCD treatment outcome: Abramowitz, Franklin, Street, Kozak, and Foa (2000) found that only severely depressed patients were less likely to respond to EX/RP therapy for OCD. Simi- larly, highly depressed patients with OCD seem to be at greater risk for relapse following treatment discon- tinuation (Abramowitz & Foa, 2000; Basoglu, Lax, Kasvikis, & Marks, 1988). The influence of comorbid anxiety disorders on outcome has received less attention

136 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

thus far: One study reported that patients with OCD and comorbid generalized anxiety disorder (GAD) ter- minate OCD treatment at higher rates than other pa- tients (Steketee et al., 2001), and another found that the presence of posttraumatic stress disorder (PTSD) in patients with OCD attenuated response to EX/RP (Gershuny, Baer, Jenike, Minichiello, & Wilhelm, 2002). Within pediatric OCD specifically, comorbidity other than a second anxiety disorder (e.g., externaliz- ing disorder, mood disorder) was associated with poorer acute response to CBT (Storch et al., 2008), and an- other report indicated that comorbid attention-deficit/ hyperactivity disorder (ADHD) specifically attenuated CBT outcomes at follow-up among children and ado- lescents (Farrell, Waters, Milliner, & Ollendick, 2012). Notably, the mechanisms by which these comorbid conditions influence outcome have yet to be explored.

Tourette syndrome and other tic disorders also ap- pear to be related to OCD, although not sufficiently to be grouped within obsessive–compulsive and related disorders (Stein et al., 2016). Estimates of the comor- bidity of Tourette syndrome and OCD range from 28 to 63% (Comings, 1990; Kurlan et al., 2002; Leckman & Chittenden, 1990; Pauls, Towbin, Leckman, Zahn- er, & Cohen, 1986). Conversely, up to 17% of patients with OCD are thought to have Tourette syndrome (Comings, 1990; Kurlan et al., 2002; Rasmussen & Eisen, 1989). The relationship between tic comorbidity and treatment outcome are complex: in one study the presence of tics was associated with poorer treatment outcome (Matsunaga et al., 2005) while in another trial, tic comorbidity decreased pharmacotherapy treat- ment outcome but not outcome of CBT (March et al., 2007). In a more recent trial of CBT augmentation in youth on an SRI, tic status did not predict outcome to any treatment (Conelea et al., 2014); tics also did not predict outcome to CBT alone in a large trial of youth with OCD who were not receiving any SRIs (Højgaard et al., 2017).

DIFFERENTIAL DIAGNOSIS

The high comorbidity of OCD with other disorders noted earlier, as well as the similarity between the crite- ria for OCD and other psychiatric disorders, can pose diagnostic quandaries. Below we review some of the more common diagnostic difficulties likely to confront clinicians and provide recommendations for making these difficult diagnostic judgments.

Obsessions versus Depressive Rumination

It is sometimes difficult to differentiate between de- pressive ruminations and obsessions. The distinction rests primarily on thought content and the patient’s re- ported resistance to such thoughts. Unlike obsessions, ruminations are typically pessimistic ideas about the self or the world, and ruminative content frequently shifts. Additionally, depressive ruminators tend to not make repeated attempts to suppress their ruminations the way individuals with OCD try to suppress obses- sions. When depression and OCD co-occur, both phe- nomena may be present, but only obsessions should be targeted with exposure exercises. We have also found clinically that the generally pessimistic presentation of depressed patients can undermine hopefulness about improvement during EX/RP; thus, these beliefs may require therapeutic intervention even though they are not obsessional.

Anxiety Disorders

OCD has been classified previously as an anxiety dis- order, and it often co-occurs with anxiety disorders. Diagnostic criteria are sometimes similar among these related (anxiety) disorders, but the symptoms associ- ated with each diagnosis can usually be distinguished. For example, the excessive worries characteristic of GAD may appear similar to those in OCD but, un- like obsessions, worries are excessive concerns about real-life circumstances and are experienced by the in- dividual as appropriate (ego-syntonic). In contrast, obsessive thinking is more likely to be unrealistic or magical, and obsessions are usually experienced by the individual as inappropriate (ego-dystonic). There are, however, exceptions to this general rule: Individuals with either GAD or OCD may worry about everyday matters, such as their children getting sick. However, when worried about their children catching cold, par- ents with GAD might focus their concern on the long- term consequences (e.g., falling behind in school, de- velopment of a lifelong pattern of debilitation), whereas parents with OCD might focus more on the contami- nation aspect of illness (e.g., their child being infested with “cold germs”). The problem of distinguishing between obsessions and worries in a particular patient is most relevant when the patient exhibits no compul- sions, but, as we mentioned earlier, pure obsessionals comprise only about 2% of individuals with OCD (Foa et al., 1995).

Obsessive–Compulsive Disorder 137

In the absence of rituals, the avoidance associated with specific phobias may also appear similar to OCD. For example, excessive fear of germs and specific phobia both may result in persistent fear of dogs. However, un- like an individual with OCD, a person with a specific phobia can successfully avoid dogs for the most part, or reduce distress quickly by escaping dogs when avoid- ance is impractical. In contrast, the individual with OCD who is obsessed with “dog germs” continues to feel contaminated even after the dog is gone, and some- times knowing that a dog was in the vicinity several hours earlier can also produce obsessional distress even if there is no possibility that the dog will return. This distress often prompts subsequent avoidance behaviors (e.g., taking off clothing that might have been near the contaminating dog) not typically observed in specific phobias.

Body Dysmorphic Disorder

The preoccupation with imagined physical defects of BDD is formally similar to the obsessions of OCD, and BDD is grouped with obsessive–compulsive and related disorders. The best way to differentiate between this disorder and OCD is to examine for content specificity of the fear-provoking thoughts. Most individuals with BDD are singly obsessed, whereas most individuals with OCD have multiple obsessions.

Tourette Syndrome and Tic Disorders

To differentiate the stereotyped motor behaviors that characterize Tourette syndrome and tic disorders from compulsions, the functional relationship between these behaviors and any obsessive thoughts must be examined. Motor tics are generally experienced as involuntary and are not aimed at neutralizing distress brought about by obsessions. There is no conventional way to differentiate them from “pure” compulsions, but OCD with “pure” compulsions is extremely rare (Foa et al., 1995). As we noted earlier, there appears to be a high rate of comor- bidity between OCD and tic disorders (e.g., Pauls et al., 1986); thus, both disorders may be present simultane- ously in a given patient. Interestingly, tics were similarly responsive to an EX/RP protocol when compared in a randomized study to habit-reversal training in which a competing response is substituted for the tic; this find- ing suggests that the conceptual model underlying the treatment of tics might require modification (Verdellen, Keijsers, Cath, & Hoogduin, 2004).

Delusional Disorder and Schizophrenia

Individuals with OCD may present with obsessions of delusional intensity (for a review, see Kozak & Foa, 1994). Approximately 5% of patients with OCD report complete conviction that their obsessions and compul- sions are realistic, with an additional 20% reporting strong but not fixed conviction. Therefore, it is impor- tant to consider the diagnosis of OCD “with poor in- sight” even if these beliefs are very strongly held. The differentiation between delusional disorder and OCD can depend on the presence of compulsions in OCD (Eisen et al., 1998). In OCD, obsessions of delusional intensity are usually accompanied by compulsions.

It is also important to recognize that the content of obsessions in OCD may be quite bizarre, as in the delu- sions of schizophrenia, but bizarreness in and of itself does not preclude a diagnosis of OCD. For example, one patient seen at our center was fearful that small bits of her “essence” would be forever lost if she passed too close to public trash cans. This patient did not report any other symptoms of formal thought disorder, such as loose associations, hallucinations, flat or grossly in- appropriate affect, and thought insertion or projection. Following a course of EX/RP that focused on exercises designed to expose the patient to the loss of her “es- sence” (e.g., driving by the city dump), her OCD symp- toms were substantially reduced. On occasion patients do meet diagnostic criteria for both OCD and schizo- phrenia, and a dual diagnosis is appropriate under these circumstances. Importantly, EX/RP with such patients should proceed only if the associated treatment exer- cises do not exacerbate the comorbid thought disorder symptoms.

COGNITIVE AND BEHAVIORAL MODELS

Mowrer’s (1939) two-stage theory for the acquisition and maintenance of fear and avoidance behavior has been commonly adopted to explain phobias and OCD. As elaborated by Mowrer (1960), this theory proposes that in the first stage, a neutral event becomes associ- ated with fear by being paired with a stimulus that by its nature provokes discomfort or anxiety. Through conditioning processes, objects, as well as thoughts and images, acquire the ability to produce discomfort. In the second stage of this process, escape or avoidance responses are developed to reduce the anxiety or dis- comfort evoked by the various conditioned stimuli and

138 CliniCal Handbook of PsyCHologiCal disorders

are maintained by their success in doing so. Dollard and Miller (1950) adopted Mowrer’s two-stage theory to explain the development of phobias and obsessive– compulsive neurosis. As noted earlier, because of the intrusive nature of obsessions, many situations that provoke obsessions cannot readily be avoided. Passive avoidance behaviors, such as those utilized by phobics, are also less effective in controlling obsessional distress. Active avoidance patterns in the form of ritualistic be- haviors are then developed and maintained by their suc- cess in alleviating this distress.

In light of equivocal empirical support for the two- stage theory and its limitations, Rescorla (1982) pro- posed a model of learning theory that emphasizes change in expectations as the mechanism of change in conditioning and extinction. Influenced by their theo- ry, Foa, Yadin, and Lichner (2012) adopted emotional processing theory (Foa & Kozak, 1986) to explain the mechanism of exposure and response prevention, sug- gested that disconfirmation of beliefs underlies the ef- fects of this treatment (i.e., patients learn that the nega- tive outcome they expected from being exposed to their fear situation did not materialize).

Another explanation was offered by Salkovskis’s (1985) cognitive analysis of OCD. He posited that intrusive obsessional thoughts are stimuli that may provoke certain types of negative automatic thoughts. Accordingly, an intrusive thought leads to mood dis- turbances only if it triggers negative automatic thoughts through interaction between the unacceptable intru- sion and the individual’s belief system (e.g., only bad people have sexual thoughts). According to Salkovskis, exaggerated senses of responsibility and self-blame are the central themes in the belief system of a person with OCD. Neutralization, in the form of behavioral or cog- nitive compulsions, may be understood as an attempt to reduce this sense of responsibility and to prevent blame. In addition, frequently occurring thoughts regarding unacceptable actions may be perceived by the individ- ual with OCD as equivalent to the actions themselves, so, for example, even if the person has not sinned, the thought of sinning is as bad as sinning itself.

Salkovskis (1985) further proposed that five dysfunc- tional assumptions characterize individuals with OCD and differentiate them from persons without OCD:

(1) Having a thought about an action is like perform- ing the action; (2) failing to prevent (or failing to try to prevent) harm to self or others is the same as having caused the harm in the first place; (3) responsibility is not

attenuated by other factors (e.g., low probability of oc- currence); (4) not neutralizing when an intrusion has oc- curred is similar or equivalent to seeking or wanting the harm involved in that intrusion to actually happen; (5) one should (and can) exercise control over one’s thoughts. (p. 579)

Thus, while the obsession may be ego-dystonic, the automatic thought it elicits will be ego-syntonic. By extension, this model suggests that treatment of OCD should largely focus on identifying the erroneous as- sumptions and modifying the automatic thoughts. This theory paved the way for various elaborations on the cognitive models, experimental studies of the model, and the development of cognitive therapies that derive from the central role of these key cognitive factors.

Salkovskis’s (1985) theory sparked examination of the role of responsibility in the psychopathology of OCD (Ladoucer et al., 1995; Rachman, Thordarson, Shafran, & Woody, 1995; Rhéaume, Freeston, Dugas, Letarte, & Ladoucer, 1995). Further attention has been paid to what Rachman (1998) referred to as thought– action fu- sion (TAF), wherein individuals believe that simply hav- ing an unacceptable thought increases the likelihood of the occurrence of a feared outcome, and that thoughts of engaging in repugnant activities are equivalent to actu- ally having done so. Contemporary cognitive theorists would then suggest that obsessive– compulsive beliefs such as TAF, exaggerated responsibility, and intolerance of uncertainty likely result in increased and ultimately futile efforts at thought suppression and other ill- advised mental control strategies, which would then yield in- creased frequency of such thoughts and associated dis- tress (Purdon & Clark, 2002). Hence, a vicious cycle of avoidance maintains and strengthens the OCD, and the cognitive therapies that derive from these contemporary models would directly target these obsessive–compulsive beliefs in an effort to break the cycle.

In an integrated cognitive-behavioral account, Foa and Kozak (1985, 1986) conceptualized anxiety dis- orders in general as specific impairments in emotional memory networks. Following Lang (1979), they view fear as an information network existing in memory that includes representation about fear stimuli, fear respons- es, and their meaning. With regard to the fear content, Foa and Kozak (1986) suggested that fear networks of individuals with anxiety disorders are characterized by the presence of erroneous estimates of threat, un- usually high negative valence for the feared event, and excessive response elements (e.g., physiological reactiv-

Obsessive–Compulsive Disorder 139

ity), and are resistant to modification. This persistence may reflect failure to access the fear network because of either active avoidance or the content of the fear network precludes spontaneous encounters with situa‑ tions that evoke anxiety in everyday life. Additionally, anxiety may persist because of some impairment in the mechanism of extinction. Cognitive defenses, excessive arousal with failure to habituate, faulty premises, and erroneous rules of inference are all impairments that would hinder the processing of information necessary for modifying the fear structure to reduce fear behavior.

Foa and Kozak (1985) suggested that several forms of fear occur in individuals with OCD. The patient who fears contracting venereal disease from public bathrooms and washes to prevent such harm has a fear structure that includes excessive associations between the stimuli (e.g., bathrooms) and the anxiety/distress responses, as well as mistaken beliefs about the harm re‑ lated to the stimulus. For other individuals with OCD, fear responses are associated with mistaken meaning rather than with a particular stimulus. For example, some patients who are disturbed by perceived asymme‑ try, and who reduce their distress by rearranging ob‑ jects, do not fear the objects themselves, nor do they an‑ ticipate disaster from the asymmetry. Rather, they are upset by their view that certain arrangements of stimuli are “improper.”

Like Reed (1985), Foa and Kozak (1985) proposed that in addition to the pathological content of the ob‑ sessions, OCD is distinguished from other disorders by pathology in the mechanisms underlying information processing. Specifically, they suggested that patients with OCD experience impairments in taking into ac‑ count the rules for making inferences about harm, often concluding that a situation is dangerous based on the absence of evidence for safety, and that they often fail to make inductive leaps about safety from informa‑ tion about the absence of danger. Consequently, rituals performed to reduce the likelihood of harm can never provide safety and must be repeated. In an elaboration on emotional processing theory and the mechanism by which exposure works, Foa, Huppert, and Cahill (2006) suggested that in vivo exposure to the feared stimulus in the absence of the anticipated harm cor‑ rects the exaggerated probability estimates; imaginal exposure not only corrects the exaggerated cost but also strengthens the discrimination between “thoughts about harm” and “real harm,” thus altering the asso‑ ciations between threat meaning of stimulus and/or re‑ sponse elements in the fear structure.

Animal models of fear conditioning and extinction (see Bouton, 1993) have suggested that the original con‑ ditioned stimulus–unconditioned stimulus (CS‑US) as‑ sociation learned during fear conditioning is not erased during an extinction procedure, but rather rendered am‑ biguous as new information is learned when the CS no longer predicts the US. This process means that the CS now has two meanings: the original excitatory mean‑ ing, plus an additional inhibitory one (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). With respect to application in humans, Craske and colleagues have pos‑ ited that anxious individuals show deficits in the mech‑ anisms thought to be central to extinction learning; accordingly, there is great clinical value in optimizing inhibitory learning during exposure therapy to maxi‑ mize treatment outcomes. One such strategy involves overtly setting up exposures as tests of patient expectan‑ cies so as to provide maximal opportunity for violation of said expectancies. In order to do so, it is important to shift language away from whether a patient is ha‑ bituating, focusing instead on whether he/she is learn‑ ing that his/her expectations of negative outcome do not occur. In addition, the application of an inhibitory learning model in treatment would include emphasiz‑ ing the importance of decontextualizing inhibitory as‑ sociations, as well as helping the patient develop distress tolerance (Blakey & Abramowitz, 2016). Experimental tests of the relative efficacy of this approach to con‑ ducting exposure versus other approaches (e.g., models that emphasize within‑session habituation) have yet to be undertaken specifically with patients with clinical OCD. It will also be important to determine whether patients with OCD with explicit feared consequences (e.g., “I will kill my baby if I do not ritualize in response to thoughts of harming her”) fare better using the in‑ hibitory learning model when compared to those whose urges to ritualize are driven more by disgust or by “not just right” experiences without fear related to specific external consequences.

TREATMENTS

Exposure and Ritual Prevention

The prognostic picture for OCD has improved dra‑ matically since Victor Meyer (1966) first reported on two patients who responded well to a treatment that included prolonged exposure to obsessional cues and strict prevention of rituals. This procedure, known at the time as “exposure and ritual prevention” (EX/RP),

140 CliniCal Handbook of PsyCHologiCal disorders

was later found to be extremely successful in 10 of 15 cases and partly effective in the remainder. Patients treated with this regimen also appeared to maintain their treatment gains: At a 5-year follow-up, only two of these patients had relapsed (Meyer & Levy, 1973; Meyer, Levy, & Schnurer, 1974).

As was the case with Meyer’s program, current EX/RP treatments typically include both prolonged exposure to obsessional cues and procedures aimed at blocking rituals. Exposure exercises are often done in real-life settings (in vivo), for example, by asking the patient who fears accidentally causing a house fire by leaving the stove on, to leave the house without checking the burners. When patients report specific feared conse- quences of refraining from rituals, these fears may also be addressed via imaginal exposure. In fact, in vivo and imaginal exposure exercises are designed specifically to prompt obsessional distress. It is believed that repeated, prolonged exposure to feared thoughts and situations provides information that disconfirms mistaken associ- ations and evaluations held by the patients and thereby promotes habituation (Foa & Kozak, 1986). Exposure is usually done gradually by confronting situations that provoke moderate distress before confronting more up- setting ones. Exposure homework is routinely assigned between sessions, and patients are also asked to refrain from rituals.

Since Meyer’s (1966) initial positive report of the ef- ficacy of EX/RP, many subsequent studies of EX/RP have indicated that most EX/RP treatment completers make and maintain clinically significant gains. Ran- domized controlled trials (RCTs) have indicated that EX/RP is superior to a variety of control treatments, including placebo medication (Marks, Stern, Mawson, Cobb, & McDonald, 1980; Foa et al., 2005), relaxation (Fals-Stewart, Marks, & Schafer, 1993; Simpson et al., 2008), and anxiety management training (Lindsay, Crino, & Andrews, 1997). Recent meta-analytic find- ings examining randomized trials clearly support the efficacy of CBT for both adult (Öst, Havnen, Hansen, & Kvale, 2015) and pediatric OCD (Öst, Riise, Werge- land, Hansen, & Kvale, 2016). Moreover, several studies have now indicated that these encouraging findings for EX/RP are not limited to highly selected RCT samples (Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000; Kay, Eken, Jacobi, Riemann, & Storch, 2016, Roth- baum & Shahar, 2000; Valderhaug, Larsson, Gote- stam, & Piacentini, 2007; Warren & Thomas, 2001).

In general, EX/RP has been found quite effective in ameliorating OCD symptoms and has produced great

durability of gains following treatment discontinua- tion. In our review of the literature, it also was appar- ent that among the many variants of EX/RP treatment, some are relevant for outcome and others are not. We review the literature on the relative efficacy of the ele- ments that comprise EX/RP to help clinicians decide which EX/RP components are most essential.

EX/RP Treatment Variables

EXPOSURE VERSUS RITUAL PREVENTION VERSUS EX/RP

To separate the effects of EX/RP on OCD symptoms, Foa, Steketee, Grayson, Turner, and Latimer (1984) randomly assigned patients with washing rituals to treatment by exposure only (EX), ritual prevention only (RP), or their combination (EX/RP). Each treatment was conducted intensively (15 daily 2-hour sessions conducted over 3 weeks) and followed by a home visit. Patients in each condition were found to be improved at both posttreatment and follow-up, but EX/RP was superior to the single-component treatments on almost every symptom measure at both assessment points. In comparing EX and RP, patients who received EX re- ported lower anxiety when confronting feared contami- nants than did patients who had received RP, whereas the RP group reported greater decreases in urge to ritu- alize than did the EX patients. Thus, it appears that EX and RP affected different OCD symptoms. The findings from this study clearly suggest that EX and RP should be implemented concurrently; treatments that do not include both components yield inferior out- come. It is important to convey this information to pa- tients, especially when they are experiencing difficulty either refraining from rituals or engaging effectively in exposure exercises during and between sessions.

IMPLEMENTATION OF RITUAL PREVENTION

Promoting abstinence from rituals during treatment is thought to be essential for successful treatment out- come, but the preferred method of RP has changed over the years. In Meyer’s (1966) EX/RP treatment program, hospital staff members physically prevented patients from performing rituals (e.g., turning off the water supply in a patient’s room). However, physical intervention by staff or family members to prevent pa- tients from ritualizing is no longer typical or recom- mended. It is believed that such prevention techniques

Obsessive–Compulsive Disorder 141

are too coercive to be an accepted practice today. More- over, physical prevention by others may actually limit generalizability to nontherapy situations in which oth- ers are not present to intercede. Instead, instructions and encouragement to refrain from ritualizing and avoidance are now recommended. As noted earlier, al- though exposure itself can reduce obsessional distress, it is not so effective in reducing compulsions. To maxi- mize treatment effects, the patient needs to refrain vol- untarily from ritualizing, while engaging in systematic exposure exercises. The therapist should strongly em- phasize the importance of refraining from rituals and help the patient with this difficult task by providing support, encouragement, and suggestions about alter- natives to ritualizing.

USE OF IMAGINAL EXPOSURE

Treatment involving imaginal plus in vivo EX/RP at follow-up was superior to an in vivo EX/RP program that did not include imaginal exposure (Foa, Steketee, Turner, & Fischer, 1980; Steketee, Foa, & Grayson, 1982). However, a second study did not find that the addition of imaginal exposure enhanced long-term ef- ficacy compared to in vivo exposure only (De Araujo, Ito, Marks, & Deale, 1995). The treatment program in the former study (Foa et al., 1980) differed from that of De Araujo and colleagues on several parameters (e.g., 90-minute vs. 30-minute imaginal exposures, respec- tively); thus, the source of these studies’ inconsistencies cannot be identified.

In our clinical work, we have found imaginal ex- posure to be helpful for patients who report that di- sastrous consequences will result if they refrain from rituals. Because many of these consequences cannot be readily translated into in vivo exposure exercises (e.g., burning in hell), imaginal exposure allows the patient an opportunity to confront these feared thoughts. Also, the addition of imagery to in vivo exposure may circumvent the cognitive avoidance strategies used by patients who intentionally try not to consider the con- sequences of exposure while confronting feared situa- tions in vivo. In summary, although imaginal exposure does not appear essential for immediate outcome, it may enhance long-term maintenance and be used as an adjunct to in vivo exercises for patients who fear disastrous consequences. For patients who only report extreme distress as a consequence of refraining from rituals and avoidance behaviors, imaginal exposure may not be needed.

GRADUAL VERSUS ABRUPT EXPOSURES

No differences in OCD symptom reduction were de- tected in a study comparing patients who confronted the most distressing situations from the start of thera- py to those who confronted less distressing situations first, yet patients preferred the more gradual approach (Hodgson, Rachman, & Marks, 1972). However, be- cause patient motivation and agreement with treatment goals are core elements of successful EX/RP, situations of moderate difficulty are usually confronted first, fol- lowed by several intermediate steps, before the most dis- tressing exposures are attempted. Thus, we emphasize that exposure will proceed at a pace that is acceptable to the patient, and that no exposure will ever be attempted without the patient’s approval. At the same time, it is preferable to confront the highest item on the treatment hierarchy relatively early in treatment (e.g., within the first week of intensive treatment) to allow sufficient time to repeat these difficult exposures over the later sessions.

DURATION OF EXPOSURE

Duration of exposure was once believed to be impor- tant for outcome in that prolonged, continuous expo- sure was found to be more effective than short, inter- rupted exposure (Rabavilas, Boulougouris, & Perissaki, 1979). Indeed, reduction in anxiety (habitation) across sessions has been associated with improvement fol- lowing exposure-based treatments for OCD and for PTSD (e.g., Jaycox, Foa, & Morral, 1998; Kozak, Foa, & Steketee, 1988; van Minnen & Hagenaars, 2002). However, several studies have not found a strong rela- tionship between within-session habituation and fear and symptom reduction (Jaycox et al., 1998; Kozak et al., 1988; Mathews, Johnston, Shaw, & Gelder, 1974; Rowe & Craske, 1998). In an elaboration on emotional processing theory, Foa and colleagues (2006) found that the recent deemphasis of the relationship between within-session habituation and outcome is not critical to emotional processing theory, because the proposed mechanism underlying symptom reduction is the mod- ification of the relevant erroneous associations through disconfirming information, not through habituation per se. In practical terms, this means patients should be instructed that although, optimally, they should persist with exposure until the anxiety is substantially reduced, the more important factor is repeating the same expo- sures, to promote reduction of associated anxiety over time. Patients with OCD might be particularly vul-

142 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

nerable to fears of ending exposures “too soon,” hence, doing the treatment incorrectly, so this new instruc- tion might help encourage patients to go about their business without ritualizing or avoiding, regardless of whether anxiety still lingers on from an exposure task. The deemphasis of the critical importance of habitu- ation in the moment is more pronounced procedur- ally when using acceptance and commitment therapy (e.g., Twohig et al., 2010), but, generally speaking, this viewpoint appears to be gaining acceptance among cog- nitive-behavioral therapists as well. For example, clini- cally we often remind patients that whether they are anxious is less relevant than what they do (or do not do) when they are anxious, since ritualizing and avoidance will maintain fear down the line.

FREQUENCY OF EXPOSURE SESSIONS

Optimal frequency of exposure sessions has yet to be established. Intensive exposure therapy programs that have achieved excellent results (e.g., Foa, Kozak, Steke- tee, & McCarthy, 1992) typically involve daily ses- sions over the course of approximately 1 month, but quite favorable outcomes have also been achieved with more widely spaced sessions (e.g., Abramowitz, Foa, & Franklin, 2003; De Araujo et al., 1995; Franklin et al., 1998). A recent RCT in pediatric OCD found no dif- ference between intensive and weekly treatment (Storch et al., 2007). Clinically, we have found that less frequent sessions may be sufficient for highly motivated patients with mild to moderate OCD symptoms, who readily understand the importance of daily exposure home- work. Patients with very severe symptoms, or those who for various reasons cannot readily comply with EX/RP tasks between sessions, are typically offered intensive treatment.

THERAPIST-ASSISTED VERSUS SELF-EXPOSURE

Evaluations of the presence of a therapist during ex- posure have yielded inconsistent results. In one study, patients with OCD receiving therapist-assisted expo- sure were more improved immediately posttreatment than those receiving clomipramine and self-exposure, but this difference was not evident at follow-up (Marks et al., 1988). However, these results are difficult to in- terpret in light of the study’s complex design. A sec- ond study using patients with OCD also indicated that therapist-assisted treatment was not superior to self-exposure at posttreatment or at follow-up (Em-

melkamp & van Kraanen, 1977), but the number of patients in each condition was too small to render these findings conclusive. In contrast to the negative find- ings of Marks and colleagues (1988) and Emmelkamp and van Kraanen (1977), therapist presence yielded superior outcome of a single, 3-hour exposure session compared to self-exposure for persons with specific phobia (Öst, 1989). Because specific phobias are, on the whole, less disabling and easier to treat than OCD, one may surmise that therapist presence should also influ- ence treatment outcome with OCD. Moreover, using meta-analytic procedures, Abramowitz (1996) found that therapist-controlled exposure was associated with greater improvement in OCD and GAD symptoms compared to self-controlled procedures. Comparable outcomes were found for patients receiving EX/RP with therapist assistance and those who received teletherapy (Lovell et al., 2006), which further raises the question of whether therapist assistance is required for good out- come. In light of these inconsistent findings, no clear answer is available on the role of therapist assistance with exposure tasks in OCD treatment. However, we have found clinically that the presence of a therapist can be useful in helping patients to remain engaged in ex- posures while anxiety is high, to avoid subtle rituals or avoidance behaviors during exposure (e.g., distraction, mental rituals), and to remain sufficiently motivated despite distress. Researchers have begun to examine the question of whether telephone therapy or Skype would also be effective, including adapted CBT protocols for Tourette syndrome (Himle, Olufs, Himle, Tucker, & Woods, 2010) and OCD specifically (e.g., Bachofen et al., 1999; Comer et al., 2017); such research may pro- vide greater confidence that these methods can be used efficaciously, which will help to address the ongoing problem of the paucity of OCD treatment expertise that plagues most communities.

EX/RP versus Other Treatment Approaches

In this section we review the literature on the efficacy of standard individual EX/RP treatment versus other therapeutic approaches, including group treatment, family-based EX/RP treatment, cognitive therapy, and pharmacotherapy.

INDIVIDUAL VERSUS GROUP EX/RP

Intensive individual EX/RP, although effective, can pose practical obstacles, such as high cost for treatment,

Obsessive–Compulsive Disorder 143

and scheduling problems for patient and therapist alike. Additionally, because experts in EX/RP treat- ment are few and far between, patients may need to wait for long periods or travel substantial distances to be treated. Thus, some researchers have begun to exam- ine the efficacy of more affordable and efficient treat- ment modalities. One such alternative is group treat- ment. Fals-Stewart and colleagues (1993) conducted a controlled study in which patients with OCD were randomly assigned to individual EX/RP, group EX/RP, or a psychosocial control condition (relaxation). Each of the active treatments was 12 weeks long, with sessions held twice weekly, and included daily exposure home- work. Significant improvement in OCD symptoms was evident in both active treatments, with no differences detected between individual and group EX/RP imme- diately posttreatment or at 6-month follow-up. Profile analysis of OCD symptom ratings collected through- out treatment did indicate a faster reduction in symp- toms for patients receiving individual treatment. These results offer evidence for the efficacy of group treat- ment. However, because patients were excluded from this study if they were diagnosed with any personality disorder or with comorbid depression, it may be that the sample was somewhat atypical. In addition, none of the participants had received previous OCD treatment, which is also unusual for this population and suggestive of a less symptomatic sample. Thus, inferences about the broader OCD population merit caution until these results are replicated.

Barrett, Healy-Farrell, and March (2004) found that individual and group CBT were highly and simi- larly efficacious for children and adolescents with OCD relative to a wait-list control; this raises the possibility that group interventions might hold particular promise in the treatment of youth with OCD. Also in youth, Asbahr and colleagues (2005) found group CBT and sertraline comparable at posttreatment, but there was less relapse in the former condition. Another Australian research group found comparable outcomes for group treatment compared to individual treatment, both of which were superior to a wait-list control (Anderson & Rees, 2007); not surprisingly, though, individual treat- ment was associated with more rapid response.

FAMILY INVOLVEMENT VERSUS STANDARD EX/RP TREATMENT

Emmelkamp and colleagues (1990) examined whether family involvement in treatment would enhance the

efficacy of EX/RP for OCD. Patients who were mar- ried or living with a romantic partner were randomly assigned to receive EX/RP either with or without part- ner involvement in treatment. Results indicated that OCD symptoms were significantly lowered following treatment for both groups. No differences between the treatments emerged, and initial marital distress did not predict outcome. However, the reduction in anxiety/ distress reported for the sample as a whole was mod- est (33%), which may have resulted from the relatively short treatment sessions and absence of in vivo exposure exercises in treatment sessions.

Mehta (1990) also examined the effect of family involvement on EX/RP treatment outcome. To adapt the treatment to serve the large numbers of young un- married people seeking OCD treatment and the “joint family system” prevalent in India, Mehta used a family- based rather than spouse-based treatment approach. Patients who did not respond to previous pharmaco- therapy were randomly assigned to receive treatment by systematic desensitization and EX/RP, either with or without family assistance. Sessions in both conditions were held twice weekly for 12 weeks; response preven- tion was described as “gradual.” In the family condition, a designated family member (parent, spouse, or adult child) assisted with homework assignments, supervised relaxation therapy, participated in response prevention, and was instructed to be supportive. On self-reported OCD symptoms, a greater improvement was found for the family-based intervention at posttreatment and at 6-month follow-up. Although this study had meth- odological problems that complicate interpretation of findings (e.g., use of self-report OCD measures only, unclear description of treatment procedures), it offers some preliminary evidence that family involvement may be helpful in OCD treatment. Clinically, we rou- tinely enlist the support of family members in EX/RP, providing psychoeducation about the illness and its consequences during the early stages of treatment plan- ning, and advice and encouragement in managing the patient’s request for assurances, his/her avoidant behav- iors, and violation of EX/RP rules between sessions. We also try to reduce family members’ criticism of the patient and unconstructive arguing about OCD and related matters when these issues arise in the therapy.

Published randomized studies of CBT for OCD with youth have each included parents at least to some extent in treatment (Barrett et al., 2004; de Haan, Hoogduin, Buitelaar, & Keijsers, 1998; Pediatric OCD Treatment Study Team, 2004), and a direct comparison

144 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

of CBT, with and without a family component, using an otherwise identical protocol has yet to be conducted in pediatric OCD. Research on whether family involve- ment enhances individual CBT outcomes in other anxiety disorders has generally yielded mixed findings, however, and a large RCT indicated that both forms of treatment are efficacious and essentially equivalent to one another (Bogels & Bodden, 2005). Higher family dysfunction in general was associated with poorer long- term outcome in one study (Barrett, Farrell, Dadds, & Boulter, 2005), as was family accommodation of OCD rituals specifically (Peris et al., 2012), and at this point it might be clinically prudent to include a more com- prehensive family component when family members are very directly involved in the patient’s rituals (e.g., reassurance seeking) or when family psychopathology threatens generalizability of treatment gains to a chaot- ic home environment. It also may be that greater family involvement in treatment is needed when the patient is very young (Freeman et al., 2003, 2007, 2014).

EX/RP VERSUS COGNITIVE THERAPIES

Increased interest in cognitive therapy (e.g., Beck, 1976; Ellis, 1962), coupled with dissatisfaction with formula- tions of treatment mediated by processes such as extinc- tion (Stampfl & Levis, 1967) or habituation (Watts, 1973), prompted examination of the efficacy of cogni- tive procedures for anxiety disorders in general and for OCD in particular. A number of early studies found few differences between standard behavioral treat- ments and behavioral treatments enhanced with vari- ous cognitive approaches (e.g., Emmelkamp & Beens, 1991; Emmelkamp, Visser, & Hoekstra, 1988). Re- cent advances in cognitive conceptualizations of OCD have apparently yielded more efficacious and durable cognitive treatments. Freeston and colleagues (1997) found a cognitive-behavioral intervention efficacious compared to a wait-list control group for patients with “pure” obsessions. Several other studies (Cottraux et al., 2001; McLean et al., 2001; Vogel, Stiles, & Götestam, 2004; Whittal, Thordarson, & McLean, 2005) have suggested equivalent results for CBT and EX/RP, re- spectively, although some procedural overlap between the two conditions in these studies makes their find- ings difficult to interpret. In concert with studies at- testing to the utility of cognitively oriented approaches for conditions that are quite similar to OCD, such as hypochondriasis (Barsky & Ahern, 2004; Warwick, Clark, Cobb, & Salkovskis, 1996), it does appear that

cognitive therapies hold promise for the treatment of OCD and might be an efficacious potential alternative to EX/RP (Öst et al., 2015). However, Whittal, Woody, McLean, Rachman, and Robichaud (2010) failed to find a difference between cognitive therapy and stress management training (SMT) for a sample with primary obsessions and mental rituals, although this appeared to be due to the fact that SMT yielded substantial and lasting benefit compared to pretreatment rather than because cognitive therapy did not.

The question of whether cognitive therapy improves the efficacy of EX/RP is generally difficult to discern, because both exposure therapy and cognitive therapy are intended to modify mistaken cognitions. An RCT that compared “pure” forms of CT or EX/RP, with or without medication, found similar, yet somewhat at- tenuated, outcomes relative to what might typically be expected from either treatment (van Balkom et al., 1998). Foa and Kozak (1986) argued that the discon- firmation of erroneous associations and beliefs is a crucial mechanism underlying the efficacy of exposure treatments, hence disputing discussions that mistaken cognitions from EX/RP might be expected to hamper outcome. For example, a patient and therapist sitting on the bathroom floor in a public restroom conduct- ing an exposure to contaminated surfaces routinely discuss risk assessment, probability overestimation, and so forth, as the therapist helps the patient achieve the cognitive modification necessary for improvement. The practical issue of interest is how to maximize efficacy: Is informal discussion of cognitive distortions during the exposure exercises sufficient, or should the therapist engage in formal Socratic questioning of hypothesized distortions, such as inflated responsibility? Notably, in a meta-analytic review, cognitive therapies for OCD that included some form of exposure to feared stimuli were superior to those that did not, suggesting that exposure may be necessary to maximize outcomes (Abramowitz, Franklin, & Foa, 2002).

To expand on this point further, Hiss, Foa, and Kozak (1994) investigated whether formal relapse prevention techniques following intensive EX/RP en- hanced maintenance of gains. Notably, all discussions about cognitive factors typically included during the core treatment (e.g., discussion of lapse vs. relapse, posttreatment exposure instructions, themes of guilt and personal responsibility, and feared consequences) were removed. Patients received this modified EX/RP, followed by either a relapse prevention treatment or a psychosocial control treatment (associative therapy). All

Obsessive–Compulsive Disorder 145

patients in both conditions were classified as respond- ers at posttreatment (defined as 50% or greater reduc- tion in OCD symptoms), with treatment gains better maintained in the relapse prevention group than in the associative therapy condition at 6-month follow- up. The percentages of responders at follow-up were 75% in the relapse prevention condition and 33% in associative therapy. The higher than usual observed relapse rate in the associative therapy condition may have resulted from the removal of cognitive techniques typically utilized during the core treatment, such as discussion of feared consequences. These findings, and those discussed earlier, further underscore our belief that blended treatment designed to provide patients the opportunity to disconfirm their erroneous cognitions makes the most sense clinically. Accordingly, our ap- proach clearly incorporates informal cognitive proce- dures, and discussions of the outcome of exposures are geared toward challenging mistaken beliefs; this is ac- complished in the context of a treatment approach that still emphasizes the importance of EX/RP in bringing about such changes.

Serotonergic Medications

Effectiveness of Medications

The use of serotonergic medications in the treatment of OCD has received a great deal of attention. Of the tricyclic antidepressants, clomipramine (CMI) has been studied most extensively. In controlled trials, CMI has consistently been found to be superior to placebo (e.g., DeVeaugh-Geiss, Landau, & Katz, 1989). Similar re- sults have been obtained with the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine, and sertraline (see Öst et al., 2015). Accordingly, each of these medications has been approved by the U.S. Food and Drug Administration (FDA) as treatments for adult OCD. On the whole, these studies suggest that up to 60% of patients show some response to treatment with SSRIs. However, even the average treatment gain achieved by treatment responders is moderate at best (Greist, 1990). In addition, amelioration of obsessive– compulsive symptoms is maintained only as long as the drug is continued: For example, in an early controlled, double-blind discontinuation study, 90% of patients re- lapsed within a few weeks after being withdrawn from CMI (Pato, Zohar-Kadouch, Zohar, & Murphy, 1988). More recent discontinuation studies with slower taper periods have not yielded such dramatic results, but

they nevertheless converge to suggest that maintenance treatment is necessary to sustain achievements attained with pharmacotherapy alone for OCD (Dougherty, Rauch, & Jenike, 2002).

EX/RP versus Pharmacotherapy

Many controlled studies have indicated that serotoner- gic antidepressants are superior to placebo in ameliorat- ing OCD symptoms (for a review, see Greist, Jefferson, Kobak, Katzelnick, & Serlin, 1995). However, only a few controlled studies have directly compared the rela- tive or combined efficacy of antidepressant medications and EX/RP, and several studies that have made such a comparison included complex designs that make it difficult to draw confident conclusions about relative and combined efficacy (e.g., Marks et al., 1980, 1988). Cottraux and colleagues (1990) compared fluvoxamine (FLV) with antiexposure instructions, FLV plus weekly EX/RP, and pill placebo (PBO) plus EX/RP, and found FLV + EX/RP and FLV + antiexposure instructions su- perior to PBO + EX/RP; there was a trend toward an advantage for combined treatment, but it failed to reach significance. Hohagen and colleagues (1998) compared EX/RP + FLV to EX/RP + PBO and found that both groups improved significantly and comparably on com- pulsions, but the patients who received EX/RP + FLV were significantly better at posttreatment on obsessions than those who received EX/RP + PBO. Subanalyses indicated that patients with secondary depression also fared better if they were receiving EX/RP + FLV.

The relative and combined efficacy of CMI and in- tensive EX/RP was examined in a multicenter, RCT conducted at our center (Penn) and at Columbia Uni- versity. Findings with both treatment completer and in- tention-to-treat (ITT) data indicated at posttreatment that the active treatments were superior to placebo, EX/ RP was superior to CMI, and the combination of the two treatments was not superior to EX/RP alone (Foa et al., 2005); relapse was more evident following treat- ment discontinuation in the CMI group than in either treatment that included intensive EX/RP (EX/RP, EX/ RP + CMI; Simpson et al., 2004). However, the design used in the Penn–Columbia study may not have op- timally promoted an additive effect for CMI, because the intensive portion of the EX/RP program was largely completed before patients reached their maximum dose of CMI. In addition, combined treatment effects may be more evident when intensive EX/RP is not used (Foa, Franklin, & Moser, 2002). Notably, an additive effect

146 CliniCal Handbook of PsyCHologiCal disorders

for combined treatment was found in a study in pedi- atric OCD at Penn, Duke, and Brown (Pediatric OCD Treatment Study Team, 2004), although examination of effect sizes by site indicated that the CBT monother- apy effect at Penn was very large, and no additive effect for combined treatment was found at this site.

In summary, although there is clear evidence that both pharmaceutical treatment with serotonergic medi- cations and EX/RP treatments are effective for OCD, information about their relative and combined efficacy remains scarce, because most of the studies that exam- ined these issues have been methodologically limited. Nevertheless, no study has found clear, long-term supe- riority for combined pharmacotherapy plus EX/RP over EX/RP alone. The absence of conclusive findings not- withstanding, many experts continue to advocate com- bined procedures as the treatment of choice for OCD (e.g., Greist, 1992). In clinical practice, it is common to see patients in EX/RP treatment who are taking SSRIs concurrently. In uncontrolled examinations of EX/RP treatment outcome for adults (Franklin, Abramowitz, Bux, Zoellner, & Feeny, 2002) and youth (Franklin et al., 1998; Piacentini, Bergman, Jacobs, McCracken, & Kretchman, 2002) treated in OCD outpatient clinics, no posttreatment differences in OCD symptom sever- ity were detected between patients who received EX/RP alone and those who received SSRI medication when receiving EX/RP. From these data we can surmise that concomitant pharmacotherapy is not required for every patient to benefit substantially from EX/RP, and that concomitant pharmacotherapy does not appear to in- hibit EX/RP treatment response. With respect to EX/ RP augmentation in SSRI partial responders, there is now evidence from randomized trials that EX/RP aug- mented treatment outcome compared to medication alone in youth (Franklin et al., 2011) and compared to stress management training in adults (Simpson et al., 2010). More definitive conclusions about the effects of augmenting pharmacotherapy with EX/RP await a more carefully controlled examination, however.

ASSESSMENT

Following a diagnostic interview to ascertain the pres- ence of OCD, it is advisable to quantify the severity of the OCD symptoms with one or more of the instru- ments described below. Quantification of symptom se- verity assists the therapist in evaluating how successful treatment was for a given patient. In our clinic, we use

several assessment instruments. As in most OCD clini- cal research studies, however, the primary measure of OCD symptom severity used in our center is the Yale– Brown Obsessive–Compulsive Scale (Y-BOCS; Good- man et al., 1989a, 1989b).

Yale–Brown Obsessive–Compulsive Scale

The Y-BOCS (Goodman et al., 1989a, 1989b), a stan- dardized, semistructured interview, takes approximately 30 minutes to complete. The Y-BOCS Severity scale in- cludes 10 items (five assess obsessions and five, compul- sions), each of which is rated on a 5-point scale ranging from 0 (No symptoms) to 4 (Severe symptoms). Assessors rate the time occupied by the obsessions and compul- sions, the degree of interference with functioning, the level of distress, attempts to resist the symptoms, and level of control over the symptoms. The Y-BOCS has shown adequate interrater agreement, internal consis- tency, and validity (Goodman et al., 1989a, 1989b). The Y-BOCS served as the primary measure of outcome in most of the published OCD pharmacotherapy and CBT treatment studies conducted during the 1990s.

Self‑Report Measures

Obsessive–Compulsive Inventory—Revised

The Obsessive–Compulsive Inventory—Revised (OCI-R; Foa, Huppert, et al., 2002) is an 18-item, self- report measure that assesses the distress associated with obsessions and compulsions. In addition to the total score, six separate subscale scores are calculated by add- ing the three items that comprise each subscale: Wash- ing, Checking, Ordering, Obsessing, Hoarding, and Neutralizing. Foa, Huppert, and colleagues reported good internal consistency, test–retest reliability, and discriminant validity in clinical patients with OCD, PTSD, generalized social phobia, and nonanxious con- trols. The total score ranges from 0 to 72, and each sub- scale ranges from 0 to 12.

Other Self‑Report Measures

A few self-report instruments for assessing OCD symp- toms, such as the Leyton Obsessional Inventory (Ka- zarian, Evans, & Lefave, 1977) and the Lynfield Ob- sessional/Compulsive Questionnaire (Allen & Tune, 1975), are also available. These instruments are limited in that they assess only certain forms of obsessive–

Obsessive–Compulsive Disorder 147

compulsive behavior and/or they include items that are unrelated to OCD symptoms. More recently, Storch and colleagues (2009) have developed the Children’s Florida Obsessive–Compulsive Inventory, which is in- tended primarily for screening purposes.

INITIAL INTERVIEW

After a diagnosis of OCD has been established, and be- fore actually beginning treatment, the therapist should schedule 4–6 hours of appointments with the patient. In these sessions, the therapist needs to accomplish three important tasks. First, the sessions are used to collect the information necessary to develop a treat- ment plan. Specifically, the therapist must first identify specific cues that cause the patient distress (threat cues), avoidance, rituals, and feared consequences. Second, the therapist should develop a good rapport with the patient, who will engage in exposure exercises designed to elicit anxiety and distress during intensive EX/RP; the lack of a good relationship between therapist and the patient may compromise outcome. Third, the thera- pist needs to explore the patient’s beliefs about OCD and the perceived consequences of refraining from ritu- als and avoidance, because this information guides the informal discussions of cognitive processes that take place throughout EX/RP.

Threat cues may be either (1) tangible objects in the environment or (2) thoughts, images, or impulses that the person experiences (for lack of better terms, we have labeled them “external cues” and “internal cues,” re- spectively). Passive avoidance and ritualistic behavior (sometimes called “active avoidance”) both serve to re- duce the distress associated with the threat cues. Ritu- als may be further divided into overt or covert (mental) forms. It is essential that patients understand the dif- ference between obsessions and mental compulsions, because obsessions are treated with systematic exposure and mental compulsions, with ritual preventions. Dur- ing treatment, patients should be instructed to report any mental compulsions to the therapist, because per- forming such compulsions during exposure exercises attenuates the effects of these exercises in the same way that behavioral compulsions do.

External Fear Cues

Most individuals with OCD experience fear in reaction to specific environmental cues (objects, persons, or situ-

ations), but each patient has his/her own idiosyncratic threat cues. For example, individuals who fear con- tamination from toilets may differ as to whether they fear all toilets or only those open to the public. One patient may fear only the toilet itself, whereas another may also fear bathroom floors, doorknobs, and faucets. Similarly, two individuals may experience distress at the prospect of a fire burning down their home, but whereas one experiences the distress only when she is the last person to leave the house, the other experiences distress before going to bed at night when his children are present.

The therapist needs to gather specific information about cues that elicit the patient’s distress to identify the basic sources of the fear. Identification of the basic source is important for planning the treatment pro- gram. Confronting the source of the fear is essential for successful behavioral treatment of OCD. Often, when such exposure does not take place during treat- ment, relapse occurs. For example, a patient who feared contamination by her hometown was treated with EX/ RP 3,000 miles away from the town. Because of the distances involved, direct exposure to the town was impossible, so treatment comprised exposure to objects contaminated directly or indirectly by contact with the town. Although the patient habituated to the objects used in the exposure sessions, she continued to fear her hometown. Within 1 year after treatment, she had de- veloped fears to new objects related to her hometown. Not until she engaged in repeated exposures to the town itself did she experience lasting improvement.

It is important that the therapist conduct a thorough investigation of objects, situations, and places that evoke obsessional distress for the patient at the time of presentation and at onset. Such information helps to identify the source of the distress. To facilitate com- munication with the patient about situations that evoke distress, a Subjective Units of Discomfort Scale (SUDS) ranging from 0 to 100 points is introduced. Patients are asked to rate each situation with respect to the level of distress they expect to experience upon exposure. The source of the distress is expected to be 100. The follow- ing dialogue between therapist and patient illustrates the process of gathering information about distressing situations.

THERAPIST: When do you get the urge to wash your hands?

PATIENT: In a lot of places. There are so many places.

148 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: Are there any places where the urges are particularly strong?

PATIENT: Well when I am sitting in my living room, particularly near the fireplace. Also in the laundry room, which I never go to. Also, when I walk in the park.

THERAPIST: Let’s talk about your living room. How upset are you when you are sitting next to your fire- place?

PATIENT: That’s bad. I guess about a 90. THERAPIST: Can you tell me what makes you so upset

in your living room? PATIENT: Well that is a long story  .  .  . and I know it

doesn’t make sense. THERAPIST: Go on. It’s important that we understand

what makes you uncomfortable and fearful in your living room.

PATIENT: About 2 years ago, I got up in the morn- ing and went into the living room, and I saw a dead squirrel in the fireplace. I guess he got in through the chimney. So, I figured that if the squirrel was dead, he must have been sick. I know that a lot of squirrels have rabies, so I thought that if the squirrel died of rabies, then there are germs all over the chimney.

THERAPIST: Have you tried to have the chimney and the fireplace cleaned?

PATIENT: Yes, we did have a company come in and clean the whole area, but I’m not sure that they can clean away the germs.

THERAPIST: I understand. How about the laundry room? How upsetting is it to be in the laundry room?

PATIENT: That would be a 100; that’s why I don’t go in there.

THERAPIST: How did the laundry room become dan- gerous?

PATIENT: Oh, that’s another story. Until a year ago, my children used to keep their guinea pigs in the laun- dry room. One day we found the female guinea pig dead. So I thought that it probably died of rabies, too.

THERAPIST: Oh, I understand. So you are generally afraid you will contract rabies if you come in contact with things that you think are contaminated with rabies germs. Is this true?

PATIENT: Exactly. That’s why I don’t like to walk in

the woods or the park. You know, those places have all kind of animals, and you can never tell where the germs might be.

It is clear from this conversation that it was not liv- ing rooms, laundry rooms, or parks per se that the patient feared. Rather, any situation or object that, in her mind, had some probability of being infested with rabies germs became a source of contamination. Some contamination-fearful patients, however, cannot spec- ify feared consequences of coming into contact with stimuli they perceive to be contaminated. For these patients, the primary fear is that they will not be able to tolerate the extreme emotional distress generated by being contaminated. With such patients, it is also im- portant to probe further to discern whether they have fears about the long-term health consequences of expe- riencing high and unremitting anxiety in response to stimuli that prompt obsessions.

Internal Fear Cues

Anxiety and distress may also be generated by images, impulses, or abstract thoughts that the individual finds disturbing, shameful, or disgusting. Examples of such cues include impulses to stab one’s child, thoughts of one’s spouse injured in an accident, or images of reli- gious figures engaged in sexual activity. Clearly, inter- nal threat cues may be produced by external situations, such as the sight of a knife triggering the impulse to stab one’s child. Some patients may become distressed when they experience certain bodily sensations, such as minor pains triggering the fear of having cancer.

In many cases, patients may be reluctant to ex- press their obsessive thoughts, because they are either ashamed of them or fear that expressing them will make the consequence more likely to occur. In these cases, the therapist needs to encourage the expression of these thoughts through direct questioning and a matter-of- fact attitude. Sometimes it helps to tell the patient that many people with and without OCD have unwanted thoughts (as many as 85% of normal individuals; Rach- man & DeSilva, 1978). It may also be helpful to remind the patient that talking about the obsessions will be a part of therapy; the evaluation session provides an op- portunity to begin this process.

THERAPIST: So tell me, when is it that you feel the urge to count?

Obsessive–Compulsive Disorder 149

PATIENT: It seems like I’m always counting something, but it’s mostly when I think about certain things.

THERAPIST: What kind of things? PATIENT: I don’t know. Bad things. THERAPIST: Can you give me some examples of bad

thoughts that will make you want to count? PATIENT: (brief silence) I really prefer not to talk about

them. It makes things worse. THERAPIST: You mean it makes the counting worse? PATIENT: Yes. THERAPIST: All right, I know now that when you think

or talk about certain bad things, you have an urge to count, but I still don’t know what those bad things are. How about you tell me so that I can help you with them?

PATIENT: I’d really rather not. Can’t we talk about something else?

THERAPIST: It is important that I know what the thoughts are to plan your treatment. I’ll try to help you. Do the thoughts involve someone being hurt?

PATIENT: Yes. THERAPIST: Do the thoughts involve only certain peo-

ple getting hurt or could it be anyone? PATIENT: Mostly my family. THERAPIST: OK, what else can you tell me about the

thoughts? PATIENT: I really don’t want to say any more. THERAPIST: I know this is scary, but remember that

facing your fears is what this treatment is all about. PATIENT: OK. It’s not always thoughts. Sometimes I

see pictures in my mind, where my brother or my mom and dad are killed. I’m afraid when I talk about these thoughts and pictures that they really will die.

THERAPIST: A lot of people have thoughts that they don’t like to have. Even people without OCD. Just because you have these thoughts, or talk about them, doesn’t mean that bad things will actually happen or that you want them to come true.

It is important to reassure the patient that unpleas- ant thoughts occur often and to emphasize the dis- tinction between thoughts and reality. Many patients with OCD have magical ideas in which the distinction between “thinking about” and “making things hap- pen” is blurred, a process labeled by Salkovskis (1985)

as “thought–action fusion” (TAF). It is important to point out to the patient that thoughts are different from actions. Also, many patients think that if negative thoughts enter their mind, then it means they wish the bad thing will happen. The therapist should assure the patient that thinking about bad things does not mean that one wants them to happen. These sorts of infor- mal discussions of mistaken beliefs are an integral part of correct implementation of EX/RP. Such discussions should accompany the treatment planning process and be reiterated as needed during exposure exercises. It is, however, important that such discussions accompany EX/RP exercises rather than replace them.

Feared Consequences

Many individuals with OCD are afraid that something terrible will happen if they fail to perform their rituals. Such patients with washing rituals, for example, typi- cally fear that they and/or someone else will become ill or disabled, or die, as a result of being contaminated. Many patients with checking rituals fear that because of their negligence, certain catastrophes will occur, such as their homes burning down, or that they might kill someone while driving. Some patients have only a vague notion of what these negative consequences might be (e.g., “I don’t know exactly what will happen, but I feel that if I don’t count to 7, something bad will happen to my family”). Others do not fear catastrophes at all, but they cannot tolerate the emotional distress they ex- perience if they do not perform rituals. Some fear that unless they ritualize, anxiety will increase continually, until they have a nervous breakdown. Approximately two-thirds of patients with OCD could clearly identify consequences other than emotional distress that would result when they refrained from performing rituals, whereas the remainder could report no such conse- quences (Foa et al., 1995).

It is important to identify the specific details of the patient’s feared consequences to plan an effective expo- sure program. For example, the content of the imaginal exposure of a patient who checks while driving for fear of having hit a pedestrian and being sent to jail differs from that of a patient who fears that hitting a pedestri- an will result in punishment by God. Similarly, patients who ritualistically place objects in a specific order may differ with respect to their feared catastrophes. Some perform the ritual to prevent catastrophic consequences (e.g., death of parents), whereas others do so only to re- duce distress elicited by disordered objects. The former

150 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

would benefit from treatment that includes both imagi- nal and in vivo exposure, whereas the latter is likely to profit from in vivo exposure alone.

Strength of Belief

Clinical observations have led to suggestions that in- dividuals with OCD who have poor insight do not respond well to exposure and response prevention, al- though two later studies failed to find a linear relation- ship between strength of belief in feared catastrophes and improvement following exposure and response pre- vention (Foa et al., 1999; Lelliott, Noshirvani, Basoglu, Marks, & Monteiro, 1988). Two issues need to be con- sidered in evaluating these collective findings. First, the reliability and validity of the strength of belief measures used in previous studies are unknown. Second, the re- lationship between overvalued ideation and treatment outcome may not be linear. Clinical observation sug- gests that only patients who express extreme belief in their obsessional ideation show poor outcome. Indeed, Foa and colleagues (1999) found that only extremely strong belief (fixed belief) was associated with attenuat- ed outcome. Such patients may appear delusional when discussing their feared catastrophes. We hypothesize that the effect of fixed belief on outcome may be me- diated by treatment compliance: Patients who are con- vinced that feared disasters will ensue if they engaged in prescribed exercises probably will not complete the tasks as assigned.

When assessing the strength of belief, it is important to remember that a patient’s insight into the senseless- ness of his/her belief often fluctuates. Some patients readily acknowledge that their obsessional beliefs are irrational, but the beliefs still cause marked distress. A few individuals firmly believe that their obsessions and compulsions are rational. In most patients, though, the strength of belief fluctuates across situations, making it difficult to ascertain the degree to which they believe the obsessions are irrational. The following example is an inquiry into the strength of a patient’s belief in her obsessional fear of contracting acquired immune defi- ciency syndrome (AIDS).

THERAPIST: How likely is it that you will contract AIDS from using a public restroom?

PATIENT: I’m really terrified that I will get AIDS if I use a bathroom in a restaurant.

THERAPIST: I know that you are afraid of getting AIDS,

but if you think logically, how likely do you think you are to get AIDS by sitting on a public toilet?

PATIENT: I think I will get AIDS if I use a public toilet. THERAPIST: So do you mean to say that there is a 100%

chance of you getting AIDS if you sit on a public toilet once?

PATIENT: Well, I don’t know about once, but if I did it again and again I would.

THERAPIST: What about other people? Will they get AIDS if they use a public toilet?

PATIENT: I guess so. I’m not sure. THERAPIST: Since most people use public bathrooms,

almost everyone should have AIDS by now. How do you explain the fact that a relatively small number of people have AIDS?

PATIENT: Maybe not everybody is as susceptible to AIDS as I am.

THERAPIST: Do you think that you are more suscep- tible than other people?

PATIENT: I don’t know for sure. Maybe the likelihood of my getting AIDS is only 50%.

Based on the interaction just described, the thera- pist concluded that the patient was not an “overvalued ideator”; thus, the prognosis for this patient is brighter than it would be if she continued strongly to hold her original belief. Accordingly, the implementation of EX/ RP for this patient would follow the standard guide- lines.

Avoidance and Rituals

To maximize treatment efficacy, all avoidance and ritu- alistic behaviors, even seemingly minor ones, should be prevented. Therefore, the therapist should gather complete information about all passive avoidance and rituals. When the therapist is in doubt as to whether a particular avoidance behavior is related to OCD, he/she might suggest an “experiment” in which the patient is exposed to the avoided situation. If the patient experi- ences anxiety or distress, the avoidance behavior should be prevented as part of treatment. Similarly, if it is un- clear whether a given action constitutes a ritual, a re- sponse prevention “experiment” may be implemented. If refraining from performing the action evokes dis- tress, the action is identified as a ritual and should be addressed in therapy.

Obsessive–Compulsive Disorder 151

Individuals with OCD, like those with specific pho- bias, often attempt to avoid anxiety-evoking situations. Most passive avoidance strategies are fairly obvious (e.g., not entering public restrooms, not preparing meals, and not taking out the trash). However, the therapist also needs to be attentive to subtle forms of avoidance, such as carrying money in one’s pockets to avoid opening a wallet, wearing slip-on shoes to avoid touching laces, and using drinking straws to avoid contact with a glass or a can. Patients with obsessive–compulsive checking rituals also engage in subtle avoidance behaviors that are important to explore, such as arranging their work schedules to ensure that they are rarely, if ever, the last person to leave the business, thus ensuring that the re- sponsibility for checking the safe falls on a coworker.

Active rituals, such as passive avoidance, may be ex- plicit (e.g., prolonged washing, repeated checks of the door, and ordering of objects) and/or subtle (e.g., wip- ing hands on pant legs, blinking, and thinking “good” thoughts). It is important that the therapist identify both explicit and subtle rituals, so that both may be ad- dressed during treatment.

Although compulsive rituals are intended to reduce the distress associated with obsessions, patients some- times report that the performance of these rituals is aversive in itself. For example, Ms. S, who was obsessed with the orderliness of objects on her shelves, found re- ordering the shelves aversive, because she was unable to find the “perfect” place for everything. Similarly, Mr. J, who felt contaminated by chemicals, found the act of decontaminating himself by repeated handwash- ing aversive, because he was unable to decide when his hands were sufficiently clean; therefore, he washed until his hands became raw. Rituals may also become aversive because of their intrusion into other aspects of the person’s life. For example, Mr. J, who would take 2-hour-long showers to feel adequately clean, was rep- rimanded repeatedly by his supervisor for arriving late to work.

When certain compulsions become aversive, some patients decrease the time they spend performing the ritual by increasing avoidance behaviors, or by substi- tuting other, less time-consuming rituals. For example, Ms. E, who was obsessed with fears of contamination by funeral-related objects (e.g., cemeteries and people returning from a funeral), responded with hours of showering and handwashing. She eventually retreated into her bedroom and avoided all contact with the outside world. Mr. J, described earlier, avoided taking a shower for days at a time, but between showers he

wiped his hands compulsively and avoided touching his wife. In some cases, seemingly “new” rituals may de- velop during the course of treatment to function in the place of those previously identified and eliminated. For example, Mr. F, who was concerned about his hands becoming contaminated, successfully resisted the urge to wash his hands, but soon after response prevention was implemented, he started to rub his hands together vigorously to “decontaminate” them. When such a sub- stitute ritual is identified, it also needs to be addressed in treatment with ritual prevention. Therapists must re- main alert to not only such shifts in ritualistic behaviors but also alert patients to the possibility of such shifts.

History of Main Complaint and Treatment History

Many individuals with OCD are unable to give a de- tailed account of the onset of their symptoms because the symptoms began subtly, many years ago. Neverthe- less, therapists should attempt to collect as much infor- mation as possible about the onset and course of the disorder. Such information may provide clues about as- pects of the fear network and variables associated with the maintenance of symptoms, and may help to antici- pate difficulties that may arise during treatment (e.g., old obsessions or rituals that may resurface as more prominent ones diminish).

Many such individuals also have an extensive his- tory of psychological and pharmacological treatments, and it is important to make a detailed inquiry about the outcome of previous treatments. If the patient has been treated with EX/RP, the therapist should assess whether the treatment was implemented appropri- ately and the patient was compliant with treatment demands. Knowledge that a patient experienced diffi- culty complying with response prevention instructions, or that previous therapy failed to provide adequate ex- posure experiences or response prevention instructions, is important for designing the behavioral program. Other factors that may have prevented successful out- come or caused relapse, such as job stress, death in the family, or pregnancy, should be discussed. At the same time, a prior failed course of EX/RP should not neces- sarily be viewed as prognostic, especially if the patient recognizes why the therapy was less successful in the past. One of our patients, who had failed multiple trials of less intensive EX/RP, came to our center with the knowledge that his noncompliance with exposure exer- cises between weekly sessions greatly reduced the effects of treatment. He also noted that the slow progress he

152 CliniCal Handbook of PsyCHologiCal disorders

observed in these previous therapies demoralized him and caused further disengagement from the treatment. When offered a choice of daily versus twice-weekly ses- sions, he opted for the daily treatment, noting that the more intensive approach might decrease the chance of similar lapses. He has now successfully completed the intensive regimen.

In our clinic we have observed that a substantial majority of our outpatients have been treated, or are currently being treated, with serotonergic medications. Some seek EX/RP to augment the partial gains they have achieved with the medication. Others wish to dis- continue the medication because it was ineffective, it had side effects, or they do not want to continue taking medicine indefinitely. Assessment of the patient’s treat- ment goals is necessary for planning his/her treatment program.

Social Functioning

Obsessive–compulsive symptoms may severely disrupt the daily functioning of patients. Therapists should as- sess the impact of OCD symptoms on the various areas of functioning. When appropriate, this information should be used to design suitable exposure exercises. For example, Ms. D experienced difficulties completing as- signments at work, because she repeatedly checked each task. Treatment included exposures to performing tasks at work without checking. Even if the client is not cur- rently working, exposures simulating work situations may be necessary if symptoms created difficulties in previous jobs.

OCD clearly has a deleterious effect on the intimate relationships of many patients. About half of married individuals seeking treatment for OCD experience marital distress (Emmelkamp et al., 1990; Riggs et al., 1992). Other family and social relationships may also suffer as a result of OCD symptoms. The impairment in social functioning may arise because social contact is either perceived as threatening (e.g., “I may spread germs to other people”) or so much of the patient’s time and energy is invested in performing rituals and plan- ning ways to avoid distressing situations. Again, infor- mation about the relation of social dysfunction to OCD symptoms may lead the therapist to include specific ex- posures aimed at ameliorating these social difficulties.

The assessment of social functioning should also in- clude an evaluation of what role, if any, other people play in the patient’s compulsive rituals. If the patient re- lies on others for reassurance or compliance with rituals

(e.g., family members must remove their shoes before entering the house), the therapist should instruct fam- ily members how to respond appropriately when asked to participate in the patient’s rituals. A careful analysis of the relationship is called for before specific instruc- tions are given to significant others. Moreover, if family members tend to criticize the patient when obsessional distress arises, it is important to address these negative exchanges in treatment. We have often addressed this issue with a combination of empathic discussion of the frustration experienced by the family member and role playing of more effective responses.

Mood State

Although some patients with serious depression and OCD may benefit from behavioral therapy for OCD (Foa, Franklin, et al., 1992), research suggests that severe depression may limit the extent of reduction of OCD symptoms and the maintenance of those gains (e.g., Abramowitz et al., 2000). Therefore, it is impor- tant to assess the mood state of the patient prior to be- ginning behavioral therapy. Patients with severe depres- sion should be treated with antidepressant medication or cognitive therapy to reduce the depressive symptoms prior to implementing behavioral therapy for the OCD. Treatment with serotonergic antidepressants may re- duce OCD symptoms, as well as depression. Because the effects of such medication on OCD symptoms may not be evident until 3 months after treatment begins, the therapist needs to use his/her clinical judgment to decide whether to begin EX/RP when the depression decreases or wait until the effects of the medication on OCD symptoms can be assessed.

Choice of Treatment

How should a therapist determine the most suitable treatment for a given patient? As discussed earlier, EX/RP, as well as serotonergic medications, have dem- onstrated efficacy for OCD. Therapist and patient are faced with the choice of EX/RP, pharmacotherapy, or a combination of the two. Neither treatment is effective with all patients, and no consistent predictors of who will benefit most from which treatment modality have been identified. Therefore, unless the patient has been particularly successful or unsuccessful with some previ- ous course of treatment, the decision should be based on factors such as availability of treatment, amount of time the patient is able or willing to invest in treatment,

Obsessive–Compulsive Disorder 153

and his/her motivation and willingness to tolerate side effects.

The intensive treatment requires a considerable in- vestment of time over a period of several weeks. Many patients are unable, or unwilling, to devote 4–5 hours a day to treatment. These patients should be advised to try pharmacological treatment, which does not require the same extensive time commitment. Recent investiga- tions of the effects of a twice-weekly EX/RP regimen compared to intensive treatment suggested comparable outcomes at follow-up (Abramowitz et al., 2003; Storch et al., 2007); thus, in our center, we routinely offer either program to patients considering EX/RP. Some patients may be unwilling (sometimes expressed as “I can’t do that”) to experience the temporary discomfort caused by EX/RP. These patients, too, may be advised to try medications. The need to develop “readiness programs” designed to prepare such patients to accept EX/RP treatment is often cited in light of the relatively high refusal rate among patients offered EX/RP. Such programs may include testimonials from previously treated patients, cognitive strategies designed to help the patient calculate objective risks more accurately, psychoeducation about OCD and EX/RP, and a review of the outcome literature for various treatments (Tolin, Maltby, Diefenbach, Hannan, & Worhunsky, 2004). An initial RCT of EX/RP plus motivational interview- ing (MI) did not yield outcomes that were superior to EX/RP alone (Simpson et al., 2010), but the study did not specifically recruit patients who were experiencing low motivation. Manualizing programs specifically for those patients and examining the acceptance rate and efficacy of EX/RP infused with MI constitutes the next step in this line of research.

Patients who are concerned about the potential (or have already experienced) side effects of medications or their unknown long-term effects often prefer EX/RP. Other patients are concerned with the prospect of en- tering an “endless” treatment because, according to present knowledge, relapse occurs when medication is withdrawn (Pato et al., 1988; Thorén, Asberg, Chron- holm, Jörnestedt, & Träskman, 1980). This concern is particularly relevant for women who plan to bear chil- dren and need to withdraw from the medication during pregnancy. EX/RP should be recommended to these patients because its effects are more enduring.

As discussed earlier, the long-term effects of combin- ing EX/RP and medication are unclear; therefore, it is premature to recommend treatment programs that combine the two therapies. However, some patients

who present for treatment are already on antidepressant medication. Because these medications were found not to interfere with the effectiveness of EX/RP (Franklin et al., 2000), it is recommended that patients continue to take the medication if they have experienced some improvement in either obsessive–compulsive symp- toms or depression. However, if the patient has not ex- perienced improvement with medication, withdrawal of the medication before or during EX/RP should be considered. Special consideration should be given to patients with severe depression concurrent with their OCD. It is recommended that these patients be treat- ed with antidepressants or cognitive therapy for the depression prior to entering intensive EX/RP for the OCD given recent findings of somewhat attenuated outcome for severely depressed patients (Abramowitz et al., 2000).

INTENSIVE EX/RP PROGRAM

The intensive treatment program comprises four phas- es: (1) information gathering, (2) intensive EX/RP, (3) a home visit, and (4) maintenance and relapse prevention.

Information Gathering and Treatment Planning

The first stage of information gathering consists of a thorough diagnostic evaluation to determine that the patient’s main psychopathology is OCD. The second step is to assess whether the patient is appropriate for EX/RP. We recommend that individuals who are abus- ing drugs or alcohol should be treated for the substance abuse prior to intensive treatment for OCD. Patients who have clear delusions and hallucinations are also poor candidates for intensive treatment. Individuals with severe MDD should be treated for depression be- fore beginning treatment for OCD. The patient’s mo- tivation to comply with the demands of intensive treat- ment should be carefully evaluated. It is important to describe the treatment program in enough detail that the patient is not surprised when treatment begins. If the patient does not express strong motivation and commitment to treatment, it might be preferable to delay implementation of intensive treatment or to offer alternative treatments, such as medication. As noted earlier, a study of less intensive EX/RP for patients who appear otherwise motivated, yet cannot accommodate the daily regimen into their schedules, suggested an outcome comparable to intensive treatment; future re-

154 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

search with much larger samples is needed to determine whether patient factors predict differential outcome to either treatment schedule.

Once a patient is judged to be appropriate for in- tensive treatment, information gathering for treatment planning begins. This phase typically comprises 4–6 hours of contact with the patient over a period of 2–3 days. During this phase, the therapist collects informa- tion about the patient’s obsessive–compulsive symp- toms, general history, and the history of treatment for OCD, as described earlier. During these sessions, the therapist discusses the rationale for treatment, describes the program in detail, teaches patients to monitor their rituals, and develops a treatment plan.

First Information‑Gathering Session

It is very important to discuss the rationale for treat- ment and to describe the treatment program in detail. The program requires that the patient abandon his/ her obsessive–compulsive habits, therefore temporarily experiencing substantial discomfort. If patients do not understand why they are asked to suffer this short-term distress or are not convinced that treatment will work, they are unlikely to comply with treatment instruc- tions. The treatment rationale is explained as follows:

“You have a set of habits that, as you know, are called obsessive–compulsive symptoms. These are habits of thinking, feeling, and acting that are extremely unpleasant, wasteful, and difficult to get rid of on your own. Usually, these habits involve thoughts, im- ages, or impulses that habitually come to your mind, even though you don’t want them. Along with these thoughts you have unwanted feelings of extreme dis- tress or anxiety and strong urges to do something to reduce the distress. To try to get rid of the anxiety, people get into the habit of engaging in various spe- cial thoughts or actions, which we call ‘rituals.’

“Unfortunately, as you know, the rituals do not work all that well, and the distress decreases for a short time only, then comes back again. Eventually, you may find yourself doing more and more ritual- izing to try to reduce anxiety, but even then the re- lief is temporary and you have to do the ritual all over again. Gradually, you find yourself spending so much time and energy ritualizing—which does not work that well anyway—that other areas of your life are seriously disrupted.

“The treatment we are about to begin is called exposure and response prevention. It is designed to break two types of associations. The first association is between sensations of anxiety and the objects, situ- ations, or thoughts that produce this distress. [The therapist uses information collected as examples; e.g., ‘Every time you touch anything associated with urine you feel anxious, distressed, or contaminated.’] The second association we want to break is that between carrying out ritualistic behavior and the feeling of less anxiety or less distress. In other words, after you carry out [specifies the identified rituals], you tem- porarily feel less distress. Therefore, you continue to engage in this behavior frequently. The treatment we offer breaks the automatic bond between the feelings of discomfort/anxiety/contamination of [specifies the obsession] and your rituals. It will also train you not to ritualize when you are anxious.”

After presenting the treatment rationale, the thera- pist should begin to collect information about the pa- tient’s OCD symptoms. The rationale for information gathering and a description of the treatment is present- ed as follows:

“In the next two sessions, I will ask you specific questions about the various situations and thoughts that generate discomfort or anxiety in you. We will order them according to the degree of distress they generate in you on a scale from 0 to 100, where 0 means No anxiety and 100 means Maximum anxiety or panic. The exposure treatment program involves confronting you with situations and thoughts that you avoid because they generate anxiety and urges to carry out ritualistic behavior. Why do we want to expose you to places and objects that will make you uncomfortable, situations that you have attempted to avoid even at much cost? We know that when people are exposed to situations that they fear, anxiety grad- ually declines. Through exposure, then, the associa- tion between anxiety and [specifies the obsession] weaken because you are repeatedly exposed to these situations, so that the previously evoked anxiety de- creases with time.

“For many people with OCD the obsessions occur within their imagination and rarely take place in real- ity. This makes it impossible to practice exposure by actually confronting those situations for prolonged periods. For example, if a person fears that her home

Obsessive–Compulsive Disorder 155

will burn down, we certainly do not wish to have her house catch on fire in order to practice exposure. Similarly, someone who fears that he has run over a person who is now lying in the road cannot in reality be exposed to such a situation.

“If confrontation with the feared situation is nec- essary to reduce obsessions, how can you improve without directly confronting the situation? You can confront these fears through imagery, in which you visualize the circumstances that you fear will hap- pen. In imagery practice, you create in your mind detailed pictures of the terrible consequences that you are afraid will occur if you do not engage in the ritualistic behavior. During prolonged exposure to these images, the distress level associated with them gradually decreases.

“When people with OCD encounter their feared situations or their obsessional thoughts, they become anxious or distressed and feel compelled to perform the ritualistic behavior as a way to reduce their distress. Exposure practices can cause this same distress and urge to ritualize. Usually, performing rituals strength- ens the pattern of distress and rituals. Therefore in treatment, ritual prevention is practiced to break the habit of ritualizing. This requires that you stop ritual- izing, even though you are still having urges to do so. By facing your fears without resorting to compulsions, you gradually become less anxious. Behavior thera- pists call this process habituation. Therefore, during the 3 weeks of intensive exposure, the association be- tween relief from anxiety and carrying out [specifies the patient’s rituals] will become weaker because you will not be allowed to engage in such behaviors; there- fore, you will find out that your anxiety decreases even if you do not resort to these activities.”

The initial information-gathering session is also used to begin training the patient to monitor his/her rituals accurately. Accurate reports of the frequency and dura- tion of ritualistic behavior are important to evaluate the progress of treatment and to demonstrate the reality of changes to the patient. In some cases, the monitoring also serves an active role in treatment. Patients begin to recognize that rituals do not truly occur “all day long” and the act of monitoring the rituals may decrease their frequency and duration.

“It is very important for the treatment program that we have an accurate picture of the extent to which

you engage in obsessive thinking and compulsive be- havior. Having a clear picture of how much of your time is taken up by your problem will help us to monitor your progress and adjust the treatment pro- gram accordingly. Therefore, during this week, while I am still collecting information to form a treatment program, I would like you to record your symptoms every day. It is not easy to report accurately on how much you engage in your obsessive–compulsive be- havior; therefore, we will spend some time now and in the next session going over some rules for how to record your symptoms. Here are some monitoring forms on which you will record your thoughts and rituals.”

The therapist should specify which ritual(s) the pa- tient is to record, go over the instructions carefully with the patient, and practice filling out the form with the patient using an “imaginary day” of his/her life. The following rules are helpful in monitoring rituals:

1. Use your watch to monitor the time you spend on your rituals.

2. Do not guess the time of ritualizing; be exact. 3. Write the time immediately on your monitoring

form. 4. Do not save the recording to the end of the day or

the beginning of the next day. 5. Write a short sentence to describe the trigger for

ritualizing.

Prior to beginning treatment, the patient identifies an individual (e.g., parent, spouse, or close friend) who can serve as a support person during the intensive treatment program. The patient is instructed to rely on this person for support during exposures, and the support person is asked to help monitor compliance with response preven- tion instructions. If the patient experiences difficulty resisting the urge to ritualize, then the support person is contacted for support. Because the support person is involved in the therapy, the therapist allocates time during the information-gathering phase to describe the treatment and discuss its rationale with him or her.

The therapist makes an effort to ensure that the sup- port person and the patient mutually agree that the support person will offer constructive criticism and observations. In making these suggestions, the sup- port person should be sensitive to any difficulties that have arisen in the past. For example, Mr. B, who served

156 CliniCal Handbook of PsyCHologiCal disorders

as his wife’s primary source of reassurance, also criti- cized her severely when he “caught” her performing her handwashing ritual. To prevent these responses from hampering treatment, to help the husband supervise his wife’s response prevention, the therapist spent time with the couple negotiating appropriate, uncritical re- sponses to the wife’s requests for reassurance.

The support person is in regular (at least twice week- ly) contact with the therapist and is not only informed about the specific homework exposures that the patient has to accomplish but also relays his/her observations about the patient’s behavior outside the therapy session. In addition, with the consent of the patient, the support person should contact the therapist if major treatment violations occur (e.g., refusing to do homework or en- gaging in ritualistic behavior).

Second Information‑Gathering Session

At the beginning of the second information-gathering session, the therapist devotes time to the patient’s self- monitoring form, which includes examining the de- scriptions of situations that trigger ritualistic behavior and offering constructive comments when necessary. The therapist reminds the patient to use short phrases or sentences to describe the trigger situations, assesses the accuracy of the patient’s time estimates, and empha- sizes the need for accurate measurements.

Generating a Treatment Plan

The bulk of the second information-gathering session is allotted to gathering detailed information about the patient’s symptoms and, based on what is learned about the symptoms, developing a treatment with the patient. It is important to explain to the patient how the ex- posure exercises that comprise his/her treatment will reduce the OCD symptoms. For, example, the patient with religious obsessions is told that the imaginal expo- sure to burning in hell in excruciating detail is designed to reduce his obsessional distress when a less elaborate image of burning in hell comes into his mind. It is im- portant that patients understand the rationale under- lying the central concept in EX/RP, that confronting obsession-evoking stimuli during treatment increases their suffering in the short run but will reduce it in the long run. We often tell patients that the difficulties they experience during the first week of exposure sessions are likely to diminish with proper implementation of EX/RP.

Describing Homework

At the end of the second information-gathering ses- sion, the therapist describes the homework assignments included in the treatment program. The homework, which usually requires 2–3 hours, in addition to the 2-hour treatment session, comprises additional expo- sure exercises to be done between treatment sessions at the patient’s home or elsewhere (e.g., a shopping mall or a relative’s home). We suggest that the patient monitor his/her SUDS level every 10 minutes during the home- work exposures. In some cases, when it is impossible for the patient to maintain an exposure for 45–60 minutes, the therapist works with the patient to develop a plan that allows the exposure to be prolonged. For example, instead of asking the patient to spend 45 minutes sit- ting in the restroom of a local restaurant, the therapist might suggest that he/she contaminate a handkerchief on the toilet seat and carry this “contamination rag” in a pocket.

Treatment Period

The treatment program at our center typically com- prises fifteen 2-hour treatment sessions conducted daily for 3 weeks. Clinical observation suggests that massed sessions produce better results than do sessions spread out over time; therefore, we recommend a minimum of three sessions per week. Each session begins with a 10- to 15-minute discussion of homework assignments and the previous day’s ritual monitoring. The next 90 minutes are divided into 45 minutes each of imaginal and in vivo exposure. The final 15 minutes are spent discussing the homework assignment for the following day. This format may be adjusted when necessary. For example, if an in vivo exposure requires that therapist and patient travel to a local shopping mall to contami- nate children’s clothing, the entire session is devoted to this activity. Some patients have difficulty engaging emotionally in imaginal exposures (i.e., the images fail to elicit distress). In these cases, treatment should focus exclusively on in vivo exercises.

We recommend that the therapist discuss the plan for that session with the patient in the beginning of the ses- sion. Barring any unusual circumstances (e.g., patient’s stated objection to proceeding with the planned expo- sure), it is important to limit these discussions to no more than 15 minutes. Patients with OCD are usually very fearful of engaging in exposure tasks, and elabo- rate discussion of the task at hand may serve as a form

Obsessive–Compulsive Disorder 157

of avoidance of going ahead with the exposure. These preexposure discussions are also fertile ground for as- surance seeking (i.e., the patient asking the therapist if he/she is certain that the proposed exercise is safe). The therapist should answer such questions carefully, avoid- ing either extreme (i.e., neither providing compulsive reassurance nor conveying to the patient that the pro- posed exposure is objectively dangerous).

Imaginal exposure exercises are typically conducted prior to in vivo exercises in each session, often as a pre- lude to the scheduled in vivo exercise. During imaginal exposure the patient is seated in a comfortable chair and is given the following instructions:

“Today you will be imagining [describes scene]. I’ll ask you to close your eyes so that you won’t be dis- tracted. Please try to picture this scene as fully and vividly as possible, not like you are being told a story, but as if you were experiencing it now, right here. Every few minutes I will ask you to rate your anxiety level on a scale from 0 to 100. Please answer quickly and try not to leave the image.”

The imaginal exposure sessions are audiotaped, and the patient is asked to repeat the exposure by listening to the tape as part of that day’s homework. The situ- ations included in in vivo exposure vary greatly from patient to patient (particularly with patients with prom- inent checking rituals). Below are some examples of in- structions that might be offered to patients during in vivo exposure exercises.

For patients with prominent washing rituals:

“Today, you will be touching [specifies item(s)]. This means that I will ask you to touch it with your whole hand, not just the fingers, and then to touch it to your face, hair, and clothing, all over yourself, so you feel that no part of you has avoided contamination. Then I’ll ask you to sit and hold it and repeatedly touch it to your face, hair, and clothes during the rest of the session. I know that this is likely to make you upset, but remember the anxiety will eventually decrease. I also want you to go ahead and let yourself worry about the harm you are afraid will occur— for example, disease—since you won’t he washing or cleaning after this exposure. I am sorry that this treatment has to be difficult and cause so much dis- comfort, but I’m sure you can do it. You’ll find it gets easier as time goes on. OK, here it is, go ahead and touch it.”

The therapist should give the patient the object to hold, ask him/her to touch it, then ask the patient to touch the object or the “contaminated” hands directly to his/her face, hair, and clothing. Every 10 minutes the patient should be asked, “What is your level of anxiety or discomfort from 0 to 100 right now as you focus on what you’re touching?” This can be shortened to “What is your SUDS level?” once the patient understands the question.

For patients with prominent checking rituals:

“Now, I’d like you to [e.g., write out your checks to pay your monthly bills without looking at them after you’ve finished; just put them in the envelope and then we will mail them right away, without checking even once after you’ve done it]. Then we will go on and do [e.g., drive on a bumpy road without look- ing in the rearview mirror] in the same way. While doing this, I would like you to worry about what harm might occur because you aren’t checking your actions, but don’t let the thoughts interfere with ac- tually doing those activities.”

Patients should be reminded of the specific instruc- tions for response prevention on the first day of treat- ment and periodically during treatment. We have found that giving patients a printed copy of the rules for response prevention can help them to understand and remember the rules. If the rules as outlined for the patient do not adequately cover the type of ritual(s) the patient exhibits, the therapist should provide a written set of instructions modeled after these forms.

During the last few sessions of treatment, the patient should be introduced to rules of “normal” washing, cleaning, or checking. Response prevention require- ments should be relaxed to enable the patient to return to what is considered a normal routine.

Home Visit

It is important to ensure that the patient’s gains from the treatment program generalize to the home envi- ronment. Usually, homework assignments function to produce this generalization, but we have found that vis- its by the therapist to the patient’s home can be quite helpful, especially when the patient is not able to return home daily during the intensive treatment phase (e.g., patients who are from out of town or are hospitalized). The home visit also offers therapist and patient an op- portunity to discuss guidelines for “normal” behavior.

158 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

The therapist should discuss the plans for these visits with the patient and his/her family before the treatment ends. It is also important to note that, in some cases, the majority of the treatment sessions need to be conduct- ed at the patient’s home, for example, when treating a hoarder. Determining the frequency of home visits dur- ing the core treatment should be based on whether the patient’s OCD symptoms are readily “transportable” to situations outside the home, or whether they are spe- cific to the home. For patients with prominent wash- ing rituals, with “safe” rooms and areas in their houses, contamination of these areas is imperative and also quite difficult; it is often advisable that the therapist as- sist directly with these home-based exposures when it is questionable whether the patient can contaminate these “sanctuaries” successfully on his/her own.

Typically, the home visit comprises 4-hour sessions held on each of 2 days at the end of the treatment pro- gram. The bulk of the time in these sessions is used to conduct additional exposures to obsessive stimuli in and around the patient’s home or workplace. For example, the therapist might accompany the patient as he/she con- taminates objects around the house or at the local gro- cery store. Similarly, the patient might be asked to turn the stove on and off without checking and leave the house with the therapist. Most patients, particularly those who were able to return home during treatment, report little or no discomfort when doing these exposures, because they represent repetition of homework assignments. In some cases, though, the therapist will discover areas that the patient has not contaminated, or some areas at home that continue to generate distress despite previous expo- sures. The home visit should focus on exposure to situa- tions or objects that remain problematic.

With more recent development of platforms such as Skype, Zoom, and so forth, home visits become expen- sive in therapist’s time and travel. The goals of the home visits can be achieved through the computer platforms.

Maintenance Period

In addition to prescribing continued self-exposure tasks to help the patient maintain therapy gains, the therapist may wish to schedule regular maintenance sessions. These sessions may be used to plan additional exposures, to refine guidelines for normal behavior, and to address issues that arise as the patient adjusts to life without OCD.

There is some evidence that patients benefit from continued contact with the therapist following the in-

tensive therapy sessions. In one study, 12 weekly sup- portive therapy sessions (no exposure exercises) ap- peared to reduce the number of relapses in a sample of individuals with OCD treated with 3 weeks of intensive EX/RP (Foa et al., 1992). In another study, following the intensive treatment with 1 week of daily cognitive- behavioral sessions, followed by eight brief (10-minute) weekly telephone contacts, resulted in better long-term outcome than following intensive treatment with 1 week of treatment with free association (Hiss et al., 1994).

Therapeutic Setting

It is advisable for patients to remain in their normal en- vironments during intensive treatment. This is particu- larly important for patients whose fears are cued mainly by stimuli in their home environment. The hospital may be an artificially protected setting, particularly for patients with prominent checking rituals, who may not feel responsible for their surroundings and as a result do not experience their usual urges to check. If patients live too far away to commute for daily sessions, we recom- mend that they rent an apartment or hotel room near the clinic. When this is not possible, hospitalization should be considered. Hospitalization is recommended for patients deemed to be at risk for suicide or psychotic breakdown, and for those who need close supervision but lack a support system sufficient to aid them during treatment.

If a patient is employed and his/her OCD symptoms are work related, he/she should be encouraged to con- tinue working, so that relevant exposures can he includ- ed in treatment. However, since treatment requires 5–6 hours per day, the patient may opt to work half-days during the intensive treatment.

When the patient’s symptoms are unrelated to work, he/she may decide not to continue working during in- tensive treatment. Because of the time-consuming na- ture of the treatment, we often suggest that patients take some time off from work. If it is not possible for the patient to take 3 full weeks off from work, the therapist might suggest that the patient work half-days or take time off from work during the first and second weeks of the treatment program.

Therapist Variables

Intensive treatment with exposure to feared situations and response prevention of ritualistic behavior provoke

Obsessive–Compulsive Disorder 159

considerable stress for patients. Their willingness to un- dergo such “torture” attests to their strong motivation to rid themselves of the OCD symptoms. The intensive treatment regimen requires that the therapist main- tain a delicate balance between pressuring the patient to engage in the treatment and empathizing with his/ her distress. Clinical observations and findings from a study by Rabavilas and colleagues (1979) suggest that a respectful, understanding, encouraging, explicit, and challenging therapist is more likely to achieve a suc- cessful outcome than a permissive, tolerant therapist. Notably, patients of well-supervised, nonexpert EX/RP therapists appear to fare well with EX/RP (Franklin, Abramowitz, Furr, Kalsy, & Riggs, 2003; Valderhaug et al., 2007).

During treatment, patients’ behavior may range from extreme cooperation and willingness to partici- pate in exposures to blatant manipulation and refusal to follow the therapist’s instructions. An individual patient may fluctuate depending on what exposure is conducted during a particular session. To a great ex- tent, the “art” of conducting behavioral therapy for OCD involves knowing when to push, when to con- front, and when to be more flexible. Such decisions re- quire that the therapist carefully observe the patient’s reactions and make a judgment based on his/her expe- rience. As much as possible, the therapist should dis- play an attitude that counteracts the harshness of the treatment program, while maintaining the rules for therapy established at the beginning of the program. The therapist should assure the patient that he/she will not use force to implement exposure, and that no ex- posure will be planned without the patient’s consent. If the patient cannot trust that the therapist will adhere to these essential guidelines, the treatment is likely to be compromised. We also assure patients that family members will be asked not to present unplanned expo- sures to the patient (e.g., taking out the garbage) with- out discussing it.

Patient Variables

A primary factor that influences a patient’s potential for benefiting from intensive behavioral treatment is the level of his/her motivation. Because EX/RP causes high distress, patients need to be highly motivated to un- dertake the treatment. Often the level of motivation is related to the severity of the patient’s symptoms. When symptoms are sufficiently intolerable, patients are more likely to tolerate considerable discomfort for a short pe-

riod to gain relief from their symptoms in the long run. Tolin and colleagues (2004) have also discussed the im- portance of motivational readiness in EX/RP and have suggested specifically how best to prepare patients for the often grueling treatment regimen.

Sometimes individuals are pressured into entering therapy by their families, and they agree to participate in treatment only to appease a spouse or a parent. These patients are unlikely to follow the therapist’s instruc- tions strictly; therefore, they are less likely to make last- ing gains in therapy. In light of these observations, we do not recommend that patients enter into EX/RP if they are not committed to follow such instructions; al- ternative treatment strategies are typically recommend- ed in such circumstances.

It is important that the therapist clearly explain to the patient that 1 month of therapy, albeit intensive, is unlikely to eliminate all OCD symptoms. Rather, pa- tients should expect that their anxiety and the urges to ritualize will diminish and become more manageable. An expectation of becoming symptom free at the end of treatment may lead to disappointment and can poten- tiate relapse, because maintenance of treatment gains usually requires continued effort over time following the intensive treatment. Thus, in the initial interview, we tell patients that we do not have a “cure” for OCD; rather, we have a treatment that is likely to help them substantially reduce their symptoms in both the short and the long run.

It is also important to explain to patients that EX/RP treatment is not a panacea for all of their psychological and interpersonal problems. This treatment is aimed specifically at reducing patients’ obsessions and urges to ritualize. Problems that existed prior to treatment (e.g., marital discord or depression) are likely to remain, although they may be somewhat alleviated after treat- ment.

As mentioned earlier, patients with severe depression and/or an extremely strong belief in the reality of the ob- sessive fear may not benefit from EX/RP. An additional factor that has been identified as a potential hindrance to the cognitive-behavioral and pharmacological treat- ment of OCD is concurrent schizotypal personality disorder (Jenike, Baer, Minichiello, Schwartz, & Carey, 1986). Although some questions have been raised about the method used to diagnose schizotypy (see Stanley, Turner, & Borden, 1990), therapists should be alerted to the probability that patients with schizotypal per- sonality disorder may respond poorly to treatment for OCD.

160 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

CASE STUDY

In this section we demonstrate through verbatim ma- terial the process of gathering information relevant to treatment, planning the treatment program, and con- ducting exposure sessions.

Case Description

“June,” a 26-year-old married woman who had just completed her bachelor’s degree in nursing, sought treatment for a severe washing and cleaning problem. She was extremely agitated in the first interview and de- scribed herself as “crying a whole lot” during the previ- ous 6 weeks. She arrived in the company of her husband of 6 months and her sister-in-law, whom she considered a good friend. Previous treatment by systematic desen- sitization, antidepressants, tranquilizers, and cognitive restructuring had proven ineffective. June had been un- able to seek employment as a nurse due to her symptoms.

This information was collected at June’s initial evalu- ation for participation in EX/RP treatment. After as- certaining the absence of psychosis, drug and alcohol abuse, and organic disorders, June was assigned a thera- pist.

Information Gathering

Current Symptoms

First, the therapist sought information from June about the obsessional content, including external and internal fear cues, beliefs about consequences, and information about passive avoidance patterns and types of rituals. Because rituals are the most concrete symptom, it is often convenient to begin the inquiry by asking for a description of this behavior.

THERAPIST: I understand from Dr. F that you are hav- ing a lot of difficulty with washing and cleaning. Can you tell me more about the problem?

JUNE: I can’t seem to control it at all recently. I wash too much. My showers are taking a long time, and my husband is very upset with me. He and my sister- in-law are trying to help, but I can’t stop it. I’m upset all the time and I’ve been crying a whole lot lately (on the verge of tears). Nothing seems to help.

THERAPIST: I see. You look upset right now. Please try to explain what your washing has been like in the

past few days, so I can understand. How much wash- ing have you been doing?

JUNE: Much too much. My showers use up all the hot water. And I have to wash my hands, it seems like, all the time. I never feel clean enough.

THERAPIST: About how long does a shower take? How many minutes or hours would you say?

JUNE: About 45 minutes, I guess. I try to get out sooner. Sometimes I ask Kenny to make me stop.

THERAPIST: And how often do you take one? JUNE: Usually only twice, once in the morning and

once at night before bed, but sometimes, if I’m really upset about something, I could take an extra one.

THERAPIST: And what about washing your hands? How much time does that take?

JUNE: You mean how many times do I wash? THERAPIST: How long does it take each time you wash

your hands, and how often do you wash your hands in a day?

JUNE: Umm, maybe 20 times a day. It probably takes me 5 minutes each time, maybe more sometimes. I always have the feeling they’re not really clean, like maybe I touched them to the side of the sink after I rinsed and then I think they’re dirty again.

The therapist now had some basic information about the most prominent rituals. Some further questioning clarified whether other compulsions were also in evi- dence.

THERAPIST: Do you do anything else to make yourself feel clean?

JUNE: Yes, I alcohol things. I wipe with alcohol, like the car seat before I sit down.

THERAPIST: Do you wipe yourself with alcohol? JUNE: No, only things that I think are dirty. THERAPIST: Can you tell me how much you do that? JUNE: I use about a bottle of alcohol a week.

Here the therapist had to choose whether to inquire about what objects June cleans or to ask about possible additional rituals. The therapist chose to continue the inquiry about ritualistic actions, and to turn to the subject of “contaminants” as soon as the inquiry was completed.

Obsessive–Compulsive Disorder 161

THERAPIST: OK, can you think of any other things that you do to clean yourself, or other things around you that you feel are dirty?

JUNE: That’s all I can think of right now. THERAPIST: What about other kinds of what we call

“compulsive” type of activities? Do you have to check or repeat things over and over?

JUNE: No, except when I wash, if I don’t feel it’s enough. Then I wash again.

THERAPIST: No other repetitive actions besides wash- ing?

Since this patient did not appear to have multiple types of ritualistic behaviors, the therapist turned to the obsessional content. External cues are usually solicited first.

THERAPIST: What are the things that make you feel you want to wash? For instance, why do you wipe the car seat with alcohol?

JUNE: I think that maybe I got dog dirt on it when I got in from before, or Kenny might have.

THERAPIST: From your shoes? JUNE: Yes, I also worry about the hem of my dress

touching the seat. I’ve been worrying that my shoe could kick my skirt hem or when I step up a step, like to go in a building, the dress could touch the step.

THERAPIST: A dress like this? June was wearing a dress that came to just below her knee. [The likelihood that it could have touched a curb or sole of her shoe was very slim.]

JUNE: Yes. THERAPIST: Has your skirt ever had dog dirt on it? JUNE: I don’t think so, but in my mind I think that

maybe it could have gotten some on it. I suppose it would be hard for that to happen, wouldn’t it?

Thoughts that highly improbable events might have occurred are common in OCD. Such distortions may be the result of intense anxiety. Doubts about “safety” often lead to requests for reassurance or to rituals. Reas- suring June that her dress is unlikely to be soiled would have been countertherapeutic, because it perpetuates the neurotic fears. Rather, the therapist inquired fur- ther about the obsessional content.

THERAPIST: Is dog “dirt” the most upsetting thing that you worry about?

JUNE: Probably. Yes, I think so, but bathroom germs are pretty bad, too.

THERAPIST: What sort of germs? JUNE: From toilets. You know, when you go to the

bathroom. THERAPIST: Urine and feces? JUNE: Yes, urine doesn’t bother me as much as the other. THERAPIST: Why? JUNE: Because I learned in nursing school that it’s al-

most sterile. I had a hard time in the course about microbiology, because it upset me to try to learn about bacteria and microorganisms. They make it sound like there are all kinds of germs everywhere that are real dangerous. I didn’t learn it very well; I tried to avoid thinking about it.

June’s concerns with both dog dirt and bathroom germs suggested that her fear structure includes ap- prehension about potential illness. The therapist ques- tioned her to better understand the nature of the feared consequences of contamination.

THERAPIST: Are you afraid of diseases that could come from feces?

JUNE: Yes, I guess so. The thing of it is, though, I know other people don’t worry about it like I do. To them, you know, they just go to the bathroom and wash their hands and don’t even think about it. But I can’t get it out of my head that maybe I didn’t get clean enough.

THERAPIST: If you didn’t wash enough, would you get sick or would you cause someone else to get sick?

JUNE: Mostly I worry that I’ll get sick, but sometimes I worry about Kenny, too.

THERAPIST: Do you worry about a particular kind of disease?

JUNE: I’m not sure. Some kind of illness.

It is not uncommon for patients who fear harm that may ensue from not ritualizing to be unable to identify a specific feared consequence. Patients with prominent checking rituals often fear they will forget or throw out something important, but they do not always know ex-

162 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

actly what this will be. Repeaters may fear that some- thing bad will happen to loved ones but often cannot specify what particular disaster will befall them. How- ever, many individuals with OCD do fear specific con- sequences (e.g., blindness or leukemia). At this point, the therapist may choose either to complete the inquiry about external threat cues or pursue the investigation about the feared consequences and the belief that such harm is indeed likely to occur. The latter course was selected here.

THERAPIST: Let’s say that you did actually touch dog feces or human feces, and you weren’t aware of it, so you didn’t wash to remove it. What is the likelihood that you or Kenny would really get seriously ill?

JUNE: Well, I feel like it really could happen. THERAPIST: I understand that when it happens and you

become very distressed, it feels like you will actually become sick, but if I ask you to judge objectively, right now, how likely is it that you will get sick from touching feces and not washing? For example, if you were to touch feces 10 times, how many times would you get sick?

JUNE: Oh, I know it’s pretty unlikely, but sometimes it seems so real.

THERAPIST: Can you put a number on it? What’s the percent chance that if you touched a small amount of feces and didn’t wash that you’d get sick?

JUNE: I’d say low, less than 25%. THERAPIST: That means that one time in every four

you’d get sick. JUNE: No, that’s not right. I guess it’s really less than

1%.

From this dialogue, it is clear that June did not strongly believe that her feared disasters would actu- ally occur, although her initial estimate of the likeli- hood was high. A person with poor insight regarding the senselessness of his/her OCD symptoms would have assigned higher probabilities (usually over 80%) and would insist on the accuracy of his/her estimate even in the face of persistent questioning. Note also that this exchange is an example of the informal cognitive re- structuring accompanying EX/RP that we discussed earlier. The therapist may need to repeat this discussion during subsequent exposure sessions when June, highly anxious about confronting contaminants, readjusts her

likelihood estimates when anxious. Strength of belief can change in a given patient but is stronger when the patient perceives threat.

THERAPIST: OK. Now, besides disease, what else could happen if you got feces on you?

JUNE: I suppose I’m also afraid of what other people might think if I got dog feces on my shoe or on my dress. Somebody would see it or smell it and think it was really disgusting, and I was a dirty person. I think I’m afraid they would think I’m not a good person.

The therapist then questioned June further about this feared consequence, inquiring about the possibil- ity of others evaluating her character negatively because she had feces on her dress. The material regarding feared consequences was collected for later inclusion in the imaginal exposure scenes. To conclude the inquiry about the nature of the obsessions, the therapist further elucidated the external feared stimuli.

THERAPIST: Besides dog and human feces and toilets, what else can “contaminate” you? Is it OK if I use the word contaminated to describe how you feel if you handle these things?

JUNE: Yes, it’s like I can feel it on my skin, even if I can’t see it. Umm, I also get upset if I see “bird doo” on my car.

THERAPIST: Bird droppings? The whitish spots? JUNE: Yeah, I have to hold my skirt close to me so that I

don’t touch any of these spots with my clothes. THERAPIST: OK, bird doo, what else? JUNE: Dead animals, like on the roadside. I feel like

the germs, or whatever it is, get on the tires from the pavement and get on the car. Even if I don’t run over it. Like it’s spread around the street near it.

THERAPIST: What do you do if you see a dead animal? JUNE: I swerve wide around it. Once I parked the car

and as I got out, I saw this dead cat right behind the car. I had to wash all my clothes and take a shower right away. It was really a mess that day.

THERAPIST: It sounds like that was very difficult for you. Is there anything else besides dead animals that contaminates you?

JUNE: I can’t think of any. There are lots of places I

Obsessive–Compulsive Disorder 163

avoid now, but that’s because of what we just talked about.

The therapist questions June further about other items that are likely to be contaminated because of their potential relationship to the ones she has already noted.

THERAPIST: What about trash or garbage? JUNE: Yeah, that bothers me. And I also avoid gutters

on the street. THERAPIST: What’s in the gutter that upsets you? JUNE: Dead animals, I guess. And then the rain spreads

the germs down the street. Also rotten garbage. It’s really dirty. Sometimes the gutters are really disgust- ing.

THERAPIST: Um hmm. Are you afraid you could get sick from dead animals and garbage?

JUNE: Yes, it’s like the toilets or dog dirt.

To prepare for an exposure program in which ob- jects are presented hierarchically with respect to their ability to provoke discomfort, June was asked to rank her major contaminants. Here she also provided infor- mation about avoidance behaviors associated with her contaminants.

THERAPIST: Now, let’s make a list of the main things that upset you. I’m going to ask you how distressed you would be on a 0- to 100-point scale if you touched the thing I’ll name. Zero indicates no dis- tress at all and 100 means you’d be extremely upset, the most you’ve ever felt.

JUNE: OK. THERAPIST: What if you touched dog dirt? JUNE: And I could wash as much as I wanted? THERAPIST: No, let’s say you couldn’t wash for a while. JUNE: 100. THERAPIST: A dead animal. JUNE: Also 100. THERAPIST: Bird doo on your car. JUNE: That depends on whether it is wet or dry. THERAPIST: Tell me for both. JUNE: 100 wet and 95 dry. THERAPIST: Street gutter.

JUNE: 95. THERAPIST: Garbage in your sink at home. JUNE: Not too bad. Only 50. But, the trash can out-

doors would be 90. THERAPIST: Why the difference? JUNE: Because the inside of the trash can is dirty from

lots of old garbage. THERAPIST: I see. What about a public toilet seat? JUNE: That’s bad. 95. THERAPIST: Car tires? JUNE: Usually 90. But if I just passed a dead animal,

they’d be 99. THERAPIST: What about a doorknob to a public bath-

room? JUNE: The outside knob is low, like 40. But the inside

knob is 80, because people touch it right after they’ve used the bathroom, and I’ve seen that some don’t wash their hands.

THERAPIST: I understand. How about grass in a park where dogs are around?

JUNE: If I did walk in the grass, it would be about 80 or 85, but I don’t usually do it. I also have a lot of trouble on sidewalks. You know, the brown spots on the concrete. I guess most of it is just rust or other dirt, but I think maybe it could be dog dirt.

THERAPIST: How much does that bother you? JUNE: To step on a brown spot? About 90. I always walk

around them.

The therapist should continue in this manner until a list of 10–20 items is formed. More items may be neces- sary for patients with multiple obsessional fears or ritu- als. The items are ordered from low- to high-level fear in preparation for treatment by exposure. Items equivalent with regard to their level of disturbance are grouped to- gether. Moreover, it is important to probe the rationale for one stimulus differing from another, because it pro- vides further information about the patient’s particular “OCD logic.” This information is highly relevant for the construction of the exposure hierarchy and for the informal cognitive discussions about risk assessment, responsibility, and so forth.

Considerable information about avoidance patterns and rituals emerged from the previous interview about external threat cues. More details may be obtained by

164 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

asking the patient to provide a step-by-step descrip- tion of a typical day’s activities from the time he/she awakens until he/she goes to sleep. Usually, patients are not entirely accurate when describing their compulsive behaviors during the interview because, as one patient told us, they have not “thought of their OCD in that way before.” Thus, the self-monitoring tasks assist pa- tients in raising their awareness about the OCD pat- terns and provide the therapist with more accurate data about rituals and avoidant behaviors.

We were particularly concerned by June’s bathroom routines, her shower, use of the toilet, handling of tow- els and dirty clothes, and dressing and putting on shoes. Additional information about avoidance patterns may be ascertained by inquiring about other routine activi- ties, such as shopping, eating out, housecleaning, pre- paring meals, working, and so on. The following dia- logue exemplifies the degree of detail desired.

THERAPIST: June, for us to plan your treatment care- fully, I need to know what you avoid in your daily routine. Why don’t you start by describing what you do first when you wake up?

JUNE: I go to use the bathroom first. THERAPIST: Nightgown on or off? JUNE: I take off my nightgown, because I don’t want it

to touch the toilet. That way it’s clean at night after I shower.

THERAPIST: Go on. JUNE: I go to the toilet. I suppose I use a lot of toilet

paper because I don’t want to get anything on my hand. Then I have to shower after a bowel movement.

THERAPIST: How do you get ready to shower? JUNE: I have to put a new towel on the rod near the

shower. I don’t like it to touch anything before I use it. Oh, and I put my slippers facing the door, near the shower, so I can put them on without stepping on the bathroom floor when I get out of the shower. Then I get into the shower.

THERAPIST: You said you shower for 45 minutes. Why does it take so long?

JUNE: I have to wash myself in a special order and I count how many times I wash each part. Like I wash my arm four times. That’s why it takes so long.

THERAPIST: What is the order you use? JUNE: First I wash my hands, then my face and hair,

and then I go from the top down.

THERAPIST: What about the genital and anal area? [This area should disturb this patient most, because she fears contamination from fecal “germs.”]

JUNE: Oh yes, those are last, after my feet.

Such a detailed description helps the therapist to anticipate possible avoidance by the patient during treatment and to plan specific exposure instructions. Supervision of normal washing behavior at the end of treatment will address June’s tendency to count and to order her washing. During the initial session of infor- mation gathering, June was instructed to self-monitor the frequency and duration of her compulsions.

THERAPIST: Between now and our next session, I’d like you to record all the washing and cleaning that you do, including wiping things with alcohol. You can use this form (Hands her a self-monitoring of rituals form.) Please write down every time you wash, how long you washed, what made you wash, and how anxious you were before you washed. This kind of record will help us identify any sources of contamination you’ve forgotten to mention, and we can also use it to measure your progress during treatment.

JUNE: Do you want me to write in each space for each half-hour?

THERAPIST: No, only when you wash or use alcohol. JUNE: OK.

History of Symptoms and Treatment History

After assessing the patient’s current symptoms, the therapist sought information about the onset of the problem, with particular reference to the presence of specific stressors at the time and whether these stressors are still present.

THERAPIST: How long have you been washing like this? JUNE: It started about 2 years ago in my first year of

nursing school. It wasn’t real bad right away. It start- ed with the city. I had to go into the city to classes, and the city seemed real dirty.

THERAPIST: Did nursing have something to do with it? JUNE: Maybe. I was under a lot of tension. I had to quit

working as a secretary, and it was pretty hard without an income and a lot of school bills. My mother and dad weren’t much help. And then we started to learn

Obsessive–Compulsive Disorder 165

all the sterilizing techniques, and I already told you about the course in microbiology.

THERAPIST: Did it gradually get worse? JUNE: Mostly, but I did notice that it was a lot worse

after a rotation on surgery, where I was really worried about germs contaminating the instruments. That’s when I started to wash more than usual.

THERAPIST: Did you seek help at that time? JUNE: I was already seeing Dr. W at the university, and

he tried to help. THERAPIST: You were already in treatment with him?

For what reason? JUNE: He was helping me with an eating problem. I had

anorexia. I’d been seeing him for about a year when the washing started.

THERAPIST: Anorexia? Did treatment help? JUNE: Yes. I was down to 85 pounds, and I’m up around

105 now. He mostly asked me to increase my weight every week and he did “cognitive therapy,” I think it’s called.

THERAPIST: I see. What about the washing problem? JUNE: He tried the same type of therapy, but it didn’t

work for that. That’s why I’m here. My sister-in-law heard about it, and Dr. W said I should come.

THERAPIST: What about drugs? Were you ever given medication for this problem?

JUNE: Yes, I tried Anafranil [clomipramine] for a while and it helped a little, but it made me dizzy and sleepy, so I decided to stop taking it. Also, I heard that you can’t take the medication when you are pregnant, and Kenny and I want to have a baby soon. Before that, I took Xanax [alprazolam]; it calmed me down but didn’t stop the washing.

THERAPIST: Have you tried any other treatments? JUNE: Only for the anorexia. I went to another counsel-

ing center at the university for about a year, but that didn’t really help at all.

June’s history was unusual only in the relatively re- cent onset of her symptoms. Typically, patients in our clinic present a much longer duration of symptoms, with the mean around 8 years. Other centers in Eng- land and Holland report similar figures. June’s treat- ment history of trying various psychotherapeutic and pharmacological treatments prior to seeking EX/RP was quite typical. Since previous failure with nonbe-

havioral treatments has not been found to influence outcome with EX/RP, the clinician should not be dis- couraged by such a history. However, because of a pos- sible skeptical attitude about the value of treatment, the therapist should provide the patient with a clear ratio- nale for EX/RP treatment along the lines discussed ear- lier and demonstrated below.

THERAPIST: Before I continue to collect more informa- tion about your problem, let me tell you about our treatment.

JUNE: Well, Dr. F told me something about it, but I’m still not sure what this treatment is going to be like.

THERAPIST: The treatment is called exposure and ritual prevention. I’ll be asking you to confront situations and things that frighten you or make you feel con- taminated. We will do this gradually, working up to the hardest things. For example, we may begin with the outside door handles of bathrooms and work our way up to toilet seats and bird doo. We’ll do this to- gether, and I’ll be there to help you. The sessions will last 1½ or 2 hours, and we’ll meet every weekday. In addition, I’ll assign you homework to do similar things between the therapy sessions.

JUNE: You mean I have to touch them, even dog dirt? THERAPIST: Yes, to get over these kinds of fears, people

must learn to confront what they’re afraid of and stay with it until the discomfort decreases.

JUNE: Even if I did, it would probably take me a year to get used to it.

THERAPIST: Remember, you didn’t always feel like this about dog dirt. When you were younger, did you ever step in dog dirt and just wipe it off on the grass and go on playing?

JUNE: Yeah, I forget that. It seems such a long time ago. I used to not think twice about this stuff.

THERAPIST: To get you back to how you used to feel, we need to expose you directly to what you’re afraid of. Now, there’s a second part to treatment. I’m also going to ask you not to wash for 3 days at a stretch. No handwashing or showering for 3 days. Then you can take a shower, but you will have to limit it to 10 minutes. After the shower, you will have to contami- nate yourself again, then wait another 3 days for your next shower.

JUNE: I can’t believe it! I’ll never be able to do that. If I could, I wouldn’t be here. How can I not wash? Every

166 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

day I resolve to stop, but I always give in. You mean I wouldn’t be able to wash after I use the bathroom or before I eat? Other people wash after they use the toi- let. Why can’t I just wash less, like normal people do?

THERAPIST: Other people don’t have OCD. Remem- ber, for you, washing makes you feel less “contami- nated” and less anxious. Right?

JUNE: Yes. THERAPIST: If you wash, even briefly, whenever you

feel “contaminated,” you never get a chance to learn that the feeling of contamination would go away by itself without washing. If you are really very anx- ious, it might take a while, even several hours, be- fore you feel better, but it will eventually happen. On the other hand, if you wash, even briefly, every few hours, it will reinforce your idea that you have to wash to feel better.

JUNE: But why 3 days? Couldn’t I shower once a day like other people?

THERAPIST: For the same reason. You’d still feel relief, even if you waited 24 hours between washings. And that would strengthen your belief that you need to “decontaminate” by washing yourself. You must learn to use soap and water to feel clean and fresh but not to “decontaminate” yourself.

JUNE: I think I understand. I know I shower now to get the things I’m afraid of off my body. I used to shower just to get sweat and dirt off, and feel nice. I’m still not sure I could stand it though, not washing for that long.

THERAPIST: The treatment is very demanding. Be- fore we start the treatment program you will need to make a commitment to yourself that even though you will feel very uncomfortable and even quite upset at times, you won’t wash. I’ll try to help you as much as I can by planning the treatment so you know what to expect each day and by supporting you whenever you need it. Someone will have to be available to help supervise and support you any time you need it. Between sessions, you can always call me here or at home if a problem comes up. I know the treatment won’t be easy for you, but I’m sure you can do it if you make up your mind.

At this point, the therapist should not request a firm commitment. Rather, the patient should be made aware of what will be required so that he/she can adjust to these expectations and plan activities during the treat-

ment period accordingly. The patient should make the arrangements necessary to attend daily treatment ses- sions for 3–4 weeks. As we discussed earlier, two to three sessions per week may be sufficient for patients with less severe symptoms. It is important that the therapist not minimize the difficulty of the treatment regimen, so that the patient is prepared to struggle and enters treatment with a readiness to mobilize inner re- sources and emotional support from family and friends.

The history of the patient is usually taken in the first session. Because collecting histories of individuals with OCD does not differ from collecting histories of other psychiatric patients, details are not provided here.

Treatment Planning

The therapist began the second session by briefly re- viewing the patient’s self-monitoring of rituals form. The remainder of the session was devoted to developing a treatment plan.

THERAPIST: OK, now I want to discuss our plan for each day during the first week of therapy. We need to expose you both in imagination and in reality to the things that bother you, which we talked about in our first sessions. As I said already, we’ll also limit your washing. The scenes you imagine will focus on the harm that you fear will occur if you do not wash. The actual exposures will focus on confronting the things that contaminate you. Restricting your wash- ing will teach you how to live without rituals. In imaginal exposure, you will picture yourself touch- ing something you’re afraid of, like toilet seats, and not washing, and then becoming ill. We can have you imagine going to a doctor who can’t figure out what’s wrong and can’t fix it. That’s the sort of fear you have, right?

JUNE: Yes, that and Kenny getting sick, and it being my fault.

THERAPIST: OK, so in some scenes you’ll be sick, and in others Kenny will get sick. Should I add that other people blame you for not being careful? Is this what you’re afraid of?

JUNE: Yes, especially my mother. THERAPIST: OK. We’ll have her criticize you for not

being careful enough. Can you think of anything else we should add to the image?

JUNE: No, that’s about it.

Obsessive–Compulsive Disorder 167

THERAPIST: We can compose the scenes in detail after we plan the actual exposures. Let’s review the list of things you avoid or are afraid to touch and make sure that we have listed them in the right order. Then we’ll decide what to work on each day. OK?

JUNE: OK.

June reviewed the list, which included items such as trash cans, kitchen floor, bathroom floor, public hall- way carpet, plant dirt, puddles, car tires, dried dog “dirt,” and bird “doo.” Changes were made as needed.

THERAPIST: Good. Now let’s plan the treatment. On the first day we should start with things that you rated below a 60. That would include touching this carpet, doorknobs that are not inside bathrooms, books on my shelves, light switches, and stair rail- ings. On the second day, we’ll do the 60- to 70-level items, like faucets, bare floors, dirty laundry, and the things on Kenny’s desk. [The therapist continued to detail Sessions 3–5, increasing the level of difficulty each day.] In the second week, we will repeat the worse situations like gutters, tires, public toilets, bird doo, and dog dirt, and we’ll also find a dead animal to walk near and touch the street next to it.

On rare occasions, direct confrontation with a feared object (e.g., pesticides or other chemicals) may have some likelihood of producing actual harm. In such cases, the therapist’s judgment should be exercised to find a middle ground between total avoidance and endangerment. With chemicals, for example, patients are exposed to small quantities that are objectively nonharmful. In June’s case, the therapist decided that direct contact with a dead animal was not called for, and that stepping on the animal’s fur with her shoe and then touching the shoe sole constituted sufficient exposure. In general, the therapist must weigh the level of obsessional distress that will be evoked by a given exposure with the objective risks entailed in complet- ing that exposure. Patients with OCD have difficulty assessing such risks realistically; thus, it is the respon- sibility of the therapist to evaluate whether exposure is warranted. For example, patients with fears of con- tracting HIV would certainly be highly distressed if asked to handle a dirty hypodermic needle found in a city gutter, but because exposure to such stimuli is objectively risky, they should not be included on the treatment hierarchy.

THERAPIST: How does this plan sound? JUNE: The first week is OK, but I’m really scared about

the second week. I’m not sure I’ll be ready to do the bathrooms and dog dirt by then.

THERAPIST: Many people feel this way at the begin- ning, but by the end of the first week, you won’t be as frightened as you are now about touching tires or public toilets. Remember, I will be here to help you, because it will probably be difficult in the beginning.

JUNE: Yes, I know it. I feel like I don’t really have a choice anyhow. This washing is crazy and I’m disgusted with myself. I suppose I’m as ready as I’ll ever be.

THERAPIST: Good. Now remember, I’ll ask you to keep working on these things for 2–3 hours at home after each session, but you will already have done them with me, so I don’t think it will be too hard. I take it that you talked to Kenny about assisting us with supervising, since I saw him out in the waiting room.

JUNE: Yes, he said that’s fine. He wanted to know what he should do.

THERAPIST: Let’s call him in. Did you talk to your sister-in-law about being available when Kenny is at work during the day?

JUNE: Yes, she was really good about it, but she couldn’t come today because of the kids.

THERAPIST: If it’s difficult for her to come, I could talk to her on the phone. Why don’t you go get Kenny now?

Treatment

June was seen for 15 treatment sessions, held every weekday for 3 weeks. During the fourth week, the therapist visited her twice at her home for 4 hours each time. During these visits, under the therapist’s supervi- sion, June contaminated her entire house and exposed herself to objects at home and in her neighborhood that provoked distress. Thereafter, once-weekly follow-up sessions were instituted to ensure maintenance of gains and to address any other issues of concern to her.

As discussed earlier, treatment begins with exposure to moderately difficult items on the hierarchy and pro- gresses to the most disturbing ones by the beginning of the second week. The most distressing items are re- peated during the remainder of the second and third weeks. The following sequence, which occurred on the sixth day of treatment, exemplifies this process.

168 CliniCal Handbook of PsyCHologiCal disorders

THERAPIST: How was your weekend? JUNE: Not that great. I suppose it was as good as I could

expect. I took my shower Sunday night and I was so nervous about finishing in time I don’t even know if I washed right.

THERAPIST: Most people feel the same way. Remember though, you aren’t supposed to wash “right,” just to wash. Did Kenny time it?

JUNE: Yes, he called out the minutes like you said, “5, 7, 9,” and then “stop.”

THERAPIST: You stopped when he said to? JUNE: Yes, but it still wasn’t easy. THERAPIST: I know. I’m really pleased that you were

careful to follow the rules. JUNE: I have pretty much decided that this is my chance

to get better, so I’m trying my best. THERAPIST: Good. I am glad you feel so positive. How

was the homework? JUNE: I touched the floor and the soles of my shoes and

the cement. It is all written on the daily sheet there. On Saturday, I went to my sister’s, so I could play with the kids like we said. They stepped on me when I lay on the floor and I tried to touch their bottoms when I held them. On Sunday, Kenny and I went to the park. I didn’t sit in the grass, but I did walk around and touched my shoes afterward.

THERAPIST: The soles? JUNE: Yeah. We also went downtown and I threw some

things in the trash cans and pushed them down, and tried to touch the sides. It’s sort of hard because I felt conspicuous, but I did it anyway.

THERAPIST: That sounds really good. I’m glad to hear it. How about your doormat and going into the garden?

JUNE: I did the doormat and I stood in the garden, but I couldn’t touch the dirt. The neighbor’s dog always runs all over. I know I should have touched it, but I just couldn’t get up the courage.

THERAPIST: Well, you did do many other things. Let’s plan to go outside today and do it together, so it will be easier for you to walk in the garden when you go home.

JUNE: OK.

June was very compliant with the treatment regimen. Some patients occasionally lapse on response preven-

tion, particularly during the first week of the treatment program. The therapist should reinforce the patient for partial compliance but emphasize the need to comply fully with treatment instructions. With regard to expo- sure homework, it is not uncommon for patients to ne- glect completing some assignments. Again, they should be reinforced for what they have achieved and encour- aged to complete all of the assignments.

THERAPIST: How are you and Kenny doing? JUNE: He got mad on Sunday night after the shower,

because I started to ask him how he showered and if I was clean enough. I think I nagged him too much, so he lost his temper. We just watched TV, and after a while we talked a bit and he sort of apologized for getting mad. But I understand; I ask too many ques- tions. Otherwise, the rest of the weekend was OK.

THERAPIST: Well, it’s unfortunate that Kenny got mad, but it’s good that he didn’t answer your questions. He’s not supposed to reassure you about cleanliness.

JUNE: I think he has a hard time knowing when to an- swer me and when not to. I am not real sure either. Could you talk to him before Wednesday, when I shower again?

THERAPIST: That’s a good idea. I’ll call him after we’re done with today’s session. Now, today we’ll start with the scene about you driving your car to an ap- pointment with me, and you get a flat tire and have to change it. The cars splash water in the puddle near you, and it lands on the car and on you. Then you notice a dead animal when you walk behind the car, and it’s right behind you. You really feel contaminat- ed. You walk to the gas station nearby to see if they can fix the tire and you have to urinate so badly that you have to use their restroom. They agree to fix the tire if you remove it and bring it to them, because, otherwise, they are too busy. Of course, that means you will have to handle the tire that is contaminated by the dead animal. We’ll add some bird doo on the street and on the sidewalk, too. Then, later you start to feel sick, and you feel like it’s from the dead ani- mal. Sound awful enough?

JUNE: Yeah. Ugh. That one is really bad. Do I have to? Never mind, I know the answer.

THERAPIST: OK. I want you to close your eyes now and imagine that you are driving your car on West Avenue.

Obsessive–Compulsive Disorder 169

Note that the therapist checked the patient’s assign- ment from the previous day to verify that she completed it and did not engage in avoidance and rituals. This provided an opportunity to reinforce efforts at self- exposure. It is important to keep track of completion of homework, because patients do not always volunteer in- formation about omissions. They will, however, admit failure to comply if directly asked and are likely to carry out the next assignment if reinforced adequately.

With regard to the conflict between June and Kenny, it is our experience that, like Kenny, most family mem- bers are quite willing to help. Difficulty may, however, arise when they are unable to help without becoming upset, thereby increasing the patient’s tension. Provid- ing them with an opportunity to ventilate their frustra- tion by contacting the therapist, who also may coach them in alternative reactions, may reduce familial ten- sion.

That same session also included imaginal exposure to do a scenario planned in advance. Since that scenario had already been discussed in detail with the patient, it posed no surprises for her. It is presented for up to 1 hour, or until a substantial decrease in anxiety is evi- dent. Next, the patient is confronted in vivo with situa- tions like those included in the fantasized scene.

THERAPIST: It’s time to do the real thing now. I looked for a dead animal by the side of the road yesterday and I found one about a mile away. I think we should go there.

JUNE: Yuck, that’s terrific. Just for me you had to find it.

THERAPIST: Today’s our lucky day. You knew we were going to have to find one today anyhow. At least it’s close.

JUNE: Great.

Humor is encouraged and can be quite helpful if the patient is capable of responding to it. At the same time, it is important that the therapist laugh with rather than at the patient. Patients and therapists often develop a shorthand lexicon for discussing OCD and its treat- ment that is specific to them and aimed at promoting compliance with treatment. For example, one patient– therapist pair began to discuss exposure homework as “swallowing the frog,” based on a proverb that the pa- tient introduced. When the therapist asked the patient if she had “swallowed the frog” that morning, it con-

veyed the difficulty of the exposure tasks she needed to do between sessions. It is important for the therapist to observe the patient’s interpersonal style to determine whether such banter is likely to promote the therapeutic goals.

THERAPIST: (outside the office) There it is, behind the car. Let’s go and touch the curb and street next to it. I don’t think that you need to touch it directly, because it’s a bit smelly, but I want you to step next to it, then touch the sole of your shoe.

JUNE: Yuck! It’s really dead. It’s gross! THERAPIST: Yeah, it is a bit gross, but it’s also just a

dead cat if you think about it plainly. What harm can it cause?

JUNE: I don’t know. Suppose I get germs on my hand? THERAPIST: What sort of germs? JUNE: Dead cat germs. THERAPIST: What kind are they? JUNE: I don’t know. Just germs. THERAPIST: Like the bathroom germs that we’ve al-

ready handled? JUNE: Sort of. People don’t go around touching dead

cats. THERAPIST: They also don’t go running home to show-

er or alcohol the inside of their car. It’s time to get over this. Now, come on over and I’ll do it first. (June follows.) OK. Touch the curb and the street. Here’s a stone you can carry with you and a piece of paper from under its tail. Go ahead, take it.

JUNE: (looking quite uncomfortable) Ugh! THERAPIST: We’ll both hold them. Now, touch it to

your front and your skirt, and your face and hair. Like this. That’s good. What’s your anxiety level?

JUNE: Ugh! 99. I’d say 100, but it’s just short of panic. If you weren’t here, it’d be 100.

THERAPIST: You know from past experience that this will be much easier in a while. Just stay with it and we’ll wait here. You’re doing fine.

JUNE: (A few minutes pass in which she looks very upset.) Would you do this if it weren’t for me?

THERAPIST: Yes, if this were my car and I dropped my keys here, I’d just pick them up and go on.

JUNE: You wouldn’t have to wash them?

170 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: No. Dead animals aren’t delightful, but they’re part of the world we live in. What are the odds that we’ll get ill from this?

JUNE: Very small, I guess. I feel a little bit better than at first. It’s about 90 now.

THERAPIST: Good! Just stay with it now.

The session continued for another 45 minutes, or until anxiety decreased substantially. During this pe- riod, conversation focused generally on the feared situ- ations and the patient’s reaction to them. The thera- pist inquired about June’s anxiety level approximately every 10 minutes. It is important to note that June and the therapist have engaged in conversation throughout the exposure task, discussing issues such as habitua- tion, risk, responsibility, and long-term outcomes. At the same time, it is imperative to refocus the patient on the exposure task at hand to ensure that he/she remains engaged with it. Thus, asking for SUDS ratings serves two purposes: It provides data about fear reduction, and it refocuses the patient on the exposure. However, if the informal discussion serves as a distractor, helping the patient “not think about” what he/she is doing, the therapist should limit such conversations.

THERAPIST: How do you feel now? JUNE: Well, it is easier, but I sure don’t feel great. THERAPIST: Can you put a number on it? JUNE: About 55 or 60, I’d say. THERAPIST: You worked hard today. You must be

tired. Let’s stop now. I want you to take this stick and pebble with you so that you continue to be con- taminated. You can keep them in your pocket and touch them frequently during the day. I want you to contaminate your office at work and your apartment with them. Touch them to everything around, in- cluding everything in the kitchen, chairs, your bed, and the clothes in your dresser. Oh, also, I’d like you to drive your car past this spot on your way to and from work. Can you do that?

JUNE: I suppose so. The trouble is going home with all of this dirt.

THERAPIST: Why don’t you call Kenny and plan to get home after he does, so he can be around to help you. Remember, you can always call me if you have trouble.

JUNE: Yeah. That’s a good idea. I’ll just leave work after he does. See you tomorrow.

This scenario illustrates the process of in vivo ex- posure. The therapist answered clearly the questions raised without detouring from the essential purpose of the session, exposure to the feared contaminant. After the initial increase, the anxiety may begin to drop rela- tively quickly for some patients and may require longer for others. As noted previously, it is advisable to contin- ue the exposure until the patient appears visibly more at ease and reports a substantial decrease in anxiety (40 or 50%).

After 10–15 sessions, the patient’s reported anxiety level is expected to decrease considerably. At the 15th session, June reported a maximum discomfort of 70 SUDs (still somewhat high, although reduced from 99 SUDs) that lasted for a few minutes. Her minimal anxiety was 35 SUDs. Her average anxiety level during this session was 45 SUDs. Ideally, by the end of treat- ment, the highest level should not exceed 50 SUDs and should drop below 20 SUDs at the end of the session. In June’s case, more follow-up sessions were required, because her anxiety was still quite high.

To facilitate a transition to normal washing and cleaning behavior, the therapist instituted a normal washing regimen during the third week of treatment. The patient was allowed one 10-minute shower daily and no more than five 30-second handwashes when there was visible dirt on her hands or when they were sticky.

When the therapist arrived for a home treatment ses- sion the next week, the following conversation ensued:

THERAPIST: How did it go over the weekend? JUNE: Not too bad. But I got sort of upset Saturday.

We went to a picnic and there were several piles of dog dirt around. I had on my flip-flops and I wanted to play volleyball. You can’t in flip-flops, so I went barefoot.

THERAPIST: That’s great! I’m glad to hear it. JUNE: Yeah, but then I got really upset about going

home and carrying it into the apartment. I did it. I walked all over barefoot and with the flip-flops, but I worried about it for another whole day, until I talk- ed to Kenny about my thoughts on Sunday around noon. I felt better when he said he wouldn’t worry about it. It seems like I feel guilty or something, like

Obsessive–Compulsive Disorder 171

the house isn’t clean enough. But lately if he says it is clean, I’ve been able to take his word for it.

THERAPIST: Well, in time you’ll be able to make this kind of judgment yourself. How about your washing and cleaning?

JUNE: It was all right. I washed for half a minute before I ate, because I was dusty from playing volleyball. I deliberately didn’t wash when I got home, because I felt bad and I knew that if I did, it would be to “de- contaminate” myself. I showered Saturday night and I did feel relieved, but I knew I should go and walk around barefoot and touch the floors I’d walked on. So I did that.

THERAPIST: That’s great! It sounds like you handled it fine. I’m really pleased. You avoided washing when it would mean reducing feelings of contamination, and you exposed yourself when you felt concerned about germs. That’s excellent. Now, let’s go over the problem situations that still need work here at home. What things still disturb you?

JUNE: The basement. I haven’t done much with the kitty litter box and old shoes that I threw down there a year ago, because they got contaminated. The closet still has some contaminated clothes. And I still worry about the backyard some. Also, the porch. Pi- geons have been perching on the roof, and there are droppings on the railing now, so I thought I’d wait until you came to do that.

THERAPIST: OK. Let’s start low and work up. Which is easiest?

JUNE: The basement and closets. THERAPIST: Fine, down we go.

Exposure to contaminants during the home visit is conducted in the same manner as that during treat- ment sessions. Typically, home sessions last longer, from 2 to 4 hours, until all “dirty” items are touched and “clean” places are contaminated. These visits should be repeated if the patient expresses considerable concern about his/her ability to adopt a permanent regimen of nonavoidance.

Follow‑Up Sessions

June was seen weekly for 3 months, until she experienced a setback following the development of a new obsession. She became concerned about hitting a pedestrian while

driving. Thoughts that she “might have hit someone” intruded, particularly after turning a corner or glancing in the mirror to change lanes. Once evoked, they per- sisted for several hours. To overcome this new problem, the therapist directed June to increase her driving and refrain from retracing her path or looking in the mirror to check for casualties. June was told that she could stop her car only if she knew for certain that she hit someone. Thoughts that it “might” have occurred were to be ig- nored. To reduce June’s anxiety about having obsessions (e.g., “Oh, my God, here it is again. This is terrible”), she was advised to expect occasional recurrences of obses- sive thoughts. The frequency of obsessions about hitting someone decreased from several each day to once weekly after 3 weeks of self-exposure; the associated anxiety di- minished from 95 to 50 SUDs or less.

Of June’s germ-related obsessions, only that of dog feces partially recurred. Fears of public bathrooms and dead animals remained low. The therapist felt that June’s fear of dog feces had received insufficient atten- tion during treatment. To address this return of fear, June was seen three times a week for 1-hour exposure sessions, in which she touched brown spots on the side- walk and walked near, and eventually stepped on, dog feces. Homework included going to parks, walking on sidewalks without looking, stepping on dog feces, and stepping on the grass where she thought dogs had been. This treatment continued for 4 weeks and was reduced to twice a week for an additional 3 weeks. Thereafter, June came once weekly for another 6 weeks, during which the therapist assigned self-exposure and dealt with June’s everyday concerns. News media coverage of herpes led to a brief concern about public toilets, but this dissipated within a few days.

In the dialogue below, the therapist reviewed with June her progress at a 9-month follow-up.

THERAPIST: I’d like to know how you feel compared to when you first came here 9 months ago.

JUNE: I’m definitely a lot better. But I still have some bad days when I worry a lot about something, and I get down on myself. But when I remember how upset I was last summer and all that washing I did, it’s re- ally a whole lot better. Maybe about 80% better. I’m not ready to be a floor nurse yet, but the job I got after treatment is pretty good for now. Kenny and I are doing fine, except he’s real sensitive if I bring up one of my fears. I wish he’d just listen and say, “OK”

172 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

or something, instead of looking worried about me. It’s like he’s afraid I’m going to get upset again. It makes it hard for me to talk freely, but sometimes he does handle it fine. I really can’t complain. He’s been through a lot, too, when I was really a mess last year and before that.

THERAPIST: I’m glad to hear you feel so much better. You look a lot more at ease. You laugh more now. I don’t know if you recall, but you never did in the beginning.

JUNE: I remember. THERAPIST: What’s left now, the other 20%? JUNE: Obsessions, I guess. I can still work on my fear

of driving over someone. Mostly it lasts less than 15 minutes, but now and then it hangs on through an evening.

THERAPIST: How often? JUNE: Once every week or two, I think. And I still have

an urge to avoid walking on the grass in parks. Like I’m hyperalert. I do it pretty often, but I’m self-con- scious.

THERAPIST: You mean you have to remind yourself not to avoid dog feces?

JUNE: Yeah. And I tend to see things in black and white, all good or all bad. I catch myself feeling guilty for dumb things like eating dessert after a full meal. I can stop, but it’s like I’m out to punish myself or think badly about what I did. I have to watch out for it. Still, the thoughts are nothing like they used to be. I can have fun now. And work is pretty absorbing, so I can go whole days without getting down on myself for something. Will I always do that?

THERAPIST: Maybe to some extent. We know that you have a tendency to obsess. Most people who have had an obsessive–compulsive problem say that the rituals and urges to do them decrease more quickly than the obsessive ideas. You might have disturbing thoughts for a while, but you can expect them to become less frequent if you’re careful not to attempt to control them through rituals or by avoiding things. Can you handle that?

JUNE: I suppose so. They’re not a lot of fun, but I feel like I’m living a normal life again. I suppose everyone has some problems to deal with.

Rarely do patients report complete remission of all obsessions. It is unrealistic to lead a patient to expect

that 4 weeks of treatment will result in a total absence of obsessions and rituals. Patients should expect some con- tinued struggle with obsessions and urges to ritualize. Strategies for coping with such occasional difficulties should be rehearsed.

COMPLICATIONS DURING BEHAVIORAL TREATMENT

Obviously, difficulties may arise during implementa- tion of EX/RP treatment for OCD. Several of these are described below and possible solutions are discussed.

Noncompliance with Response Prevention

Individuals with OCD often report engaging in rituals despite the response prevention instructions. In most cases, these represent brief “slips” that the therapist ad- dresses by reiterating the rationale for the treatment regimen and the need to follow the response prevention instructions strictly. The therapist also may offer ways the ritual might be “undone” (e.g., recontaminating or turning the stove on and off again).

Sometimes the patient’s support person reports vio- lations of response prevention to the therapist. The therapist should discuss the violations with the patient, emphasizing the fact that continued failure to comply with the response prevention instructions may result in treatment failure. The following is an example of how violations of response prevention may be presented to the patient.

“I understand from your father that on three occa- sions this weekend he saw you checking the front door lock five or six times before you left the house. As we agreed in the first session, he called to inform me about your checking. I am sure you remember that we agreed that you would check the doors only once, and that if you had a problem, you would dis- cuss it with your father or me right away, so we could help you overcome your urge to ritualize. Will you explain to me what happened?”

If the patient acknowledges the slip and responds with a renewed agreement to follow instructions, the therapist need not pursue the issue further. However, if a second significant infraction of the response pre- vention instructions occurs, the therapist should again remind the patient of the therapy rules and the rationale

Obsessive–Compulsive Disorder 173

for these rules, and “troubleshoot” with the patient how to implement ritual prevention successfully. During the course of this discussion, if it becomes evident that the patient is unwilling to consider these recommendations and remains committed to rituals and avoidance as a means to reduce obsessional distress, then the therapist may broach the subject of discontinuing treatment, un- less the patient is ready to comply.

“It seems that right now you aren’t able to stop ritu- alizing. For treatment to be successful, it is essential that you completely stop your rituals. Every time that you relieve your discomfort by ritualizing, you prevent yourself from learning that anxiety would have de- clined eventually without rituals, and you don’t permit your obsessional fears to be disconnected from distress and anxiety. Exposing you to feared situations without stopping your rituals won’t be helpful. If you cannot follow the no-rituals rule quite strictly, then we ought to stop treatment now and wait until you are really pre- pared to follow through with all the requirements. It is very hard for people to resist the urge to ritualize, and it may be that you are just not ready yet and will feel more able to do so in the future. It is much better for us to stop treatment now than to continue under condi- tions where you are unlikely to benefit from treatment. That would only leave you feeling more hopeless about future prospects for improvement.”

As discussed earlier, patients sometimes replace iden- tified rituals with less obvious avoidance patterns. For example, a patient may use hand lotion to “decontami- nate” the hands instead of the excessive washing that was done originally. If this occurs, the therapist should immediately instruct the patient to stop the new ritual. Other examples of replacement washing rituals include brushing off one’s hands or blowing off “germs”; exten- sive checks are often replaced with quick glances. Di- rect questioning of the patient to solicit such informa- tion should proceed as follows:

“Now that you’ve stopped your washing rituals, do you find yourself doing other things to relieve your anxiety? For example, some people start to wipe their hands with paper towels or tissues as a substitute for washing with soap and water. Are you doing any- thing like this?”

If the answer is “yes,” the therapist should identify these new behaviors as rituals and instruct the patient

to resist engaging in them in the same manner as he/she resists other compulsions.

Continued Passive Avoidance

Patients who continue to avoid situations likely to evoke obsessional distress are also likely to experience attentu- ated outcome in EX/RP. For example, a patient may put “contaminated” clothing back in the closet as in- structed, but in doing so he/she may ensure that the contaminated clothes do not touch clean garments. Such avoidance reflects an ambivalent attitude toward treatment and hinders habituation of anxiety to feared situations. Because such processes may hinder outcome, the presence of continued and frequent avoidance be- havior calls for the therapist and patient to reevaluate whether the patient should continue treatment.

THERAPIST: Jim, let’s make sure that you are doing your homework the right way. I know that you had a problem putting your dirty underwear in with your other dirty clothes. How are you doing with it now?

PATIENT: Well, I was afraid you might ask that. I still haven’t mixed them up. I was too scared to do it.

THERAPIST: We discussed this several days ago and you were instructed to do it that night. It would have been better had you told me the next day that you weren’t able to. What I’d like you to do for tomorrow is to bring in some dirty clothes. Bring in the under- wear and the other clothes in separate bags, and we will mix them here in the office. Are there any other things you have been avoiding that you haven’t told me about?

PATIENT: I don’t think so. THERAPIST: I want you to pay careful attention to

things you are doing, or not doing, and make a list of anything you are avoiding, particularly things that you are supposed to do for therapy. It is very impor- tant that you don’t protect yourself by avoiding dis- tressing situations, since if you don’t face these situ- ations, your obsessive–compulsive symptoms won’t get better. Let’s give it another try, but if you can’t bring yourself to confront these problematic situ- ations without these little avoidances, perhaps you would be better off delaying your treatment to a later time when you will be more ready to comply with the treatment program.

174 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Arguments

Some individuals who carry out the required exposure without ritualizing may attempt to engage the thera- pist in arguments about the assignments. It is quite tempting to get involved in arguments with patients over what they will or will not do during treatment. To avoid this, it is important for the therapist and the patient to agree on some ground rules before the inten- sive program begins. Patients must agree to follow the treatment plan that they developed in conjunction with the therapist, and to expose themselves to the distress- ing situations without argument. New, feared situations that are discovered should be discussed, and a new ex- posure program should be developed and agreed to, be- fore exposures to the new situations are carried out. If a patient balks at or attempts to alter a planned exposure, the therapist should acknowledge and empathize with the patient’s discomfort, inquire about the reasons for the hesitation, and encourage the patient to proceed in the following manner:

“I’m sorry to see that you are having so much trouble sitting on the floor. I know it’s difficult and that you’re frightened, but it won’t do you any good if we delay the exposure for another day or let you skip it all together. You really need to touch the floor, so let’s go ahead and do it now. We have agreed that today is the ‘floor’ day, and I wouldn’t be doing you a favor if I allowed you to avoid it. Remember, though, I am here to support you as much as I can when you become upset.”

In some instances, difficulties may be overcome by first exposing the patient to similar items that generate a lower level of distress. For example, if a patient refuses to touch a toilet seat, then the therapist may ask him/ her first to touch the bathroom floor or the door to the bathroom stall. Thereafter, the patient might touch the walls of the stall and the toilet handle before proceeding to the toilet seat itself.

Emotional Overload

Occasionally, during treatment, a patient will become overwhelmed by fear or another emotion that is not di- rectly related to his/her OCD symptoms. For example, a patient may be upset by a recent event (e.g., the death of a relative) or by fears of facing future plans (e.g., liv- ing on one’s own or getting a job). Implementing ex-

posure exercises is inadvisable when the patient is ex- tremely upset, because it is unlikely that the patient will adequately attend to the exposure stimulus; therefore, anxiety is unlikely to habituate. Instead, the therapist should discuss the distressing situation with the patient and proceed with exposure only when the patient is calmer. On rare occasions, exposure may be postponed altogether until the next day’s session. If this becomes a repetitive pattern, it may be advisable to interrupt treat- ment until the crisis is over.

Nonanxious Reactions to Exposures

Occasionally, patients respond to exposures with emo- tions other than anxiety or distress, such as anger or de- pression. Clinical observations suggest that anger often serves as a means for the patient to avoid the distress or anxiety that is the target of exposure. If this happens, the anger should be viewed as an avoidance. The thera- pist should refocus the patient on the anxiety-evoking aspects of the situation and point out to the patient that the anger only stands in the way of progress.

Sometimes, during imaginal exposure, when a pa- tient is exposed to the feared consequences of his/her behaviors, the patient becomes depressed. Such depres- sion and other emotional reactions may reduce the ef- ficacy of treatment, and the therapist needs to help the patient to focus on the anxiety-evoking cues. This may be done by directing the content of the imaginal ex- posure away from the feared consequences and toward the external threat cues. In some cases, such redirection does not resolve the problem, and the patient continues to display a depressive reaction to the exposure. When this happens, alternative scenarios that do not elicit de- pression should be developed.

Emergent Fears and Rituals

As mentioned earlier, sometimes patients develop “new” fears or rituals during treatment. Often, the content of these new symptoms is closely related to the original fears and may be treated by extending to these fears the EX/RP instructions given earlier in treatment. For example, following the successful implementation of response prevention for his compulsive handwash- ing, Mr. F began to rub his hands together to decon- taminate them. The therapist identified this as another ritual and instructed Mr. F to resist the urge to rub his hands together. Next, Mr. F began subtly to rub his fin- gers against the palms of his hands to cleanse his hands

Obsessive–Compulsive Disorder 175

and to reduce anxiety. The therapist asked Mr. F to stop this ritual as he had the others and was again successful.

Some emergent fears may not be as clearly connect- ed to the patient’s original fears. For example, the fear that June developed of hitting someone while driving was not obviously related to her fears of contamina- tion. Further assessment often results in the discovery of a conceptual link between the two reported fears. In June’s case, her fear of being blamed for causing someone to become ill or die, and her concern about being thought of as a “bad person” because she killed someone, or because she smelled of dog feces, may have been the connection between her two identified fears. In such cases, it is important for the therapist to develop exposures that include cues for this more general fear. June’s therapist might conduct imaginal exposures that include images of people criticizing June or blaming her for causing someone to die.

Negative Family Reactions

Because family members have typically experienced years of frustration with the patient’s symptoms, it is not surprising that some are impatient, expecting treat- ment to progress smoothly and to result in total symp- tom remission. It is not uncommon for family members to become disappointed or angry when they perceive that the symptoms are not subsiding quickly enough. In such cases, the therapist should assure family members that occasional strong anxiety reactions are to be ex- pected and do not reflect failure. The family should be encouraged to respond calmly and be supportive should the patient experience a burst of anxiety.

Often, families have developed patterns of behavior designed to reduce the patient’s distress. Some family members may continue these patterns either in an at- tempt to protect the patient from upsetting situations or because it is difficult to break habits established over years of accommodating the patient’s requests. For example, Mr. P, who was accustomed to entering his home through the basement, immediately remov- ing his clothes, and showering for his wife’s sake, was instructed to enter through the front door and toss his overcoat on the couch. Similarly, family members may find themselves continuing to perform a variety of household activities that they have come to regard as their responsibility because of the patient’s wishes to avoid the distress that the activity caused. For instance, Mr. P was responsible for preparing all the family meals, because his wife was distressed by the possibil-

ity that she might inadvertently contaminate the food. Because such familiar patterns may hinder progress in treatment, the therapist should ask both the patient and family members about such habits and prescribe appro- priate alternative behaviors that maximize the patient’s exposure and minimize avoidance.

Functioning without Symptoms

At the end of treatment, many individuals with OCD find themselves left with a considerable void in their daily routines. The fact that they no longer need to al- locate a large portion of their day to performing rituals leaves them wondering what to do. The therapist should be sensitive to these issues and aid in planning new so- cial or occupational goals to be achieved following ther- apy. If needed, the therapist should conduct additional sessions or refer the patient to another therapist, who will focus on adjustment-related issues. It may also be the case that behavioral treatments such as acceptance and commitment therapy (ACT) are directly applicable to this problem given the explicit focus on functioning; patients with OCD might be especially vulnerable to the belief that they cannot move forward successfully in their lives unless their obsessions are gone, and ACT is particularly well suited to address these kinds of prob- lems. Preliminary evidence from a case series suggested the applicability of ACT to OCD (Twohig, Hayes, & Masuda, 2006), and an RCT provided stronger evi- dence for the efficacy of ACT (Twhohig et al., 2010).

Because they have spent years performing their ritu- als, patients may be unsure about what constitutes nor- mal behavior. The therapist should offer guidelines for appropriate washing, checking, repeating, or ordering. If rituals are still present, the therapist needs to instruct patients to continue the response prevention of some behaviors to ensure maintenance of treatment gains. A patient may also develop a fear that the OCD symp- toms will return. The therapist should reassure the pa- tient that a single washing of his/her hands does not signal the beginning of a relapse.

CONCLUSION

In this chapter, we have reviewed the literature on OCD and its treatment, and provided verbatim dialogue from patient–therapist interactions to demonstrate how EX/RP is implemented. Our review illustrates clearly that much is already known about CBT and pharmaco-

176 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

therapy for OCD. In our clinical practice with adults, we are guided by the empirical research summarized in this chapter, although not all of our clinical deci- sions are unequivocally supported by empirical studies. For example, no controlled, direct comparison study has indicated that intensive EX/RP yields superior outcome to less intensive treatment, yet we typically provide intensive treatment to our adult patients with at least moderately severe OCD. Although our clinical experience suggests that weekly sessions are probably insufficient to produce meaningful gains in most adult patients with OCD, it has yet to be established whether two or three weekly sessions would yield results compa- rable to daily sessions both immediately after treatment and at follow-up. Future research should examine this important issue to establish a “dose–response” curve for EX/RP; in our view clinically, the patient’s initial severity, comorbidity, and motivational readiness to en- gage in the treatment influence our recommendations regarding the EX/RP visit schedule. Another important issue is how to best combine EX/RP with medication. Future research will allow us to identify the optimal treatment course for a particular patient.

Empirical results and clinical observations converge to indicate that psychosocial treatment for OCD must involve both EX and RP instructions, and that failure to conduct exposures to the most anxiety-evoking situ- ations is likely to compromise outcome. With respect to the therapist-assisted versus self-exposure issue, we routinely choose therapist-assisted exposure in our clinical practice. At present, eliminating therapist assis- tance with exposure exercises seems premature, because existing studies have methodological problems such as insufficient sample sizes, and an RCT in pediatric OCD indicated that EX/RP with in-session exposure was superior to a brief form of EX/RP that did not in- clude this procedural element (Franklin et al., 2011). With respect to the role of cognitive interventions in the treatment of OCD, the EX/RP program described in this chapter is a “cognitive-behavioral” treatment in that it targets both cognitions and behaviors; however, we do not typically include formal cognitive restruc- turing. Future research needs to delineate which cog- nitive and behavioral procedures are most effective for correcting particular pathological emotions. Cognitive procedures may also be utilized in “readiness programs” designed to help patients who are highly ambivalent about EX/RP realize that the treatment is both toler- able and effective. Empirical research to date suggests that although antidepressant medications for OCD do not interfere with the efficacy of CBT, combination

treatment is not necessarily more effective than EX/RP alone. However, the partial symptom reduction typi- cally found in pharmacotherapy studies for OCD may render some patients more willing to tolerate the dis- tress associated with EX/RP; thus, premedication may be helpful in promoting readiness in such cases.

What factors seem to enhance long-term efficacy of EX/RP for OCD? Studies suggest that patients with OCD who show great improvement immediately after CBT are more likely to retain their gains at follow-up than those who make only moderate posttreatment gains (e.g., Simpson et al., 2004). Thus, emphasis on procedures that are likely to lead to maximal short- term efficacy also serves to yield superior maintenance of gains. In our clinical experience, understanding of the treatment rationale, active engagement in exposure exercises, strict adherence to ritual prevention instruc- tions, willingness to design and implement exposure exercises between sessions, and willingness to confront even the most difficult tasks on the fear hierarchy are all factors associated with positive treatment outcome. Thus, verbal reinforcement of patients when they ac- complish these goals, and reinstruction when they do not, are important in promoting lasting improvement. In addition, relapse prevention techniques designed specifically for OCD have been found effective in pro- moting maintenance of gains at follow-up (Hiss et al., 1994). In clinical practice, we begin discussing relapse prevention procedures long before treatment is com- pleted, and we focus on maintaining gains in the last few active treatment sessions. Some continuing contact with the treating clinician is also thought to be of bene- fit; thus, brief follow-up sessions are held in the first few months after the active treatment is completed, with contact as needed following the formal follow-up phase. As part of relapse prevention, we often ask our patients to plan EX/RP exercises for hypothetical obsessions they might encounter in the future (e.g., “If you became obsessed in 6 months that touching tree bark would re- sult in your contracting a terrible illness, what exercises should you do?”) to encourage them to problem-solve around OCD issues for themselves rather than relying on the therapist’s instruction. We also emphasize that the occasional occurrence of obsessions should not be a cause of great alarm, provided that patients implement EX/RP to combat these recurring obsessions and urges to ritualize. The patients who are accepting of this real- ity are often the ones most able to apply what they have learned in treatment, and this process enables them to keep their OCD symptoms under control long after treatment has terminated.

Obsessive–Compulsive Disorder 177

REFERENCES

Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive–compulsive dis- order: A meta-analysis. Behavior Therapy, 27, 583–600.

Abramowitz, J. S., & Foa, E. B. (2000). Does major depres- sive disorder influence outcome of exposure and response prevention for OCD? Behavior Therapy, 31, 795–800.

Abramowitz, J. S., Foa, E. B., & Franklin, M. E. (2003). Exposure and ritual prevention for obsessive–compulsive disorder: Effects of intensive versus twice-weekly sessions. Journal of Consulting and Clinical Psychology, 71, 394–398.

Abramowitz, J. S., Franklin, M. E., & Foa, E. B. (2002). Em- pirical status of cognitive-behavioral therapy for obsessive Empirical status of cognitive-behavioral therapy for obses- sive–compulsive disorder: A meta-analytic review. Roma- nian Journal of Cognitive and Behavior Psychotherapies, 2, 89–104.

Abramowitz, J. S., Franklin, M. E., Street, G. P., Kozak, M. J., & Foa, E. B. (2000). Effects of comorbid depression on response to treatment for obsessive–compulsive disorder. Behavior Therapy, 31, 517–528.

Allen, J. J., & Tune, G. S. (1975). The Lynfield Obsessional/ Compulsive Questionnaire. Scottish Medical Journal, 20, 21–24.

Angst, J. (1993). Comorbidity of anxiety, phobia, compulsion and depression. International Clinical Psychopharmacology, 8(Suppl. 1), 21–25.

Anderson, R. A., & Rees, C. S. (2007). Group versus indi- vidual cognitive-behavioural treatment for obsessive– compulsive disorder: A controlled trial. Behaviour Research and Therapy, 45(1), 123–137.

Antony, M. M., Downie, F., & Swinson, R. P. (1998). Di- agnostic issues and epidemiology in obsessive–compulsive disorders. In R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive–compulsive disorder: Theory, research and treatment (pp.  3–32). New York: Guilford Press.

Asbahr, F. R., Castillo, A. R., Ito, L. M., Latorre, R. D., Moreira, M. N., & Lotufo-Neto, F. (2005). Group cogni- tive-behavioral therapy versus sertraline for the treatment of children and adolescents with obsessive–compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44(11), 1128–1136.

Bachofen, M., Nakagawa, A., Marks, I. M., Park, J., Greist, J. H., Baer, L., et al. (1999). Home self-assessment and self-treatment of obsessive–compulsive disorder using a manual and a computer-conducted telephone interview: Replication of a UK–US study. Journal of Clinical Psychia- try, 60, 545–549.

Barrett, P., Farrell, L., Dadds, M., & Boulter, N. (2005). Cognitive-behavioral family treatment of childhood ob- sessive–compulsive disorder: Long-term follow-up and predictors of outcome. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1005–1014.

Barrett, P., Healy-Farrell, L., & March, J. S. (2004). Cog-

nitive-behavioral family treatment of childhood obses- sive–compulsive disorder: A controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 46–62.

Barksy, A. J., & Ahern, D. K. (2004). Cognitive behavior therapy for hypochondriasis: A randomized controlled trial. JAMA, 291(12), 1464–1470.

Basoglu, M., Lax, T., Kasvikis, Y., & Marks, I. M. (1988). Predictors of improvement in obsessive–compulsive disor- der. Journal of Anxiety Disorders, 2, 299–317.

Beck, A. T. (1976).  Cognitive therapy and the emotional disorders.  Retrieved from https://proxy.library.upenn. edu/login?url=https://www-proquest-com.proxy.library. upenn.edu/books/cognitive-therapy-emotional-disorders/ docview/616069239/se-2?accountid=14707.

Bellodi, L., Scuito, G., Diaferia, G., Ronchi, P., & Smeraldi, E. (1992). Psychiatric disorders in the families of patients withobsessive–compulsive disorder. Psychiatry Research, 42(2), 111–120.

Blakey, S. M., & Abramowitz, J. S. (2016). The effects of safety behaviors during exposure therapy for anxiety: Crit- ical analysis from an inhibitory learning perspective. Clin- ical Psychology Review, 49, 1–15.

Bogels, S. M., & Bodden, D. (2005, November). Family versus child CBT for childhood anxiety disorders: Short and long- term results of a multicenter study. In S. M. Bogels (Chair), Family-Based Prevention and Treatment of Childhood Anxiety Disorders symposium presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, Washington, DC.

Bouton, M. E. (1993). Context, time, and memory retrieval in the interference paradigms of Pavlovian learning. Psy- chological Bulletin, 114(1), 80–99.

Brown, T., Campbell, L., Lehman, C., Grisham, J., & Man- cill, R. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110(4), 585–599.

Comer, J. S., Furr, J. M., Kerns, C. E., Miguel, E., Coxe, S., Elkins, R. M., et al. (2017). Internet-delivered, family- based treatment for early-onset OCD: A pilot randomized trial. Journal of Consulting and Clinical Psychology, 85(2), 178–186.

Comings, D. E. (1990). Tourette syndrome and human behav- ior. Duarte, CA: Hope Press.

Conelea, C. A., Walther, M. R., Freeman, J. B., Garcia, A. M., Sapyta, J., Khanna, M., et al. (2014). Tic-related ob- sessive–compulsive disorder (OCD): Phenomenology and treatment outcome in the pediatric OCD treatment study II. Journal of the American Academy of Child and Adolescent Psychiatry, 53(12), 1308–1316.

Cottraux, J., Mollard, L., Bouvard, M., Marks, L., Sluys, M., Nury, A. M., et al. (1990). A controlled study of fluvox- amine and exposure in obsessive–compulsive disorder. In- ternational Clinical Psychopharmacology, 5, 17–30.

Cottraux, J., Note, I., Yao, S. N., Lafont, S., Note, B., Mol- lard, E., et al. (2001). A randomized controlled trial of

178 CliniCal Handbook of PsyCHologiCal disorders

cognitive therapy versus intensive behavior therapy in obsessive–compulsive disorder. Psychotherapy and Psycho- somatics, 70(6), 288–297.

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23.

Dalsgaard, S., Thorsteinsson, E., Trabjerg, B. B., Schul- lehner, J., Plana-Ripoll, O., Brikell, I., et al. (2020). Inci- dence rates and cumulative incidences of the full spectrum of diagnosed mental disorders in childhood and adoles- cence. JAMA Psychiatry, 77(2), 155–164.

De Araujo, L. A., Ito, L. M., Marks, I. M., & Deale, A. (1995). Does imaginal exposure to the consequences of not ritual- ising enhance live exposure for OCD?: A controlled study: I. Main outcome. British Journal of Psychiatry, 167, 65–70.

de Haan, E., Hoogduin, K. A., Buitelaar, J. K., & Keijsers, G. P. (1998). Behavior therapy versus clomipramine for the treatment of obsessive–compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1022–1029.

Denys, D., Tenney, N., van Megen, J. G., de Geus, F., & Westenberg, H. G. (2004). Axis I and II comorbidity in a large sample of patients with obsessive–compulsive disor- der. Journal of Affective Disorders, 80, 155–162.

DeVeaugh-Geiss, J., Landau, P., & Katz, R. (1989). Treat- ment of OCD with clomipramine. Psychiatric Annals, 19, 97–101.

Diniz, J. B., Rosario-Campos, M. C., Shavitt, R. G., Curi, M., Hounie, A. G., Brotto, S. A., et al. (2004). Impact of age at onset and duration of illness on the expression of comorbidities in obsessive–compulsive disorder. Journal of Clinical Psychiatry, 65, 22–27.

Dollard, J., & Miller, N. E. (1950).  Personality and psycho- therapy: An analysis in terms of learning, thinking, and cul- ture. New York: McGraw-Hill.

Dougherty, D. D., Rauch, S. L., & Jenike, M. A. (2002). Pharmacological treatments for obsessive compulsive dis- order. In P. E. Nathan & J. M. Gordon (Eds.), A guide to treatments that work (2nd ed., pp.  387–410). New York: Oxford University Press.

Eisen, J. L., Phillips, K. A., Baer, L., Beer, D. A., Atala, K. D., & Rasmussen, S. A. (1998). The Brown Assessment of Beliefs Scale: Reliability and validity. American Journal of Psychiatry, 155, 102–108.

Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.

Emmelkamp, P. M. G., & Beens, H. (1991). Cognitive ther- apy with obsessive–compulsive disorder: A comparative evaluation. Behaviour Research and Therapy, 29, 293–300.

Emmelkamp, P. M. G., de Haan, E., & Hoogduin, C. A. L. (1990). Marital adjustment and obsessive–compulsive disorder. British Journal of Psychiatry, 156, 55–60.

Emmelkamp, P. M. G., & van Kraanen, J. (1977). Therapist- controlled exposure in vivo: A comparison with obsessive–

compulsive patients. Behaviour Research and Therapy, 15, 491–495.

Emmelkamp, P. M. G., Visser, S., & Hoekstra, R. J. (1988). Cognitive therapy vs. exposure in vivo in the treatment of obsessive–compulsives. Cognitive Therapy and Research, 12, 103–114.

Fals-Stewart, W., Marks, A. P., & Schafer, J. (1993). A com- parison of behavioral group therapy and individual be- havior therapy in treating obsessive–compulsive disorder. Journal of Nervous and Mental Disease, 181, 189–193.

Farrell, L. J., Waters, A., Milliner, E., & Ollendick, T. (2012). Comorbidity and treatment response in pediatric OCD: A pilot study of group cognitive-behavioral treatment. Psy- chiatry Research, 199, 115–123.

Flament, M., Koby, E., Rapoport, J. L., Berg, C., Zahn, T., Cox, C., et al. (1990). Childhood obsessive–compulsive disorder: A prospective follow-up study. Journal of Child Psychology and Psychiatry and Allied Disciplines, 31, 363– 380.

Flament, M., Whitaker, A., Rapoport, J. L., Davies, M., Berg, C., Kalikow, K., et al. (1988). Obsessive compulsive disorder in adolescence: An epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 764–771.

Foa, E. B., Abramowitz, J. S., Franklin, M. E., & Kozak, M. J. (1999). Feared consequences, fixity of belief, and treat- ment outcome in patients with obsessive–compulsive dis- order. Behavior Therapy, 30, 717–724.

Foa, E. B., Franklin, M. E., & Moser, J. (2002). Context in the clinic: How well do CBT and medications work in combination? Biological Psychiatry, 51, 989–997.

Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 3–24). New York: Guilford Press.

Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., & Hajcak, G., et al. (2002). The Obsessive–Compul- sive Inventory: Development and validation of a short ver- sion. Psychological Assessment, 14(4), 485–495.

Foa, E. B., & Kozak, M. J. (1985). Treatment of anxiety dis- orders: Implications for psychopathology. In A. H. Tuma & J. D. Maser (Eds.), Anxiety and the anxiety disorders (pp. 421–452). Hillsdale, NJ: Erlbaum.

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bul- letin, 99, 20–35.

Foa, E. B., Kozak, M. J., Goodman, W. K., Hollander, E., Jenike, M. A., & Rasmussen, S. (1995). DSM-IV field trial: Obsessive–compulsive disorder. American Journal of Psychiatry, 152, 90–96.

Foa, E. B., Kozak, M. J., Steketee, G., & McCarthy, P. R. (1992). Treatment of depressive and obsessive–compulsive symptoms in OCD by imipramine and behavior therapy. British Journal of Clinical Psychology, 31, 279–292.

Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S. O.,

Obsessive–Compulsive Disorder 179

Campeas, R., Franklin, M. E., et al. (2005). Treatment of obsessive–compulsive disorder by exposure and ritual prevention, clomipramine, and their combination: A ran- domized, placebo-controlled trial. American Journal of Psy- chiatry, 162, 151–161.

Foa, E. B., Steketee, G., Grayson, J. B., Turner, R. M., & Latimer, P. (1984). Deliberate exposure and blocking of obsessive–compulsive rituals: Immediate and long-term effects. Behavior Therapy, 15, 450–472.

Foa, E. B., Steketee, G., Turner, R. M., & Fischer, S. C. (1980). Effects of imaginal exposure to feared disasters in obsessive–compulsive checkers. Behaviour Research and Therapy, 18, 449–455.

Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive–compulsive disorder: Therapist guide (2nd ed.). New York: Oxford University Press.

Franklin, M. E., Abramowitz, J. S., Bux, D. A., Zoellner, L. A., & Feeny, N. C. (2002). Cognitive-behavioral therapy with and without medication in the treatment of obses- sive–compulsive disorder. Professional Psychology: Research and Practice, 33, 162–168.

Franklin, M. E., Abramowitz, J. S., Furr, J., Kalsy, S., & Riggs, D. S. (2003). A naturalistic examination of thera- pist experience and outcome of exposure and ritual preven- tion for OCD. Psychotherapy Research, 13, 153–167.

Franklin, M. E., Abramowitz, J. S., Kozak, M. J., Levitt, J., & Foa, E. B. (2000). Effectiveness of exposure and ritual prevention for obsessive–compulsive disorder: Random- ized compared with non-randomized samples. Journal of Consulting and Clinical Psychology, 68, 594–602.

Franklin, M. E., Kozak, M. J., Cashman, L., Coles, M., Rheingold, A., & Foa, E. B. (1998). Cognitive-behavioral treatment of pediatric obsessive–compulsive disorder: An open clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 412–419.

Franklin, M., Sapyta, J., Freeman, J., Khanna, M., Compton, S., Almirall, D., et al. (2011). Cognitive-behavior therapy augmentation of pharmacotherapy in pediatric obses- sive–compulsive disorder: The Pediatric OCD Treatment Study II (POTS II). Journal of the American Medical As- sociation, 306, 1224–1232.

Freeman, J. B., Choate-Summers, M. L., Moore, P. S., Gar- cia, A. M., Sapyta, J. J., Leonard, H. L., et al. (2007). Cognitive behavioral treatment of young children with obsessive–compulsive disorder. Biological Psychiatry, 61, 337–343.

Freeman, J. B., Garcia, A. M., Fucci, C., Karitani, M., Miller, L., & Leonard, H. L. (2003). Family-based treatment of early-onset obsessive–compulsive disorder [Special issue]. Journal of Child and Adolescent Psychopharmacology, 13(2), 71–80.

Freeman, J., Sapyta, J., Garcia, A., Compton, S., Khanna, M., Flessner, C., et al. (2014). Family-based treatment of early childhood obsessive–compulsive disorder: The Pedi-

atric Obsessive–Compulsive Disorder Treatment Study for Young Children (POTS Jr)—a randomized clinical trial. JAMA Psychiatry, 71(6), 689–698.

Freeston, M. H., Ladouceur, R., Gagnon, F., Thibodeau, N., Rhéaume, J., Letarte, H., et al. (1997). Cognitive- behavioral treatment of obsessive thoughts: A controlled study. Journal of Consulting and Clinical Psychology, 65, 405–413.

García-Soriano, G., Rufer, M., Delsignore, A., & Weidt, S. (2014). Factors associated with non-treatment or delayed treatment seeking in OCD sufferers: A review of the litera- ture. Psychiatry Research, 220(1–2), 1–10.

Gershuny, B. S., Baer, L., Jenike, M. A., Minichiello, W. E., & Wilhelm, S. (2002). Comorbid posttraumatic stress disorder: Impact on treatment outcome for obsessive– compulsive disorder. American Journal of Psychiatry, 159, 852–854.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Delgado, P., Heninger, G. R., et al. (1989a). The Yale– Brown Obsessive–Compulsive Scale: II. Validity. Archives of General Psychiatry, 46, 1012–1016.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., et al. (1989b). The Yale–Brown Obsessive–Compulsive Scale: I. Develop- ment, use, and reliability. Archives of General Psychiatry, 46, 1006–1011.

Greist, J. H. (1990). Treatment of obsessive–compulsive dis- order: Psychotherapies, drugs, and other somatic treat- ments. Journal of Clinical Psychiatry, 51, 44–50.

Greist, J. H. (1992). An integrated approach to treatment of obsessive compulsive disorder. Journal of Clinical Psychia- try, 53(Suppl.), 38–41.

Greist, J. H., Jefferson, J. W., Kobak, K. A., Katzelnick, D. J., & Serlin, R. C. (1995). Efficacy and tolerability of se- rotonin reuptake inhibitors in obsessive–compulsive dis- order: A meta-analysis. Archives of General Psychiatry, 46, 53–60.

Hanna, G. L. (1995). Demographic and clinical features of obsessive–compulsive disorder in children and adoles- cents. Journal of the American Academy of Child and Adoles- cent Psychiatry, 34, 19–27.

Himle, M. B., Olufs, E., Himle, J., Tucker, B., & Woods, D. W. (2010). Behavior therapy for tics via videoconference delivery: An initial pilot test in children. Cognitive and Be- havioral Practice, 17, 329–337.

Hiss, H., Foa, E. B., & Kozak, M. J. (1994). Relapse pre- vention program for treatment of obsessive–compulsive disorder. Journal of Consulting and Clinical Psychology, 62, 801–808.

Hodgson, R. J., Rachman, S., & Marks, L. M. (1972). The treatment of chronic obsessive–compulsive neurosis: Follow-up and further findings. Behaviour Research and Therapy, 10, 181–189.

Hohagen, F., Winkelmann, G., Rasche-Raeuchle, H., Hand, I., Konig, A., Munchau, N., et al. (1998). Combination of

180 CliniCal Handbook of PsyCHologiCal disorders

behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo: Results of a multicentre study. British Journal of Psychiatry, 173, 71–78.

Højgaard, D. R. M. A., Skarphedinsson, G., Nissen, J. B., Hybel, K. A., Ivarsson, T., & Thomsen, P. H. (2017). Pe- diatric obsessive–compulsive disorder with tic symptoms: Clinical presentation and treatment outcome. European Child and Adolescent Psychiatry, 26(6), 681–689.

Insel, T. R., & Akiskal, H. (1986). Obsessive–compulsive dis- order with psychotic features: A phenomenologic analysis. American Journal of Psychiatry, 12, 1527–1533.

Jaycox, L. H., Foa, E. B., & Morral, A. R. (1998). Influence of emotional engagement and habituation on exposure therapy for PTSD. Journal of Consulting and Clinical Psy- chology, 66, 185–192.

Jenike, M., Baer, L., Minichiello, W., Schwartz, C., & Carey, R. (1986). Concomitant obsessive–compulsive disorder and schizotypal personality disorder. American Journal of Psychiatry, 143, 530–532.

Kay, B., Eken, S., Jacobi, D., Riemann, B., & Storch, E. A. (2016). Outcome of multidisciplinary, CBT-focused treat- ment for pediatric OCD. General Hospital Psychiatry, 42, 7–8.

Kazarian, S. S., Evans, D. L., & Lefave, K. (1977). Modi- fication and factorial analysis of the Leyton Obsessional Inventory. Journal of Clinical Psychology, 33, 422–425.

Keijsers, G. P., Hoogduin, C. A., & Schaap, C. P. (1994). Predictors of treatment outcome in the behavioural treat- ment of obsessive–compulsive disorder. British Journal of Psychiatry, 165, 781–786.

Kessler, R. C., Demier, O., Frank, R. G., Olfson, M., Pin- cus, H. A., Walters, E. E., et al. (2005). Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine, 352(24), 2515–2523.

Kogan, C. S., Stein, D. J., Rebello, T. J., Keely, J. W., Chan, K., Jacky, K. J., et al. (2020). Accuracy of diagnostic judg- ments using ICD-11 vs. ICD-10 diagnostic guidelines for obsessive-compulsive and related disorders. Journal of Af- fective Disorders, 273, 329–340.

Koran, L. M. (2000). Quality of life in obsessive–compulsive disorder. Psychiatric Clinics of North America, 23, 509–517.

Kozak, M. J., & Foa, E. B. (1994). Obsessions, overvalued ideas, and delusions in obsessive–compulsive disorder. Be- haviour Research and Therapy, 32, 343–353.

Kozak, M. J., Foa, E. B., & Steketee, G. (1988). Process and outcome of exposure treatment with obsessive–compul- sives: Psychophysiological indicators of emotional process- ing. Behavior Therapy, 19, 157–169.

Kurlan, R., Como, P. G., Miller, B., Palumbo, D., Deeley, C., Andersen, E. M., et al. (2002). The behavioral spectrum of tic disorders: A community-based study. Neurology, 59, 414–420.

Ladoucer, R., Rhéame, J., Freeston, M. H., Aublet, F., Jean, K., Lachance, S., et al. (1995). Experimental manipu- lations of responsibility: An analogue test for models of

obsessive–compulsive disorder. Behaviour Research and Therapy, 33, 937–946.

Lang, P. J. (1979). A bio-informational theory of emotional imagery. Psychophysiology, 6, 495–511.

Leckman, J. F., & Chittenden, E. H. (1990). Gilles de la Tourette syndrome and some forms of obsessive– compulsive disorder may share a common genetic diathe- sis. L’Encephale, 16, 321–323.

Leckman, J. F., Denys, D., Simpson, H. B., Mataix-Cols, D., Hollander, E., Saxena, S., et al. (2010). Obsessive– compulsive disorder: A review of the diagnostic crite- ria and possible subtypes and dimensional specifiers for DSM-V. Depression and Anxiety, 27, 507–527.

Ledley, D. R., Pai, A., & Franklin, M. E. (2007). Treating comorbid presentations: Obsessive–compulsive disorder, anxiety, and depression. In M. M. Antony, C. Purdon, & L. Summerfeldt (Eds.), Psychological treatment of OCD: Fundamentals and beyond (pp.  281–293). Washington, DC: American Psychological Association Press.

Lelliott, P. T., Noshirvani, H. F., Basoglu, M., Marks, I. M., & Monteiro, W. O. (1988). Obsessive–compulsive beliefs and treatment outcome. Psychological Bulletin, 18, 697–702.

Leon, A. C., Portera, L., & Weissman, M. M. (1995). The so- cial costs of anxiety disorders. British Journal of Psychiatry, 166(Suppl.), 19–22.

Lindsay, M., Crino, R., & Andrews, G. (1997). Controlled trial of exposure and response prevention in obsessive– compulsive disorder. British Journal of Psychiatry, 171, 135–139.

Lochner, C., & Stein, D. J. (2003). Heterogeneity of obses- sive–compulsive disorder: A literature review. Harvard Re- view of Psychiatry, 11(3), 113–132.

Lovell, K., Cox, D., Haddock, G., Jones, C., Raines, D., Gar- vey, R., et al. (2006). Telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder: Randomised controlled non-inferiority trial. British Medical Journal, 333, 883.

March, J. S., Franklin, M. E., Leonard, H., Garcia, A., Moore, P., Freeman, J., et al. (2007). Tics moderate the outcome of treatment with medication but not CBT in pe- diatric OCD. Biological Psychiatry, 61, 344–347.

Marks, I. M., Lelliott, P., Basoglu, M., Noshirvani, H., Monteiro, W., Cohen, D., et al. (1988). Clomipramine self-exposure, and therapist-aided exposure for obsessive– compulsive rituals. British Journal of Psychiatry, 152, 522– 534.

Marks, I. M., Stern, R. S., Mawson, D., Cobb, J., & Mc- Donald, R. (1980). Clomipramine and exposure for ob- sessive–compulsive rituals: I. British Journal of Psychiatry, 136, 1–25.

Masellis, M., Rector, N. A., & Richter, M. A. (2003). Quality of life in OCD: Differential impact of obsessions, com- pulsions, and depression comorbidity. Canadian Journal of Psychiatry, 48(2), 72–77.

Obsessive–Compulsive Disorder 181

Mataix-Cols, D., Marks, I. M., Greist, J. H., Kobak, K. A., & Baer, L. (2002). Obsessive–compulsive symptoms di- mensions as predictors of compliance with and response to behaviour therapy: Results from a controlled trial. Psycho- therapy and Psychosomatics, 71, 255–262.

Mathews, A. M., Johnston, D. W., Shaw, P. M., & Gelder, M. G. (1974). Process variables and the prediction of out- come in behavior therapy. British Journal of Psychiatry, 125, 256–264.

Matsunaga, H., Kiriike, N., Matsui, T., Oya, K., Okino, K., & Stein, D. (2005). Impulsive disorders in Japanese adult patients with obsessive–compulsive disorder. Comprehen- sive Psychiatry, 46, 43–49.

McLean, P. L., Whittal, M. L., Thordarson, D. S., Taylor, S., Sochting, I., Koch, W. J., et al. (2001). Cognitive versus behavior therapy in the group treatment of obsessive–com- pulsive disorder. Journal of Consulting and Clinical Psychol- ogy, 69, 205–214.

Mehta, M. (1990). A comparative study of family-based and patients-based behavioural management in obsessive– compulsive disorder. British Journal of Psychiatry, 157, 133–135.

Meyer, V. (1966). Modification of expectations in cases with obsessional rituals. Behaviour Research and Therapy, 4, 273–280.

Meyer, V., & Levy, R. (1973). Modification of behavior in ob- sessive–compulsive disorders. In H. E. Adams & P. Unikel (Eds.), Issues and trends in behavior therapy (pp. 77–136). Springfield, IL: Charles C Thomas.

Meyer, V., Levy, R., & Schnurer, A. (1974). A behavioral treatment of obsessive–compulsive disorders. In H. R. Beech (Ed.), Obsessional states (pp.  233–258). London: Methuen.

Mowrer, O. H. (1939). A stimulus–response analysis of anxi- ety and its role as a reinforcing agent. Psychological Review, 46, 553–565.

Mowrer, O. H. (1960). Learning theory and behavior. New York: Wiley.

Neziroglu, F., Stevens, K. P., Yaryura-Tobias, J. A., & McKay, D. (2000). Predictive validity of the Overvalued Ideas Scale: Outcome in obsessive–compulsive and body dys- morphic disorder. Behaviour Research and Therapy, 39, 745–756.

Öst, L. G. (1989). One-session treatment for specific phobias. Behaviour Research and Therapy, 27, 1–7.

Öst, L., Havnen, A., Hansen, B., & Kvale, G. (2015). Cog- nitive behavioral treatments of obsessive–compulsive disorder: A systematic review and meta-analysis of stud- ies published 1993–2014. Clinical Psychology Review, 40, 156–169.

Öst, L., Riise, E. N., Wergeland, G. J., Hansen, B., & Kvale, G. (2016). Cognitive behavioral and pharmacological treatments of OCD in children: A systematic review and meta-analysis. Journal of Anxiety Disorders, 43, 58–69.

O’Sullivan, G., Noshirvani, H., Marks, I., Monteiro, W., &

Lelliott, P. (1991). Six-year follow-up after exposure and clomipramine therapy for obsessive–compulsive disorder. Journal of Clinical Archives, 52, 150–155.

Pato, M. T., Zohar-Kadouch, R., Zohar, J., & Murphy, D. L. (1988). Return of symptoms after discontinuation of clomipramine in patients with obsessive–compulsive dis- order. American Journal of Psychiatry, 145, 1521–1525.

Pauls, D. L., Towbin, K. E., Leckman, J. F., Zahner, G. E., & Cohen, D. J. (1986). Gilles de la Tourette syndrome and obsessive–compulsive disorder. Archives of General Psychi- atry, 43, 1180–1182.

Pediatric OCD Treatment Study Team. (2004). Cognitive- behavioral therapy, sertraline, and their combination for children and adolescents with obsessive–compulsive dis- order: The Pediatric OCD Treatment Study (POTS) ran- domized controlled trial. Journal of the American Medical Association, 292, 1969–1976.

Peris, T. S., Sugar, C. A., Bergman, L., Chang, S., Langley, A., & Piacentini, J. (2012). Family factors predict treat- ment outcome for pediatric obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 80, 255–263.

Piacentini, J., Bergman, R. L., Jacobs, C., McCracken, J. T., & Kretchman, J. (2002). Open trial of cognitive behav- ior therapy for childhood obsessive–compulsive disorder. Journal of Anxiety Disorders, 16, 207–219.

Purdon, C., & Clark, D. A. (2002). The need to control thoughts. In R. Frost & G. Steketee (Eds.), Cognitive ap- proaches to obsessions and compulsions: Theory, research, and treatment (pp. 29–43). Oakland, CA: New Harbinger.

Rabavilas, A. D., Boulougouris, J. C., & Perissaki, C. (1979). Therapist qualities related to outcome with exposure in vivo in neurotic patients. Journal of Behavior Therapy and Experimental Psychiatry, 10, 293–299.

Rachman, S. (1998). A cognitive theory of obsessions: Elabo- rations. Behaviour Research and Therapy, 36, 385–401.

Rachman, S., & DeSilva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16, 233–248.

Rachman, S., Thordarson, D. S., Shafran, R., & Woody, S. R. (1995). Perceived responsibility: Structure and signifi- cance. Behaviour Research and Therapy, 33(7), 779–784.

Rapoport, J. L., Swedo, S. E., & Leonard, H. L. (1992). Childhood obsessive compulsive disorder (144th annual meeting of the American Psychiatric Association: Obses- sive Compulsive Disorder: Integrating Theory and Prac- tice [1991, New Orleans, LA]). Journal of Clinical Psychia- try, 53(Suppl. 4), 11–16.

Rasmussen, S. A., & Eisen, J. L. (1989). Clinical features and phenomenology of obsessive–compulsive disorder. Psychi- atric Annals, 19, 67–73.

Rasmussen, S. A., & Eisen, J. L. (1990). Epidemiology of ob- sessive–compulsive disorder. Journal of Clinical Psychiatry, 51, 10–14.

Rasmussen, S. A., & Tsuang, M. T. (1986). Clinical character- istics and family history in DSM III obsessive–compulsive disorder. American Journal of Psychiatry, 1943, 317–382.

182 CliniCal Handbook of PsyCHologiCal disorders

Reed, G. E. (1985). Obsessional experience and compulsive be- havior: A cognitive structural approach. Orlando, FL: Aca- demic Press.

Rescorla, R. A. (1982). Some consequences of associations be- tween the excitor and the inhibitor in a conditioned inhibi- tion paradigm. Journal of Experimental Psychology: Animal Behavior Processes, 8(3), 288–298.

Rhéaume, J., Freeston, M. H., Dugas, M. J., Letarte, H., & Ladouceur, R. (1995). Perfectionism, responsibility, and obsessive–compulsive symptoms. Behaviour Research and Therapy, 36, 385–402.

Riggs, D. S., Hiss, H., & Foa, E. B. (1992). Marital distress and the treatment of obsessive–compulsive disorder. Be- havior Therapy, 23, 585–597.

Rothbaum, B. O., & Shahar, F. (2000). Behavioral treatment of obsessive–compulsive disorder in a naturalistic setting. Cognitive and Behavioral Practice, 7, 262–270.

Rowe, M. K., & Craske, M. G. (1998). Effects of an expand- ing-space vs. massed exposure schedule on fear reduction and return of fear. Behaviour Research and Therapy, 36, 701–717.

Salkovskis, P. M. (1985). Obsessional compulsive problems: A cognitive-behavioral analysis. Behaviour Research and Therapy, 23, 571–583.

Simpson, H. B., Foa, E. B., Liebowitz, M. R., Ledley, D. R., Huppert, J. D., Cahill, S., et al. (2008). A randomized, controlled trial of cognitive-behavioral therapy for aug- menting pharmacotherapy in obsessive-compulsive disor- der. American Journal of Psychiatry, 165(5), 621–630.

Simpson, H. B., Liebowitz, M. R., Foa, E. B., Kozak, M. J., Schmidt, A. B., Rowan, V., et al. (2004). Post-treatment effects of exposure therapy and clomipramine in obses- sive–compulsive disorder. Depression and Anxiety, 19, 225–233.

Simpson, H. B., Zuckoff, A. M., Maher, M. J., Page, J. R., Franklin, M. E., & Foa, E. B. (2010). Challenges using motivational interviewing as an adjunct to exposure ther- apy for obsessive–compulsive disorder. Behaviour Research and Therapy, 48, 941–948.

Stampfl, T. G., & Levis, D. J. (1967). Essentials of implo- sive therapy: A learning-based psychodynamic behavioral therapy. Journal of Abnormal Psychology, 72, 496–503.

Stanley, M. A., Turner, S. M., & Borden, J. W. (1990). Schizotypal features in obsessive–compulsive disorder. Comprehensive Psychiatry, 31, 511–518.

Stein, D. J., Fineberg, N. A., Bienvenu, O. J., Denys, D., Lochner, C., Nestadt, G., et al. (2010). Should OCD be classified as an anxiety disorder in DSM V? Depression and Anxiety, 27, 495–506.

Stein, D. J., Kogan, C. S., Atmacca, M., Fineberg, N. A., Fon- tanelle, L. F., Grant, J. E., et al. (2016). The classification of obsessive–compulsive and related disorders in the ICD- 11. Journal of Affective Disorders, 190, 663–674.

Steketee, G., Chambless, D. L., & Tran, G. Q. (2001). Effects of Axis I and II comorbidity on behavior therapy outcome

for obsessive–compulsive disorder and agoraphobia. Com- prehensive Psychiatry, 42, 76–86.

Steketee, G., Eisen, J., Dyck, I., Warshaw, M., & Rasmussen, S. (1999). Predictors of course in obsessive–compulsive disorder. Psychiatry Research, 89, 229–238.

Steketee, G. S., Foa, E. B., & Grayson, J. B. (1982). Recent advances in the treatment of obsessive–compulsives. Ar- chives of General Psychiatry, 39, 1365–1371.

Storch, E., Geffken, G., Merlo, L., Mann, G., Duke, D., Munson, M., et al. (2007). Family-based cognitive-behav- ioral therapy for pediatric obsessive–compulsive disorder: Comparison of intensive and weekly approaches. Journal of American Academy of Child and Adolescent Psychiatry, 46, 469–478.

Storch, E. A., Khanna, M., Merlo, L. J., Loew, B. A., Frank- lin, M., Reid, J. M., et al. (2009). Children’s Florida Ob- sessive Compulsive Inventory: Psychometric properties and feasibility of a self-report measure of obsessive–com- pulsive symptoms in youth. Child Psychiatry and Human Development, 40(3), 467–483.

Storch, E. A., Merlo, L. J., Larson, M. J., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., et al. (2008). Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive–compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 83–92.

Swedo, S. E., Leckman, J. F., & Rose, N. R. (2012). From research subgroup to clinical syndrome: Modifying the PANDAS criteria to describe PANS (pediatric acute-onset neuropsychiatric syndrome). Pediatric Therapeutics, 2, 2.

Swedo, S. E., Leonard, H. L., Garvey, M., Mittleman, B., Allen, A. J., Perlmutter, S., et al. (1998). Pediatric autoim- mune neuropsychiatric disorders associated with strepto- coccal infections: Clinical description of the first 50 cases. American Journal of Psychiatry, 155, 264–271.

Swedo, S. E., Rapoport, J. L., Leonard, H. L., Lenane, M., & Cheslow, D. (1989). Obsessive–compulsive disorder in children and adolescents: Clinical phenomenology of 70 consecutive cases. Archives of General Psychiatry, 46, 335–341.

Thorén, P., Asberg, M., Cronholm, B., Jörnestedt, L., & Träskman, L. (1980). Clomipramine treatment of obses- sive–compulsive disorder: I. A controlled clinical trial. Ar- chives of General Psychiatry, 37, 1281–1285.

Tolin, D. F., Maltby, N., Diefenbach, G. J., Hannan, S. E., & Worhunsky, P. (2004). Cognitive-behavioral therapy for medication nonresponders with obsessive–compulsive dis- order: A wait-list-controlled open trial. Journal of Clinical Psychiatry, 65, 922–931.

Torres, A. R., Prince, M. J., Bebbington, P. E., Bhugra, D., Brugha, T. S., Farrell, M., et al. (2006). Obsessive–com- pulsive disorder: Prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000. American Journal of Psychiatry, 163(11), 1978–1985.

Obsessive–Compulsive Disorder 183

Tukel, R., Polat, A., Ozdemir, O., Aksut, D., & Turksov, N. (2002). Comorbid conditions in obsessive–compulsive disorder. Comprehensive Psychiatry, 43, 204–209.

Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). Increas- ing willingness to experience obsessions: Acceptance and commitment therapy as a treatment for obsessive–compul- sive disorder. Behavior Therapy, 37, 3–13.

Twohig, M., Hayes, S. C., Plumb, J., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H., et al. (2010). A randomized con- trolled trial of acceptance and commitment therapy versus progressive relaxation training for obsessive–compulsive disorder. Journal of Consulting and Clinical Psychology, 78, 705–716.

Valderhaug, R., Larsson, B., Gotestam, K. G., & Piacentini, J. (2007). An open clinical trial of cognitive-behaviour therapy in children and adolescents with obsessive–com- pulsive disorder administered in regular outpatient clinics. Behaviour Research and Therapy, 45, 577–589.

Valleni-Basille, L. A., Garrison, C. Z., Jackson, K. L., Waller, J. L., McKeown, R. E., Addy, C. L., et al. (1994). Fre- quency of obsessive–compulsive disorder in a community sample of young adolescents. Journal of the American Acad- emy of Child and Adolescent Psychiatry, 33, 782–791.

van Balkom, A. J., de Haan, E., van Oppen, P., Spinhoven, P., Hoogduin, K. A., Vermeulen, A. W. A., et al. (1998). Cognitive and behavioral therapies alone and in combina- tion with fluvoxamine in the treatment of obsessive com- pulsive disorder. Journal of Nervous and Mental Disease, 186, 492–499.

van Minnen, A., & Hagenaars, M. (2002). Fear activation and habituation patterns as early process predictors of re- sponse to prolonged exposure treatment in PTSD. Journal of Traumatic Stress, 15, 359–367.

Verdellen, C. W., Keijsers, G. P., Cath, D. C., & Hoogduin, C. A. (2004). Exposure with response prevention versus habit reversal in Tourette syndrome: A controlled study. Behaviour Research and Therapy, 42, 501–511.

Visser, H., van Megen, H., van Oppen, P., Hoogendoorn, A., Glas, G., Neziroglu, F., & van Balkom, A. (2017). The impact of poor insight on the course of obsessive-compul- sive disorder in patients receiving naturalistic treatment. Journal of Obsessive–Compulsive and Related Disorders, 13, 42–48.

Vogel, P. A., Stiles, T. C., & Götestam, K. G. (20040. Adding cognitive therapy elements to exposure therapy for obses- sive–compulsive disorder: A controlled study. Behavioural and Cognitive Psychotherapy, 32, 275–290.

Warren, R., & Thomas, J. C. (2001). Cognitive-behavior therapy of obsessive–compulsive disorder in private prac- tice: An effectiveness study. Journal of Anxiety Disorders, 15, 277–285.

Warwick, H. M., Clark, D. M., Cobb, A. M., & Salkovskis, P. M. (1996). A controlled trial of cognitive-behavioural treatment of hypochondriasis. British Journal of Psychiatry, 169(2), 189–195.

Watts, F. N. (1973). Desensitization as an habituation phe- nomenon: II. Studies of interstimulus interval length. Psy- chological Reports, 33, 715–718.

Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Hwu, H. G., Lee, C. K., et al. (1994). The cross na- tional epidemiology of obsessive compulsive disorder: The Cross National Collaborative Group. Journal of Clinical Psychiatry, 55(3, Suppl.), 5–10.

Whittal, M. L., Thordarson, D. S., & McLean, P. D. (2005). Treatment of obsessive–compulsive disorder: Cognitive behavior therapy vs. exposure and response prevention. Behaviour Research and Therapy, 43, 1559–1576.

Whittal, M. L., Woody, S. R., McLean, P. D., Rachman, S., & Robichaud, M. (2010). Treatment of obsessions: A ran- domized controlled trial. Behaviour Research and Therapy, 48, 295–303.

World Health Organization. (2021). International classifica- tion of diseases for mortality and morbidity statistics (11th Re- vision). Retrieved from https://icd.who.int/browsell/l-m/en.

184

Generalized anxiety disorder (GAD) has been called the “basic” anxiety disorder, in the sense that generalized anxiety is, by definition, a component of other anxiety and related disorders. Indeed, GAD, although characterized by marked fluctuations, is chronic. Some have even considered that GAD might be better conceptualized as a personality disorder, or the clinical manifestation of the temperament of neuroticism itself, since many individuals with this problem cannot report a defini- tive age of onset; rather, they note that it has been with them all their lives. Psychological and drug treatments, although often evaluated, have not produced the robust results evident with some other anxiety disorders. For this reason, further study of new treatment protocols is all the more pressing.

The protocol presented in this chapter, developed by Drs. Roemer and Orsillo at our Center for Anxiety and Related Disorders, illustrates a cutting-edge, acceptance-based approach to GAD that has achieved a high rate of success. This protocol also illustrates, along with Chapter 3 describing process-based cognitive-behavioral therapy for social anxiety disorder, principles associated with the so-called “third-wave” cognitive-behavioral approach to psychological disorders. Clinicians and students interested in how this approach is actually implemented will find the case study of “Héctor” particularly fascinating. —D. H. B.

generalized anxiety disorder (GAD) is a chronic anx- iety disorder, centrally defined by excessive anxiety

and worry (see American Psychiatric Association, 2013, for diagnostic criteria). Epidemiological studies in the United States have revealed a lifetime prevalence of 5.7–9.0% for GAD using DSM-IV criteria (Kessler et al., 2005; Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012), and 7.8% using DSM-5 criteria (Rus- cio et al., 2017). Lower lifetime prevalences have been reported in lower- and middle-income countries (Rus- cio et al., 2017).

GAD is associated with high levels of comorbidity with other psychological disorders. Over 90% of indi- viduals who meet criteria for GAD during their lifetimes

also meet criteria for at least one additional disorder (Bruce, Machan, Dyck, & Keller, 2001), and prospec- tive studies indicate that GAD is a specific risk factor for the development of other mental health disorders, par- ticularly major depression (Bruce et al., 2001). GAD is also associated with significantly reduced quality of life (Hoffman, Dukes, & Wittchen, 2008). Furthermore, individuals with GAD have more annual medical vis- its than other patients (Belanger, Ladouceur, & Morin, 2005) and are more likely to seek medical, rather than mental health, care for their symptoms (Wang et al., 2005). In fact, GAD is the most common anxiety dis- order found among primary care patients (Ballenger et al., 2001), and the mean annual medical cost of GAD

C H A P T E R 5

generalized Anxiety Disorder An Acceptance‑Based Behavioral Therapy

Lizabeth Roemer Elizabeth H. Eustis Susan M. Orsillo

Generalized Anxiety Disorder 185

is $2,138 higher than that for other anxiety disorders (mean = $6,475; Revicki et al., 2012). Given that GAD is associated with a host of physical complaints and con- ditions, including painful physical symptoms (Romera et al., 2010), gastrointestinal symptoms (Mussell et al., 2008), and cardiological complaints (Logue, Thomas, Barbee, & Hoehn-Saric, 1993), it is not surprising that patients with GAD have a tendency to overutilize medi- cal (Ballenger et al., 2001) and underutilize psychiatric (Kennedy & Schwab, 1997) services.

Although earlier diagnostic criteria for GAD incor- porated symptoms of autonomic arousal (e.g., acceler- ated heart rate), several lines of research converged to support removal of these criteria for DSM-IV. A large- scale study of reported associated symptoms indicated that autonomic symptoms were more rarely endorsed than symptoms of muscle tension, vigilance, and scan- ning, such as those described earlier (Marten et al., 1993). Furthermore, physiological studies revealed that GAD was more accurately characterized by reduced heart rate variability, most notably, vagal withdrawal during periods of worry and negative imagery (Levine, Fleming, Piedmont, Cain, & Chen, 2016), than by in- creased autonomic arousal (e.g., Thayer, Friedman, & Borkovec, 1996). Finally, experimental studies of worry revealed that worrying prior to exposure to a feared stimulus leads to less autonomic arousal than relaxation prior to exposure to a feared stimulus (e.g., Borkovec & Hu, 1990). Taken together, these studies suggest that autonomic arousal is not a necessary feature of GAD.

Instead, the central defining feature of GAD is ex- cessive worry, or repeatedly thinking about worst-case scenarios involving potential future events. Studies re- veal that worry content does not differ between indi- viduals who meet criteria for GAD and those who do not, except that those with GAD report worrying about miscellaneous topics, particularly minor matters, more than those who do not meet criteria (e.g., Roemer, Mo- lina, & Borkovec, 1997). As noted earlier, individuals with GAD report difficulty stopping their worry once it starts, and clients often note that worrying about one topic can lead to worry about another. These findings and observations suggest that worry is a cognitive habit, with clients who meet criteria for GAD getting “stuck” in cycles of worry about a wide range of topics that are difficult to stop once started. All cognitive-behavioral treatments for GAD emphasize interrupting this cycle, although methods for doing so vary.

Descriptive studies of GAD and worry have revealed affective, cognitive, and interpersonal correlates that

may have important treatment implications. Borkovec’s seminal research revealed that worry serves an avoidant function by its perceived association with decreasing the likelihood of already low base rate negative events, and by the reduction in physiological arousal noted earlier (Borkovec, Alcaine, & Behar, 2004), as well as distraction from more emotional topics by self-report (Borkovec & Roemer, 1995). Mennin, Holaway, Fresco, Moore, and Heimberg (2007) have demonstrated that GAD is associated with both self-reported deficits in emotion regulation and limits in implicit regulation of emotional processing (Etkin & Schatzberg, 2011). Studies in this area have also revealed that GAD is as- sociated with the fear of or distress about anxiety (and other emotions; Lee, Orsillo, Roemer, & Allen, 2010; Mennin et al., 2007), worry about worry (or meta- worry; Wells, 2005), and habitual avoidance of inter- nal experiences (i.e., experiential avoidance; Lee et al., 2010). Furthermore, in a clinical sample, both worry and GAD were uniquely associated with perceived un- controllability of emotional reactions, beyond shared variance with other known cognitive predictors of GAD (Stapinski, Abbott, & Rapee, 2010). Extensive research also documents an association between GAD and intolerance of uncertainty (the tendency to respond negatively to uncertain events and situations; Gentes & Ruscio, 2011), including an experimental study show- ing that manipulated uncertainty leads to increased worry (Ladouceur, Gosselin, & Dugas, 2000). In ad- dition, some researchers posit that worry in GAD may function to continue or maintain negative emotional states to avoid a shift or contrast in emotions that may be aversive (Newman & Llera, 2011; Crouch, Lewis, Erickson, & Newman, 2017). GAD is also associated with interpersonal problems (Przeworski et al., 2011), including increased marital distress (Whisman, 2007).

OVERVIEW OF EVIDENCE FOR PSYCHOLOGICAL TREATMENTS

Meta-analyses reveal that cognitive-behavioral thera- pies (CBTs) are efficacious for GAD, with large ef- fect sizes that are maintained over follow-up periods (Borkovec & Ruscio, 2001; Covin, Ouimet, Seeds, & Dozois, 2008; Cuijpers et al., 2014; Hanrahan, Field, Jones, & Davey, 2013), and evidence of comparative ef- ficacy over nondirective therapy (Borkovec & Costello, 1993). Within CBTs, a meta-analysis revealed compa- rable effects of cognitive therapy and relaxation therapy

186 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

in treating GAD (Siev & Chambless, 2007), while another found some indication that CBT was more effective at 12-month follow-up, but not 24-month follow-up ( Cuijpers et al., 2014), with too few direct comparison studies to draw strong conclusions. How- ever, GAD remains one of the least successfully treated anxiety disorders (Waters & Craske, 2005), with most studies indicating that fewer than 65% of clients meet criteria for high end-state functioning at posttreatment (Ladouceur et al., 2000; Newman et al., 2011), and one meta-analysis finding that only 46% of clients at posttreatment, and 57% of clients at 12-month follow- up, were classified as recovered (based on a measure of worry; Hanrahan et al., 2013).

As briefly reviewed earlier, recent research has re- fined and expanded our understanding of GAD in an effort to identify causal and maintaining factors to target in therapy and improve its efficacy (see Behar, DiMarco, Hekler, Mohlman, & Staples, 2009, for an extensive review). Randomized controlled trials (RCTs) informed by these models indicate that targeting the interpersonal and emotion-focused aspects of GAD (Newman et al., 2011), and intolerance of uncertainty (Dugas et al., 2010), yield effects comparable to existing CBTs for GAD. An RCT comparing a treatment that targeted metacognition (e.g., metaworry) to CBT and wait-list control found that both metacognitive therapy (MCT) and CBT yielded better outcomes than wait list, and that MCT yielded significantly larger reduc- tions in worry at posttreatment and higher recovery rates (based on a measure of worry) at posttreatment and follow-up compared to CBT (Nordahl et al., 2018). Finally, an RCT comparing emotion regulation therapy (ERT; Mennin & Fresco, 2014; Renna, Quintero, Fres- co, & Mennin, 2017) for GAD to an attention control condition found that participants randomized to ERT reported significantly greater and clinically meaningful improvements in anxiety, depression, and quality of life via both assessor-rated and self-report measures (Men- nin, Fresco, O’Toole, & Heimberg, 2018).

We developed the acceptance-based behavioral ther- apy described in this chapter (which explicitly targets reactivity to [distress about] internal experiences, and experiential and behavioral avoidance, as described below) in an effort to better target GAD and comorbid disorders. We use the term acceptance-based behavioral therapy (ABBT; Roemer & Orsillo, 2020) to refer to the broad class of therapies that are based in cognitive- behavioral theory but explicitly incorporate methods to promote acceptance of internal experiences (e.g., accep-

tance and commitment therapy [ACT]; S. C. Hayes, Strosahl, & Wilson, 2012; dialectical behavior therapy [DBT]; Linehan, 1993; mindfulness-based cognitive therapy [MBCT]; Segal, Williams, & Teasdale, 2002). This ABBT for GAD, which draws from these treat- ments, as well as Borkovec’s CBT for GAD (Bork- ovec & Sharpless, 2004), has been examined through an open trial and two RCTs. The first RCT revealed significant, large effects on clinician and self-reported GAD symptoms, as well as depressive symptoms, along with marginally significant, medium effects on clini- cian-rated additional diagnoses and self-reported qual- ity of life (Roemer, Orsillo, & Salters-Pedneault, 2008). Significant large effects also emerged on self-reported experiential avoidance and mindfulness, two proposed mechanisms of change in the treatment. All effects were maintained at 9-month follow-up. Of those treated, 77% met criteria for high end-state functioning (fall- ing within normative range on the majority of anxiety measures) at posttreatment; this proportion increased slightly (nonsignificantly) over time. ABBT produced a significant increase in engagement in valued, or per- sonally meaningful, activities (Michelson, Lee, Orsillo, & Roemer, 2011). Moreover, ABBT significantly im- pacted outcome variables proposed in other models to be central to GAD (emotion regulation deficits, intoler- ance of uncertainty, and perceived control over anxiety- related events; Treanor, Erisman, Salters-Pedneault, Roemer, & Orsillo, 2011). Next, we conducted an RCT comparing ABBT with applied relaxation, an empiri- cally supported treatment for GAD, which revealed comparable effects on clinician-rated and self-reported GAD symptoms, clinician-rated comorbid diagnoses, and self-reported depressive symptoms and quality of life (Hayes-Skelton, Roemer, & Orsillo, 2013). A large proportion of clients in both conditions met criteria for high end-state functioning (some of the highest rates reported in the literature in each condition), and gains were maintained at 6-month follow up.

Finally, there is evidence that ABBT works through its proposed mechanisms. Session-by-session changes in acceptance of internal experiences and engagement in meaningful activities predicted outcome above and be- yond change in worry (S. A. Hayes, Orsillo, & Roemer, 2010). In addition, change in decentering has been found to precede and predict subsequent change in symptoms of anxiety, while change in anxiety did not precede and predict change in decentering (Hayes-Skel- ton, Calloway, Roemer, & Orsillo, 2015). Reductions in experiential avoidance were found to predict symptom

Generalized Anxiety Disorder 187

and quality-of-life outcomes at posttreatment, above and beyond decentering (Eustis, Hayes-Skelton, Or- sillo, & Roemer, 2016). Furthermore, participants re- ported significant reductions in interpersonal problems across treatment, with increases in mindfulness predict- ing these reductions beyond shared variance with GAD severity (Millstein, Orsillo, Hayes-Skelton, & Roemer, 2015). Interestingly, in most of these secondary analy- ses, these mechanisms also emerged as predictive of out- come for participants in applied relaxation (see Hayes- Skelton, Usmani, Lee, Roemer, & Orsillo, 2012, for further discussion).

Arch and colleagues (2012) examined the relative ef- ficacy of ACT compared to CBT for a mixed-anxiety sample and found comparable effects across the full sample. Although the small size of the GAD subsample precluded within-subgroup analyses, examination of means suggests that ACT was effective in reducing cli- nician-rated and self-reported GAD symptoms in this study. A small RCT also found a significant reduction in self-reported GAD symptoms among individuals re- ceiving ABBT compared to those in a control condition (Zargar et al., 2012). Another RCT revealed significant effects of an Internet-delivered ABBT for GAD on GAD and depressive symptoms when compared to a wait-list control (Dahlin et al., 2016). Finally, a recent RCT revealed more rapid change in GAD and anxiety symptoms for a group-based ABBT treatment com- pared to a nondirective supportive group therapy (de Almeida Sampaio et al., 2020).

Taken together, these findings suggest that psycho- social treatments for GAD are efficacious, and adapta- tions of CBT that specifically target empirically deter- mined features of GAD are promising, with growing evidence supporting the efficacy of the ABBT presented in this chapter. As with all treatments based in behav- ioral theory, a well-developed case conceptualization is a necessary starting point to use evidence-based treat- ments effectively with a specific client.

AN ACCEPTANCE‑BASED BEHAVIORAL MODEL OF GAD

An acceptance-based behavioral model of GAD is grounded in behavioral learning theory. Consistent with other theories, we propose that individuals with GAD develop the habit of worry, repeatedly antici- pating potential dangers and threats. These habits are strengthened through repetition and reinforcing con-

sequences. This worry process is negatively reinforced by both the nonoccurrence of feared outcomes and the reduced physiological activation that is a positive con- sequence of engaging in worry (Borkovec et al., 2004).

Moreover, individuals with GAD come to associate universal, functional human states such as fear, anxi- ety, other emotional responses, and even worry with negative personal characteristics. As a result, individu- als with GAD respond to anxiety-related thoughts and emotional states with self-criticism and judgment. In an attempt to avoid or escape the uncomfortable, un- wanted experience of worry, and the associated nega- tive self-evaluation, individuals with GAD engage in a variety of potentially problematic behaviors. Although these behaviors interfere with quality of life, they pro- vide short-term relief from arousal and negative affect.

Drawing from decades of research on GAD, other anxiety disorders, and broader models of psychopathol- ogy (e.g., S. C. Hayes et al., 2012), we hypothesize that the following three learned behaviors contribute to the development and maintenance of GAD.

Reacting to Internal Experiences with Distress, Criticism, and Judgment (Leading to Entanglement/Fusion)

One of the most formative, consistent findings to emerge in the field of anxiety disorders has been that the experience of anxiety or fear, in and of itself (e.g., sensations of panic, worrisome thoughts, catastrophic images, recurrent painful memories), is not evidence of a disorder. Instead, reactions to these symptoms, or “re- actions to our reactions” (Borkovec & Sharpless, 2004) exacerbate their intensity and duration, cause distress, and interfere with quality of life, leading to the anxiety disorder diagnosis. The centrality of “reactions to re- actions” to the concept of psychological disorders has been documented in treatment research. Changes in reactivity to emotions predicted unique variance in all outcome variables, over and above changes in frequency of emotional responses in a study of the unified proto- col for transdiagnostic treatment of emotional disorders (Sauer-Zavala et al., 2012; see Payne, Ellard, Farchione, & Barlow, Chapter 6, this volume).

Individuals with GAD report increased anxiety sen- sitivity (i.e., fear of anxiety-related bodily sensations; Olatunji & Wolitzky-Taylor, 2009), negative reactiv- ity to their emotional responses (e.g., Lee et al., 2010; Mennin et al., 2007), and worry about their own worry (Wells, 2005). Furthermore, anxiety leads to a nar-

188 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

rowed focus of attention (both external and internal) toward potential threat (Cisler & Koster, 2010), which likely both exacerbates these reactions and is strength- ened by reactivity, further perpetuating cycles of anx- ious responding. These reactions can lead individuals to become entangled with (Germer, 2005) or “hooked” on (Chodron, 2007) their experiences of anxiety and worry, so that the anxiety comes to seem self-defining and all-encompassing. Instead of viewing anxiety as a response that is elicited in a particular context, indi- viduals can come to define themselves as “anxious,” fusing their identity with these experiences (e.g., S. C. Hayes et al., 2012). Thus, negative reactivity to emo- tions can evolve into negative personal judgments (“I’m so weak!”; “Other people don’t worry the way I do”), which in turn can increase anxiety and worry.

Becoming entangled or fused with internal expe- riences makes it much harder to see the ways that thoughts, feelings, and sensations naturally rise, fall, and change over time. It can also interfere with one’s ability to understand and respond effectively to emo- tional states, leading to diffuse experiences of distress that do not provide clear motivational information. When fear, anxiety, and worry are perceived as distress- ing, defining, and unrelenting, they naturally elicit at- tempts to escape and avoid.

Rigid Attempts to Avoid Internal Distress (Experiential Avoidance)

Trying not to think about or feel or remember some- thing distressing is a natural response. All people use strategies to turn their attention away from internal dis- tress at times, in order to bring attention to the task at hand. Yet experimental studies show that rigid, repeated efforts to put thoughts, feelings, sensations or memo- ries out of our minds (e.g., experiential avoidance; S. C. Hayes, Wilson, Gifford, Follette, & Strosahl, 1996) are often unsuccessful and can actually increase distressing thoughts, feelings, or sensations (e.g., Gross, 2002; Lev- itt, Brown, Orsillo, & Barlow, 2004; Najmi & Wegner, 2008). Furthermore, instructed effort not to think of situations can increase reported anxiety associated with the target situation (Roemer & Borkovec, 1994), sug- gesting that experiential avoidance increases distress about thoughts and emotions. These studies suggest that rigid efforts to avoid distressing thoughts, feelings, sensations, and memories can increase the frequency of these experiences, as well as the distress associated with them, further strengthening the cycle of reactivity and avoidance. Efforts at experiential avoidance are likely

to reduce distress in the short term at least sometimes, leading to immediate negative reinforcement, further strengthening this habitual response.

Reports of experiential avoidance are associated with GAD diagnoses, even beyond shared variance with de- pressive symptoms (Lee et al., 2010). Furthermore, as described earlier, experimental studies demonstrate that worry itself serves an experientially avoidant function by reducing physiological arousal in response to feared stimuli and distracting individuals from more distress- ing topics (Borkovec et al., 2004).

Limited Engagement in Personally Meaningful Actions (Behavioral Avoidance)

Reactions to internal experiences and rigid experiential avoidance not only feed on each other in a continually escalating cycle but also naturally lead to avoidance of contexts that elicit anxiety or other experiences of distress. Behavioral avoidance is a core feature of other anxiety disorders, but it has historically been over- looked in GAD. However, individuals with GAD often avoid certain situations, spend extensive time preparing for situations, procrastinate or put off decision making, or seek reassurance, all in an effort to avoid distress, anxiety, and/or uncertainty (Andrews et al., 2010). Cli- ents with GAD reported significantly less consistent engagement in valued actions (i.e., doing what they find personally meaningful) than did individuals without this diagnosis (Michelson et al., 2011).

Clients with GAD limit their engagement in per- sonally meaningful actions in many different ways. We encounter clients who engage in overt behavioral avoidance, such as declining a date or turning down an opportunity to pursue a promotion at work. Clients vary in their awareness of the specific emotional trig- gers for these choices: Sometimes they are aware of their anxiety, fears of being rejected, or worry, while often they have a more generalized sense of trying to reduce “stress.” Other times, clients who seem to be engaging in a wide range of behaviors that are important (e.g., taking on challenges at work, being involved in activi- ties with their children) describe feeling disconnected from those activities, because they are constantly wor- rying about what is ahead rather than attending to what they are doing in the moment. Borkovec notes this focus on the future instead of the present as a core characteristic of GAD (e.g., Borkovec & Sharpless, 2004), and research indicates that GAD and worry are associated with reports of reduced mindfulness (aware- ness in the present moment; Roemer et al., 2009). This

Generalized Anxiety Disorder 189

continual focus on what might go wrong in the future can lead clients to feel like spectators in their own lives: behaviorally, but not emotionally, engaged in actions that matter to them. We also see some clients whose lives are so busy with activities they feel compelled to complete in order to reduce stress (e.g., household chores, work-related tasks) or to control the uncontrol- lable (e.g., searching the Internet for ways to keep loved ones safe or for assurance that their child will grow up to be a happy adult), that they have little time left to engaged in values-based actions.

This conceptual model highlights three targets for intervention when treating clients with GAD and other comorbid disorders: (1) problematic ways of relating to internal experiences, (2) rigid strategies aimed at experi- ential avoidance, and (3) limited engagement in person- ally meaningful actions. Based on this model, the goals of an ABBT for GAD are (1) to cultivate an expanded (as opposed to narrowed) awareness and a compassionate (as opposed to critical and judgmental), decentered (as opposed to entangled and fused) stance toward internal experiences; (2) to increase acceptance of/willingness to have internal experiences; and (3) to engage mindfully in personally meaningful behaviors.

APPLYING ABBT

Context for Therapy

Our first case study of ABBT took place in group for- mat (Orsillo, Roemer, & Barlow, 2003). Although cli- ents benefited from the group context in some ways, they reported wanting a more individualized focus to help them clarify their values (i.e., what matters to them) and apply the treatment to their specific con- texts. As a result, all of our subsequent trials have used individual therapy. However, we think that the modal- ity of treatment can be adjusted to better fit specific settings. In fact, a group version of our protocol led to significant reductions in self-reported anxiety, worry, and GAD symptoms in a community setting (Heather- ington et al., 2014) and led to more rapid symptomatic change than a nondirective group therapy (de Almeida Sampaio et al., 2020). Furthermore, several elements of ABBT (e.g., psychoeducation, mindfulness practice, commitment to values-based actions) have been ef- fectively conducted in group settings in other, related treatment approaches (e.g., Evans et al., 2008; Kocov- ski, Fleming, Hawley, Huta, & Antony, 2013).

Given the prevalence of GAD in primary care con- texts, we are interested in adapting treatment so it can be

used as part of integrative primary care. Fuchs, Harad- hvala, and colleagues (2016) conducted a preliminary study that supported the feasibility of a group therapy using this approach. We wrote a self-help book (Orsillo & Roemer, 2011) and a workbook (Orsillo & Roemer, 2016) that may also be beneficial in this context. A pre- liminary RCT revealed that the workbook led to sig- nificantly greater decreases in anxiety and worry than a wait-list comparison (Serowik, Roemer, Suvak, Liver- ant, & Orsillo, 2020). We are also interested in the use of technology as one way to increase access to evidence- based care; as noted earlier, an Internet-delivered ABBT can be effective for GAD (Dahlin et al., 2016).

Briefer workshops (e.g., Blevins, Roca, & Spencer, 2011; Brown et al., 2011) may also be a useful modality for delivery of the conceptual model and suggestions for mindfulness and values-based action practices in contexts in which individual therapy is less feasible due to economic or time constraints. Our research groups have developed several brief, one-session prevention/in- tervention workshops based on our ABBT’s conceptual model for college students (Danitz & Orsillo, 2014; Danitz, Suvak, & Orsillo, 2016; Eustis et al., 2017; Eu- stis, Hayes-Skelton, Orsillo, & Roemer, 2018; Sagon, Danitz, Suvak, & Orsillo, 2018) that have yielded symptomatic improvement from both in-person and online delivery. These workshops include psychoeduca- tion on anxiety, stress, and the consequences of avoid- ance, and offer mindfulness, acceptance, and values clarification and values-based action as skills to use in response to anxiety and stress. Given the high preva- lence of racism and discrimination in the United States and the deleterious impacts these unjust experiences can have on mental health, another focus has been on developing and examining brief ABBT-informed in- terventions tailored specifically for coping with racism and discrimination. Examples of these interventions include a 1-hour computer-delivered program focused on racism-related stress for people of color that has been found to significantly reduce internalized racism (Martinez & Roemer, 2019), and an in-person cultur- ally adapted workshop for Latinx students that reduced symptoms of distress (Arbid, 2020).

Therapist Characteristics

A central aspect of ABBT involves modeling a way of responding to intense, challenging internal experiences with curiosity, awareness, compassion, and acceptance. Therefore, successful ABBT therapists are able to dis- cern emotions, validate and normalize their arising, and

190 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

make room for clients’ distress in session. By continu- ally acknowledging emotions, turning toward them in an attempt to expand awareness and increase under- standing, validating their presence with compassion, and allowing them to be present while considering a range of behavioral options, ABBT therapists provide clients with an example of how they might respond dif- ferently to their own experiences and reduce the cycle of reactivity and avoidance that contributes to mainte- nance of their symptoms. Therapists also model a de- centered awareness of internal experiences in the way they talk about thoughts, emotions, internal sensations, and behavior. For example, rather than saying, “I can see you were very anxious in that situation,” the thera- pist might note, “It sounds like a lot of worry thoughts were present and you noticed sensations of tension and restlessness in your body.” These characteristics, com- bined with a clear understanding of the model and how to apply it to specific cases, help therapists to develop a strong, positive working alliance, which was signifi- cantly associated with outcome in our most recent trial (Calloway, Hayes-Skelton, Roemer, & Orsillo, 2017).

As we describe more fully below, ABBT is meant to be applied flexibly, with therapists adapting their ap- proach, strategies used, and between-session assign- ments to meet the presentation and context of clients. As such, flexibility may be an important therapist characteristic. In a small qualitative study, as part of an RCT, we interviewed clients who identified with marginalized backgrounds in terms of race, ethnicity, sexual orientation, socioeconomic status, or religion. Clients identified the flexibility of their therapist as an important factor in how helpful they found treatment and how well it fit with their particular context (Fuchs, West, et al., 2016).

Client Characteristics

In the studies we have conducted on ABBT for GAD, we have had very few exclusion criteria, in order to maximize the generalizability of our findings. Clients frequently present with comorbid diagnoses, most commonly major depressive disorder, social anxiety disorder, and other anxiety disorders. Because ABBT targets mechanisms that are likely to underlie these other disorders as well, treatment may positively impact these comorbid conditions (e.g., Roemer et al., 2008). However, outside the constraints of protocol therapy, we would recommend integrating elements of evidence- based methods (e.g., behavioral activation, exposure) when indicated. The disorders we have ruled out in our

RCTs, primarily because they warrant specific treat- ments, include substance dependence, bipolar disorder, schizophrenia, and autism spectrum disorders. Thus, we cannot determine the impact of ABBT on these co- morbid presentations.

To date, we have only preliminarily explored poten- tial predictors of response to ABBT. To date, our data suggest that gender, age, GAD severity, frequency and intensity of worry, depressive symptoms, and comorbid diagnoses do not significantly predict outcome (Orsillo, Roemer, & Salters-Pedneault, 2008).

As with most evidence-based treatments, consider- ably more research is needed to determine the ways an ABBT for GAD might be beneficial for people from marginalized or nondominant cultural backgrounds, as well as how to use ABBT strategies to address con- textual stressors such as discrimination and lack of re- sources. A meta-analysis indicated promising results for ABBTs more broadly (Fuchs, Lee, Roemer, & Orsillo, 2013). Our small, qualitative study revealed that clients from marginalized backgrounds generally found ABBT helpful (Fuchs, West, et al., 2016). Clients particularly noted that therapist flexibility and the focus on valued living helped them engage in treatment and find it rel- evant. However, some clients reported that therapist inflexibility or not connecting to specific mindfulness exercises was a barrier. As with all treatments, cultural considerations and adaptations are a necessary part of culturally responsive ABBT (for more in-depth dis- cussions of these considerations for mindfulness and acceptance-based therapies, see Hall, Hong, Zane, & Meyer, 2011; Harrell, 2018; Proulx et al., 2018; Roemer & Orsillo, 2020; Sobczak & West, 2013).

Concurrent Pharmacological Treatment

Pharmacotherapy, including selective serotonin reup- take inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and pregabalin, is the most common mode of treatment for GAD (He et al., 2019) and is often considered a first-line treatment op- tion (Katzman et al., 2014). Benzodiazepines (BZs) continue to be commonly prescribed for GAD (Bald- win, Allgulander, Bandelow, Ferre, & Pallanti, 2012), despite the risks of tolerance and dependence (Baldwin, Hou, Gordon, Huneke, & Garner, 2017). A recent meta-analysis of pharmacotherapy for GAD demon- strated a small-to-medium effect of SSRIs, SNRIs, and BZs over placebo (Gomez, Barthel, & Hofmann, 2018). However, pharmacological interventions may produce adverse side effects, including sexual dysfunction,

Generalized Anxiety Disorder 191

drowsiness, and weight gain, which lead many patients to stop treatment early (Baldwin et al., 2017); they are less cost-effective than psychotherapeutic approaches such as CBT (Heuzenroeder et al., 2004), and can be associated with increased health care utilization (Berger et al., 2011).

Clients who were stable on medications were en- rolled in our clinical trials. Within ABBT, medications are conceptualized as one of several ways to reduce the intensity of internal reactions, so that it is easier to ac- cept them, have compassion for oneself, and engage in meaningful actions. In this way, a nonexperientially avoidant function for medication can be highlighted (medication helps one to engage more fully in life and accept whatever comes), so that it is consistent with the rest of treatment.

Overview of Treatment Elements

In our clinical trials, we have followed a 16-session, weekly, individual protocol for ABBT, with the last two sessions tapered (every other week) and focused on re- lapse prevention. The first seven sessions focus on psy- choeducation and skills building, while the remaining sessions focus on application of skills, while the client engages in personally meaningful, values-based ac- tions. Here we provide a brief overview of each element of treatment, followed by a composite case example to illustrate the way each element is addressed across the course of therapy. Those interested in more details on our approach should consult our book for therapists (Roemer & Orsillo, 2020), our self-help book (Orsillo & Roemer, 2011), and our client workbook (Orsillo & Roemer, 2016).

Clinical Assessment to Develop an Acceptance‑Based Behavioral Conceptualization

To develop a case conceptualization that guides flexible application of treatment elements, we assess symptoms, context, and the three components of the model.

SYMPTOMS

Assessing the client’s anxiety and related symptoms provides useful information about targets for change, while also supporting the therapeutic goal of chang- ing a client’s relationship with anxiety. Assessment of anxiety-related thoughts, feelings, physical sensations, and behaviors, the contexts in which anxiety typically occurs, and the frequency and severity of symptoms,

helps clients begin to observe more accurately specific elements of their anxiety responses. Ongoing self-mon- itoring of daily anxiety symptoms, as well as guided imaginal recall, can provide a more accurate assessment of specific symptoms than general report given that cli- ents who engage in habitual avoidance or suppression of their anxiety often do not have an accurate perception of its frequency, duration, or variability over time. Brief but specific self-report measures (e.g., the Depression Anxiety Stress Scales [Lovibond & Lovibond, 1995] or the trait and weekly Penn State Worry Questionnaire [Meyer, Miller, Metzger, & Borkovec, 1990; Stöber & Bittencourt, 1998]), can also be used, both to obtain baseline measures of symptoms and to track weekly fluctuations in symptoms.

Semistructured clinical interviews such as the Anxi- ety Disorders Interview Schedule (Brown & Barlow, 2014) can be used to determine both principal and co- morbid disorders to guide the selection and emphasis of specific treatment strategies. Depression is an impor- tant target of assessment, as are other clinical presenta- tions, such as eating disorders and substance-use disor- ders, which may indicate specific avoidance strategies that need to be targeted in treatment.

REACTIONS TO INTERNAL EXPERIENCES

Assessing how clients respond to their anxiety symp- toms, as well as to internal experiences (e.g., thoughts, emotions, sensations, memories) more generally, con- tributes to case conceptualization. Therapists may ask questions (e.g., “When you notice you are worrying, what thoughts, feelings and sensations do you experience next?”; “Do you find yourself having critical thoughts about your experiences of anxiety?”; and “What kinds of thoughts do you have?”) or use self-report measures that capture these constructs. Self-criticism, judgment, and reactivity that arise for clients in response to their own thoughts and feelings are important targets for intervention. Measures such as the Affective Control Scale (Williams, Chambless, & Ahrens, 1997), a mea- sure of distress in response to anxiety, depression, anger, and positive emotions, and the Self-Compassion Scale (Neff, 2003) can help to identify reactivity to emotions and self-criticism.

EXPERIENTIAL AVOIDANCE

Therapists also assess the strategies that clients use in an attempt to suppress, avoid, or change internal experi- ences (S. C. Hayes et al., 1996). Experiential avoidance

192 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

strategies may be internal, such as thought or emotion suppression (Gross & Levenson, 1997; Najmi & Weg- ner, 2008), or external, such as using substances, engag- ing in self-harm, or restricting eating. Therapists can ask clients what they do to try to manage their distress or anxiety, then listen for avoidant strategies. Efforts in which clients engage automatically or rigidly are most likely to lead to paradoxical increases in distress and symptoms. Therapists need to distinguish between ef- forts to modulate or regulate emotional distress and rigid efforts to avoid it; often, the difference is evident in what happens after the strategy is engaged. The former efforts are likely to be beneficial and may be strengths on which to build in therapy, if used flexibly, whereas the latter are more likely to lead to increased distress and interference. For instance, one client with whom we worked reported going for walks to try to clear her head of worry. When her therapist asked what she did when she returned, she reported that she was more able to focus on being with her children and enjoy their time together. On the other hand, another client who described regularly watching TV in order to dis- tract herself from her worries, said that as soon as she turned off the TV, her worried thoughts flooded back, so that she found herself watching TV for hours at a time rather than doing activities she had planned dur- ing the day. Whereas the first client’s walks might be incorporated into treatment as a way to care for herself and help her engage more effectively with her children, the second client’s therapist might help her develop al- ternative ways of responding to her anxiety. The Accep- tance and Action Questionnaire (Bond et al., 2011) and the Multidimensional Experiential Avoidance Ques- tionnaire (Gámez, Chmielewski, Kotov, Ruggero, & Watson, 2011) can help to identify experientially avoid- ant strategies; the Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004) assesses emotion regula- tion more broadly.

ENGAGEMENT IN VALUES-BASED ACTIONS

Therapists should also assess how clients are function- ing in their daily lives and the ways that anxiety and worry are interfering. Drawing from ACT (Wilson & Murrell, 2004), we focus particularly on the degree to which clients are doing what is important to them (i.e., what they value). We assess this with the Valued Liv- ing Questionnaire (Wilson, Sandoz, Kitchens, & Rob- erts, 2010), while also inviting clients to write about the ways anxiety interferes with their relationships, work–

school–household management, self-nourishment, and community involvement. This provides not only important information about current functioning but also a target and motivation for treatment to help cli- ents live fuller, more meaningful lives. This assessment often provides an important first step toward shifting the goal of therapy from anxiety reduction to enhance- ment of life.

CONTEXT AND HISTORY

As with all treatment approaches, assessing clients’ con- text is essential. Therapists need to learn how clients (as well as family and friends) understands their anxiety, their perspective on psychological challenges, and their views on psychotherapy. Therapists should also explore clients’ multifaceted cultural identity, with attention to culturally specific sources of coping and strength, culturally influenced views on emotions and emotional expression, comfort level with engaging in mindfulness practice, and the ways in which individualism or inter- dependence may influence personal values. Assessing for the presence of the contextual stressors in clients’ lives, including physical challenges, poverty, and dis- crimination, acknowledges the key role these stressors can play in maintaining psychological distress and in- creases the therapist’s awareness of potential obstacles that could arise over the course of treatment. In sum- mary, assessing culture and context helps to validate clients’ experiences, build therapeutic alliance, deepen case conceptualization, and help ensure that therapy proceeds in a culturally sensitive and responsive way (Hays, 2016; Sue & Sue, 2016).

This comprehensive assessment sets the stage for treatment elements aimed at (1) cultivating an expand- ed (as opposed to narrowed) awareness and a compas- sionate (as opposed to critical and judgmental), decen- tered (as opposed to entangled and fused) stance toward internal experiences; (2) increasing acceptance/willing- ness to have internal experiences; and (3) mindfully en- gaging in personally meaningful behaviors.

Therapeutic Relationship

The therapeutic relationship provides an important context for therapeutic change. In ABBT, the therapist provides acceptance and compassion that allows clients to begin to react differently toward their own internal experiences. Therapists explicitly validate the human- ness and naturalness of all responses that clients share,

Generalized Anxiety Disorder 193

emphasizing the way biological makeup and learning history can easily lead to anxious responses and other emotional reactions, and the way that even apparently “irrational” thoughts can be learned from social and family influences. For instance, when a client noted in session that he knew he should not be anxious about a job interview, his therapist responded that anxiety be- fore an interview is a very natural response given that he really wants the position, and that we are hardwired to fear social rejection. This response modeled a differ- ent reaction to his anxiety and was the first step toward cultivating a new, less self-critical response.

It can be challenging to empathize with and vali- date some clients, particularly when they are hostile or unresponsive. Understanding the learning history and context that produces and maintains these difficult, but also in some ways functional, behaviors helps thera- pists cultivate compassion. When a therapist expresses genuine compassion toward a client, often the client’s reactions change, at least slightly, providing more op- portunities for connection, validation, empathy, and further change.

Another challenge to the therapeutic alliance can stem from differences between client and therapist in aspects of identity (e.g., age, gender, race, religion, eth- nicity, sexual orientation, immigration status, or social class; Hays, 2016; Sue & Sue, 2016). Initiating a discus- sion of potential differences early in therapy provides an opportunity for open communication about poten- tial sources of misunderstanding and may make a cli- ent feel more comfortable bringing up any issues that emerge throughout the course of therapy. Therapists take responsibility for learning about a client’s cultural context on their own, while remaining sensitive to each client’s individual experiences and life contexts, so that they can consider how cultural and systemic factors may play a role in clients’ responses and can be used to promote growth and positive adaptation. Commu- nicating awareness of, and sensitivity to, the therapist’s own areas of relative privilege can also contribute to a stronger therapeutic alliance.

Psychoeducation

Similar to other CBTs, psychoeducation is an impor- tant component of this ABBT. Therapists present con- cepts, using handouts, particularly during the first half of therapy (then revisit these concepts as needed in the second, application phase of treatment). For each con- cept, therapists draw examples from clients’ lives (using

monitoring forms, assessment material, or asking cli- ents specifically for examples) to ensure that the mate- rial is relevant.

Psychoeducation begins with a discussion about the nature of fear, anxiety, and worry (including a discus- sion of the function of worry), followed by exploration of the function of emotions more broadly, emphasizing the habitual nature of our emotional responding and how repetition strengthens these habits, while interrup- tion can weaken them. Therapists teach clients about the natural inclination to avoid painful or threatening cues, as well as the challenges and costs associated with trying to rigidly control internal experiences and avoid anxiety-eliciting situations. Therapists draw a distinc- tion between clear emotions (that provide information about a response to a current context) and muddy emo- tions (that may be diffuse, confusing, left over, or lon- ger lasting). They also differentiate worry from problem solving, highlighting the differences between events and outcomes over which we do and do not have influ- ence or control. Therapists also describe mindfulness skills, specifically noting the ways these skills can be used to clarify emotional responses and enhance par- ticipation in valued life activities.

Psychoeducation provides a rationale for the rest of treatment, encouraging engagement in behaviors that take significant time (e.g., mindfulness practice) or effort (e.g., engaging in values-based actions). Psycho- education on its own can also help to promote a new relationship to internal experiences. Realizing how one’s emotions become muddy and overwhelming as a result of a series of understandable processes (e.g., not getting enough sleep, still feeling upset about an earlier fight with a partner) can reduce self-criticism and judg- ment, which in turn can reduce muddiness and reac- tivity. For some clients, psychoeducation alone leads to engagement in new behaviors and to new learning that promotes accepting responses to internal experiences and increased engagement in life. However, experien- tial learning is often needed to supplement this clinical strategy.

Many challenges can arise when presenting psycho- educational material. First, it can be difficult to attend to specific client concerns while also presenting exten- sive new information. Using client examples as you teach and frequently asking clients to share their reac- tions can help to balance these competing demands. Also, sometimes clients disagree with material being presented. For instance, clients may insist that avoid- ance is an effective strategy. Arguing with clients is

194 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

rarely productive, and it can weaken the therapeutic relationship. Furthermore, case conceptualizations are only hypotheses based on the literature and clinical ob- servation, so it is important not to cling rigidly to them. We find it useful, in this situation, to ask whether cli- ents are willing simply to observe the concept over the next few weeks to see whether they can learn anything new about their experience. This promotes a collabora- tive approach to treatment and helps to engage clients, while also encouraging valuable feedback on our con- ceptualization.

Mindfulness Skills Development

Mindfulness (Kabat-Zinn, 2003), or attending to the present moment with openness, curiosity, and compas- sion, is a central skill clients can use to change the na- ture of their relationship with their internal experiences (e.g., beginning to see thoughts as thoughts, or decen- tering), increase their willingness to have any reactions that arise, and promote engagement in fulfilling, mean- ingful lives. We use a wide range of methods to help cli- ents bring their awareness to the present moment, and we greet their experiences with curiosity, kindness, and compassion.

SELF-MONITORING

Self-monitoring is a common method used in all CBTs. Similar to these approaches, therapy begins with cli- ents monitoring situations in which worry arises. Each week, based on what is covered in session, new aspects of experience are added (e.g., emotions, efforts to avoid experience, engagement in values-based actions). The process of monitoring worry, other internal experiences, and behaviors helps to promote awareness and decenter- ing; clients turn toward their internal experiences rather than habitually turning away, and they see each aspect of their experience rather than blending the compo- nents together (e.g., noticing thoughts, emotions, and behaviors separately). As clients begin to notice the dis- tinction between emotion and behavior, they are more able to consider the variety of behavioral options avail- able to them even when strong emotions arise.

Self-monitoring can be challenging for some clients. They may forget to complete monitoring forms, see them as a “homework” requirement done only at the therapist’s request, or finish them in the waiting room as opposed to completing them in the moment. Thera- pists can help clients to see the usefulness of the practice

by clearly communicating the rationale for monitoring; describing how it helps build skills that can be used to clarify emotions, reduce distress, and increase engage- ment in valued activities; and reviewing the monitoring each session and connecting observations to treatment goals. Therapists can also flexibly adapt monitoring as- signments to fit with the client’s life (e.g., reduce moni- toring to one situation a day) while emphasizing the importance of doing some monitoring in the moment that a reaction occurs to facilitate the development of awareness as anxious habitual patterns unfold.

FORMAL MINDFULNESS PRACTICE

Mindfulness is a skill; therefore, practicing it regularly can be extremely helpful. Therapists help clients to de- termine when they can set aside some time in which to draw their awareness, again and again, to some aspect of their experience, such as the breath, physical sensa- tions, or thoughts. In mindfulness-based treatments such as MBCT, clients practice for 45 minutes a day; we generally use shorter mindfulness practices and allow clients to choose the length of their practice. We do have all clients practice an adapted progressive muscle relaxation in which clients tense and release a series of muscle groups, noticing the sensations they experience.1 This gives anxious clients an extended exposure to mindfulness, while providing a focus for attention that may facilitate more prolonged practice. Clients vary in how much they keep up this particular practice versus other, shorter practices.

In our approach, therapists teach clients a progression of practices across the course of treatment, beginning with focus on the breath and body, moving to aware- ness of taste and sounds, then on to more challenging practices of awareness of emotions and thoughts. Cli- ents and therapists practice together first in session, then discuss the client’s experience with the exercise. Initially, clients often label the practice as “good” or “bad,” “relaxing” or “stressful.” Therapists help clients move toward simply observing and describing their ex- perience during the practice, recognizing that all prac- tice is useful and so-called “bad” practice can teach a lot about how active one’s mind is and how to repeatedly bring awareness back to the moment despite a wander- ing mind.

When discussing in-session practice, therapists draw connections between the practice and clients’ present- ing problems. For instance, one client reported that when she practiced mindfulness of her breath, her mind

Generalized Anxiety Disorder 195

kept wandering to her frustration with her roommate, and it was clear that she was “bad” at mindfulness and was not ever going to get better. Her therapist related these self-critical thoughts and negative predictions to those that often arose when the client took on a new task at work. The therapist suggested that if she prac- ticed observing critical thoughts with compassion and curiosity during formal mindfulness, she might be able to carry these same skills into challenging work situa- tions.

Clients often have trouble setting aside time to prac- tice mindfulness regularly. Use of traditional problem- solving strategies to help the client find moments (dur- ing a subway commute, just after putting the kids to bed) to practice and emphasis on the potential benefits of practice, including increased efficiency and alertness throughout the day, can be helpful. Clients can also use mindfulness as an avoidance strategy, particularly if they initially find the practice relaxing. Therapists need to attend to the function of practice behavior to be sure that clients are not using it to avoid unwanted internal experiences.

INFORMAL MINDFULNESS PRACTICE

Although setting aside time to practice can be an excel- lent way to develop any skill, the goal is always to use the skill while engaging in life. Clients practice mind- fulness informally by engaging mindfully in daily tasks such as washing the dishes (Nhat Hanh, 1992), eating, showering, or folding laundry. They gradually begin to practice in more challenging contexts, such as during conversations, dates, meetings at work, or community events. Therapists initially help clients to remember to practice mindfulness during sessions; over time, clients begin to remind themselves to come back to the present moment while engaging in therapy, strengthening this skill so they can use it more effectively in their lives.

Engaging in Actions

Finally, therapists help clients turn their attention and effort away from trying to control their internal experi- ences and instead focus on engaging more fully in their lives. Clients begin exploring what is important to them through a series of writing assignments. First, they de- scribe how anxiety has gotten in the way of their lives in several domains (relationships, work–school–house- hold management, and self-nourishment and commu- nity involvement). Next, they write about how they

would like to be in these areas, if they did not have any anxiety. Although these writing practices are one method of identifying the values that will become the focus of therapy moving forward, in-session exploration and clarification is often needed to supplement these as- signments. Clients may struggle to differentiate values from goals, articulate values that reflect perfectionistic standards, or focus too narrowly on particular values- based actions. Helping clients to clarify personal val- ues that can guide behavior and enhance their sense of purpose and meaning is a critical step toward effective behavior change. From here, therapy involves making behavioral plans each week to incorporate values-based actions into the client’s everyday life. This may include generating new activities a client can try (e.g., making a social connection, asserting oneself at work, or joining a community organization) or helping the client to iden- tify moments in life when he/she can choose responses that reflect values-based actions (e.g., considering per- sonal values when engaged in conflict and allowing values to guide responses). Clients are encouraged to use their mindfulness skills to recognize opportunities to engage in values-based actions, use intention rather than habit to guide behavior, and increase acceptance and willingness when challenging internal experiences such as anxiety arise.

Shifting from habitual avoidance to engagement is a long, ongoing process. Some clients have difficulty ar- ticulating their values, because all of their attentional and behavioral resources have been directed toward anxiety management for so long. Once clients have clarified what they find important, approaching these actions can be extremely anxiety provoking and hard to do. However, encouragement from the therapist, culti- vation of mindfulness skills, and breaking tasks down into specific manageable pieces (e.g., asking a coworker to lunch, or having one open conversation with a par- ent) can help a client become willing to make these first important behavioral changes even though anxiety will inevitably be present. Over time, the experience of engaging in valued activities can be naturally reinforc- ing. Nonetheless, continued awareness and practice are needed so as not to fall back into old, natural patterns of avoidance due to anxiety.

Many challenges arise in pursuing values-based ac- tions. First, as Hayes and colleagues (2012) note, clients often think in terms of goals (e.g., finding a partner, losing 15 pounds) as opposed to values (e.g., sharing intimate thoughts and feelings with others, engaging in health-promoting habits). Focusing on wanting to

196 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

lose 15 pounds can lead to self-criticism in the moment, which might interfere with that goal. On the other hand, a person can take actions in the moment that are consistent with wanting to engage in health-promoting habits (e.g., going to the gym or eating a healthy lunch) that in turn also help with a goal. Therapists work to help clients identify the values and meaning that under- lie any stated goals, so that they can engage in actions in the moment that will be fulfilling and meaningful.

Therapists need to take care not to impose their own values onto clients. Cultural sensitivity is particularly important in this aspect of treatment. For instance, one client we treated with ABBT described a value of being able to provide financially for his parents, leading him to choose a profession that to him was less intrinsically interesting but would allow him to support his family. His therapist came from a more individualistic back- ground and had an initial reaction that choosing a more intrinsically rewarding profession was important. How- ever, the therapist recognized that this would impose his own values on the client rather than help the client to make choices consistent with his own values.

Therapists also need to be sensitive to the real-world constraints that can keep clients from engaging in ac- tions that matter to them. External constraints such as limited resources, inequities, racism, other forms of dis- crimination, and family contexts need to be validated and accounted for in developing treatment assignments. Relatedly, clients may want others in their lives to act differently. Although this is a very reasonable desire, changing other people is not always possible. Clients can request changes in others or take steps to address injustices in different contexts, but therapists cannot guarantee that these things will lead to clients’ hoped- for changes. Instead, the therapist can help the client make the best choices possible in the face of these con- straints, which can certainly include asking for changes and also leaving situations when possible, if necessary.

Relapse Prevention

Anxiety is a natural, habitual response, as is reactiv- ity to internal experiences and experiential avoidance. Therapists help clients develop a plan for maintaining the practices they have found most helpful in treat- ment, and to prepare for potential “lapses” in the fu- ture. Clients are encouraged to refer to their handouts and monitoring sheets when difficulties arise, and to revisit concepts and practices they found helpful in treatment.

CASE STUDY

This composite case is largely based on a single client but with details from other clients added to illustrate certain points. Identifying information is altered to protect confidentiality.

Background Information

“Héctor,” a 24-year-old Latino man, presented for treatment after being placed on academic probation. Although Héctor had an extremely strong academic re- cord as an undergraduate, he was struggling to keep up with the course demands in his first semester of medi- cal school. Héctor initially sought treatment from his primary care provider for a wide variety of stress-related symptoms, including frequent headaches, muscle ten- sion, and gastrointestinal distress. However, she urged him to seek therapy for what she believed to be an anxi- ety disorder.

In the initial assessment, Héctor endorsed symptoms consistent with GAD. He described a long history of worry that started in elementary school. His worry fo- cused centrally on his academic demands. He reported worrying constantly about the quality of his work, the sufficiency of his knowledge, and his ability to meet his own and others’ academic-related expectations. Héc- tor was the first person in his family to graduate from college, and his entire extended family was extremely proud of him and significantly invested in Héctor earn- ing a medical degree. Héctor’s mother had secured a second job to help meet his rising tuition costs, one of his uncles offered to cosign on a loan, and his cousin offered him a place to live rent-free. While he was ex- tremely grateful for their support, Héctor constantly worried about disappointing them.

Héctor was also troubled by worries about his moth- er’s health and well-being. He was concerned that she was overextending herself with two jobs, and he worried that she might have a heart attack or fall asleep when driving home and die in a car accident. Héctor also worried a fair amount about his two nephews. In his view, they spent far too much time watching television and playing video games, and needed more structure and guidance than his brother was providing.

Héctor described a number of aches and pains that he attributed to his constant, high level of physical tension. He noted that he had considerable difficulty falling asleep each night, as his mind constantly cycled through a variety of potentially negative outcomes the

Generalized Anxiety Disorder 197

next day might bring. Not surprisingly, he described having a very difficult time concentrating, especially while he was in class and when he attempted to do his assigned reading. When his anxiety and worry became too severe, he would skip class and head to the gym. In the past, when he exercised long enough, he would become so physically fatigued that he would fall asleep immediately when his “head hit the pillow.” Unfortu- nately, that coping strategy had recently become less and less effective. First, he found that he was skipping class for the gym more and more frequently, to the point that he was unable to keep up his grades. More- over, although he was still falling asleep fairly quickly postexercise, recently, he would awaken after only 1 or 2 hours of sleep.

When he was in secondary school and college, Héc- tor also found that spending time with friends and family kept his GAD symptoms in check. However, 6 months earlier, he had left his support network behind in Miami and relocated to Boston for medical school. Although he initially went out to eat with some of his classmates and occasionally attended study sessions with them, he never felt entirely comfortable at these events. He worried that his classmates did not think he belonged at such a prestigious medical school, and Héc- tor was acutely aware that he was one of very few ethnic minority students.

Engagement Session

In this session, Héctor disclosed that his family did not know he was in therapy, and that he was too ashamed to tell them about his academic issues. Héctor acknowl- edged that keeping these secrets was painful and dis- tressing, particularly because it required him to dis- tance himself even further from his main source of social support.

Although Héctor had attended a few counseling ses- sions in his first semester of college, he had no other history of psychotherapy. Héctor described his brief course of previous therapy as primarily supportive. He noted that meeting a few times with his Latino thera- pist, mostly to talk about academic stressors, had been extremely helpful in his transition to college. This ex- perience made him cautiously optimistic about the cur- rent course of therapy, although he acknowledged a fear that his problems might now be too severe to overcome completely.

Given the considerable outside-of-therapy demands associated with ABBT, the therapist asked Héctor about

potential barriers to treatment. Although Héctor had a slightly reduced schedule because of his academic pro- bation, he was still taking three courses and working 20–30 hours a week. The therapist validated Héctor’s existing commitments, but she also wanted to be realis- tic in describing the additional time commitment that would be required, particularly in the first six to eight sessions of therapy. The therapist used the training for a marathon analogy to convey the importance of setting aside sufficient time for out-of-therapy assignments. She noted that Héctor’s worry habit was deeply ingrained, and that learning new methods of responding would require some commitment to practice. Athletes training for a marathon cannot keep the same work/life schedule while adding in training sessions. Instead, they need to make some temporary accommodations to make time to run. Similarly, a client with GAD cannot develop new habits while maintaining the same busy schedule. Some time and attention must be allocated temporarily to reflecting on the treatment and practicing new ways of responding.

Finally, the (White) therapist explored how her gen- der, race, and ethnicity might affect treatment.

THERAPIST: It sounds like one of the best things about your previous course of therapy was that you really felt understood by your therapist.

HÉCTOR: Yes, I was surprised that I felt so comfortable with him. I expected that my counselor would be a woman, and I was a little hesitant about talking with a man at first. . . . I thought he might think of me as weak for seeking therapy.

THERAPIST: I think most of us go to therapy with ex- pectations about our therapist. We might expect a therapist to be older or younger, male or female, or of a particular race or ethnicity. Depending on whether the therapist meets our expectations, we may be more or less comfortable, feel more or less understood. Did you have any expectations coming in today?

HÉCTOR: Honestly? I knew I was seeing a woman be- cause of your name. And I wasn’t sure of your eth- nicity. But frankly, I didn’t really expect to have a Latina therapist based on the providers I have seen at this center.

THERAPIST: Do you have any thoughts or concerns about working with me that you would like to talk about?

HÉCTOR: Not really . . .

198 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: My hope is that we can work really well together, but it would be understandable if you didn’t necessarily trust me or feel comfortable with me right off the bat. You don’t know me at all, and it can be really difficult to open up to a stranger. Also, I know that for some people it might matter that I’m not Latina, I’m White. Sometimes that can make some- one feel like I can’t understand some kinds of expe- riences, like those related to being a minority or a person of color. But my goal is to do whatever I can to be sensitive to, and understanding of, your unique experiences. I bring some general expertise about anxiety to our work, including ways that experiences with discrimination can relate to anxiety, sometimes in subtle ways, but you are the expert on your own experience. So I will always try to check in with you about the ways in which the things we discuss and the suggestions I make fit with your experience. Please feel free to let me know if I say or do some- thing insensitive, or if you feel like I am not fully understanding what you are telling me. I definitely make mistakes, but my intention is to try to help you as best I can achieve your goals for therapy.

The therapist ended the engagement session by pro- viding some activities for Héctor to complete before the next session. First, she explained a monitoring form used throughout treatment (although the domains to monitor are changed over time as new session material is introduced, this version includes only date, situation, and worry topic as columns) and asked Héctor to begin to notice when he engaged in worry. She also gave him a copy of the Valued Living Questionnaire to complete with the following instructions:

“Sometimes anxiety and worry can prevent us from taking some actions that are consistent with our val- ues. For example, you mentioned that you skip class when you feel too anxious, even though you also noted that you care deeply about being a good stu- dent. Anxiety and worry can also make people feel as if they are on automatic pilot, or that their lives are consumed by things they must do rather than things they choose to do. This questionnaire is a first step toward identifying some of the ways in which anxi- ety and worry might be interfering with your life. Sometimes it is painful to think about the ways our lives are not as we would wish them to be. But this awareness is a first step toward making a change. So,

notice any feelings that arise as you fill out the forms, and we will be sure to talk about them next week.”

Session 1

The goal of Session 1 is to provide an overview of the treatment structure (client and therapist roles, between- session assignments, etc.), and to plan and discuss the rationale for treatment that is informed by a person- alized ABBT conceptualization of the client’s present- ing problems. The therapist asked Héctor to engage in an experiential exercise that involved imagining him- self back in one of the anxiety-provoking situations he noted on his monitoring form. Using guided imagery, the therapist helped Héctor to notice that his experi- ence of anxiety was characterized by a cycle of interre- lated thoughts (worries), physiological sensations (tight- ness in his shoulders and chest), and behaviors (leaving class early, heading to the gym).

HÉCTOR: I didn’t realize so much was happening when I am anxious. Usually, as soon as I notice I’m anx- ious, I just do whatever I can to prevent it from es- calating.

THERAPIST: That doesn’t surprise me. You have de- veloped a strong habit. When you get anxious, you immediately try to distract your attention from your experience and seek out ways to control or dampen your emotions. How difficult was it to imagine your- self back in class on Monday?

HÉCTOR: It was surprisingly easy. I definitely felt just as anxious remembering how I felt as I did sitting in the classroom.

THERAPIST: That is a great thing to notice. Something that is uniquely human is our ability to remember and imagine events vividly. Like other animals, we are hardwired to experience fear in the face of a threat—as if a predator were charging at us. But humans can also simply imagine a threat in their minds and experience the same hardwired response to threat. Do you have any idea what you were imag- ining in class that day?

HÉCTOR: On Monday, my mind just went from 0 to 100—I was barely aware of what I was thinking. But when we went through the exercise today, I noticed a series of pictures in my mind. First, I thought, I am not prepared for class. Then I imagined the professor yelling at me, my classmates laughing at me, my fam- ily’s disappointment . . .

Generalized Anxiety Disorder 199

THERAPIST: Hmm . . . if you imagined all those people rejecting you at the same time, it is not surprising that you would feel afraid. We are hardwired to seek social approval. If the entire academic community, your friends, and family all rejected you, you would have a pretty good reason for feeling afraid. Unfor- tunately, our minds don’t distinguish present threats from imagined ones.

The therapist and Héctor discussed the model of fear, anxiety, and worry guiding ABBT for GAD. The thera- pist explained that fear and anxiety serve adaptive func- tions. Anxiety allows us to imagine future threats and prepare for them. Fear energizes us to avoid and escape danger. In both of these states, our attention narrowly focuses on the threat and our escape plan, blocking out other information. Unfortunately, our ability to think, imagine (the future), and remember (the past) allows us to imagine endless threats and to respond with fear, even when no threat is present (i.e., our mental repre- sentations develop the same emotional properties as the events themselves, leading us to respond to threats that do not exist in the environment). Moreover, although we are hardwired to escape or avoid threat, sometimes, in order to do the things that matter to us, we have to approach situations that will likely elicit anxiety (e.g., allow ourselves to be vulnerable in order to gain intima- cy, take a risk at work in order to successfully negotiate a challenge). Many of us respond to this conundrum by harshly judging our natural responses and doing every- thing in our power to avoid experiencing them.

The therapist and Héctor also discussed the function of worry. Although worry is associated with clear nega- tive consequences (interferes with concentration, results in tension and fatigue), it too serves a function.

HÉCTOR: As much as my worry bothers me, in some ways, I am afraid to give it up. Sometimes it feels like the only thing I can do to control the uncontrollable.

THERAPIST: Great observation. Tell me more about that.

HÉCTOR: Well, sometimes it feels like if I stop worry- ing about my mother’s health, she will have a heart attack. Or I believe that if I don’t worry about a test, I won’t actually study.

THERAPIST: Some people notice that worrying about minor, everyday matters takes their mind off more painful thoughts and emotions. Have you ever no- ticed anything like that?

HÉCTOR: (beginning to tear up) Sometimes I think worrying about tests, or being late to class, or what I should wear to a school event is the only thing that keeps me from noticing how lonely I am. Sometimes I feel like if I stopped worrying, I would become so sad and depressed I might never get out of bed.

THERAPIST: That sounds really painful. When your mind is busy with worries, its challenging to concen- trate on anything else, and you experience tension and restlessness in your body. On the other hand, there is a real sadness here that you are away from your family and missing them, and worry can some- times distract from that sadness.

Near the end of the session, the therapist summed up her conceptualization and plan for treatment.

“Anxiety and worry narrow our focus and pull our attention toward the future. This cycle happens out- side of our awareness and can be difficult to change. In this treatment, we will use mindfulness skills to address this habit. Mindfulness increases and ex- pands our present-moment foc‘us and allows us to notice and break this cycle. We also have a tendency to judge and control our emotions because we think they are preventing us from having a satisfying life. In this treatment we will explore whether that reac- tion to our emotional responses is helpful or harm- ful, and we will consider alternative ways of respond- ing. Finally, worry is anticipatory; thus, it prevents us from engaging in activities that could be threaten- ing. But sometimes we want to approach these situa- tions—especially if they will help us to live the kind of life we value. In this treatment, we will learn to become more flexible—to consider different behav- ioral responses—rather than automatically avoiding potentially anxiety-provoking situations.”

At the end of Session 1, the therapist led Héctor in a mindfulness of breath exercise. She began by guiding him to notice the way he was sitting in the chair, then drew his attention to where he could feel his breath in his body. The therapist then guided Héctor to gently redirect his awareness back to the sensations of his in- halations and exhalations over the next several minutes, while deepening his breath, no matter how many times his mind wandered to other things. After the therapist and Héctor discussed his experience of this exercise, she asked him to practice it daily between sessions.

200 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Session 2

Session 2 primarily focuses on an introduction to mindfulness. The therapist led Héctor in a mindfulness of breath exercise, then engaged him in a debriefing.

THERAPIST: What did you notice? HÉCTOR: Well, I am pretty stressed out today. So the

exercise didn’t work as well as it did when I practiced this week.

THERAPIST: Tell me more about that. HÉCTOR: I used the breathing almost every night this

week to fall asleep. And it actually seemed to help. At least it calmed me down, so I could get to sleep quicker. But today, I just felt more stressed out.

THERAPIST: I can see why you might feel like your practice “worked” some days and not “others.” In the media, we often hear about breathing or mindful- ness practice as something we can do in a moment to feel less anxious. And as you’ve seen in your experi- ence, it can lead to a sense of calmness. Unfortunate- ly, as we’ve discussed, there really isn’t any strategy we can use in a particular moment that will make our anxiety go away. On the other hand, mindful- ness practice can help us become more aware of our experience. And this awareness can help to increase our self-compassion as we notice just how busy and critical our minds can be. Increased awareness can also help us notice habits that add to our distress and provide us with opportunities to try new ways of re- sponding. We will get to those later in therapy, but the focus now is on noticing and accepting whatever state we are in. What else did you notice?

HÉCTOR: I couldn’t keep my attention on my breath. It was all over the place. I am not sure I have the personality needed to be mindful.

THERAPIST: What a great observation. First, you no- ticed your attention was pulled in different direc- tions. I’ll bet that happens at other times in the day as well. It is useful to get to know just how busy our minds are.

HÉCTOR: I never thought of it like that. I guess it makes sense that I struggle to concentrate in class if I am having so many different thoughts all the time.

THERAPIST: I also want to gently remind you that I didn’t actually suggest that you should keep your at- tention on your breath. Just that you should notice

where your attention is and continually guide it back to the breath. Isn’t it interesting to see how quickly our minds judge whether we are doing something “right” or “wrong”?

HÉCTOR: (laughing) I sort of know what you are going to say here, but I also felt like I was breathing the wrong way. I kept breathing out of my mouth and it sounded so loud compared to your breath.

THERAPIST: (smiling) Great observation. If our minds are so judgmental about something as simple and natural as breathing, just imagine what judgmental thoughts are present when we are in class, at work, with friends. It sounds like you really used this ex- ercise as an opportunity to get to know the habits of your mind.

The therapist also led Héctor in the Raisin Exer- cise, which simply involves the practice of eating one raisin mindfully. Following this exercise, she focused on the mindfulness skill of “beginner’s mind,” essen- tially highlighting the ways in which “knowing” what to expect sometimes prevent us from accurately observ- ing different experiences. The session ended with the therapist leading Héctor through a slightly modified progressive muscle relaxation that was aimed at helping him to practice observing sensations and letting go of tension (rather than reduce anxiety).

Session 3

The therapist began Session 3 with the “mindfulness of sounds” mindfulness exercise. Héctor was able to see the similarity between this practice and the Raisin Ex- ercise in Session 2. Specifically, he noticed that it was difficult for his mind to observe the pitch, tone, and volume of the sounds around him without trying to label (a truck backing up) and judge (“That is loud and annoying”) his experience. The therapist was careful to normalize this response and to highlight the utility of becoming aware of what we are all naturally inclined to do.

After reviewing Héctor’s monitoring and mindful- ness homework, the therapist introduced a new psycho- educational topic—the function of emotions. Héctor quickly provided an example of the ways in which emo- tions such as fear can serve a communicative function. He described an incident when he was walking home from the library late at night. Although he did not hear or see anything out of the ordinary, Héctor had a sense

Generalized Anxiety Disorder 201

that he was in danger, so he took a number of precau- tionary steps: He took his headphones off, crossed the street to be in an environment with more lighting, and called his roommate on his cell phone. The next morn- ing, Héctor read that there was a mugging the previous night on campus, and he was convinced that the fear signals he received protected him from being a victim. The therapist provided an example of the consequences of ignoring the messages our emotions provide.

THERAPIST: Imagine you are experiencing sadness and disappointment because your current job is not ful- filling. That sadness is uncomfortable, so you natu- rally want to get rid of it. You might spend your eve- nings zoning out watching television alone, trying to “relax,” or you might start staying out late at night with friends, drinking and trying to have a good time, so you don’t notice that you’re feeling sad in that area of your life. You might start finding reasons to miss work or start daydreaming when you’re at work. These strategies are all aimed at reducing your sadness. And they might work in the short term, but none of them resolves the problem. What is worse is that those strategies might even create new problems as you start sleeping less, doing less well at work, and running into more conflicts at work. Even though you are doing everything you can to avoid feeling sad, the sadness is there for a reason. The first step to moving forward in that situation is noticing that you are feeling sad and recognizing that your work situ- ation is eliciting these emotions. Only then can you decide what actions to take.

HÉCTOR: That makes sense. But what about the fear I feel when I think about asking a classmate to study with me?

THERAPIST: What do you think your fear is telling you in that situation?

HÉCTOR: That he might think up some excuse to reject me and say no.

THERAPIST: Absolutely. As humans we are hardwired to seek social support and approval. It can absolutely be risky to put ourselves out there to be accepted or rejected. But here is the thing. While it is impor- tant to acknowledge the message our emotions are sending, we don’t always have to follow their advice. Emotions are associated with action tendencies— when we feel fear, we are prepared to flee, when we feel anger, we are prepared to fight. But our emotions

don’t actually control our behavior. And often when we consider taking an action that could be really meaningful—opening up and appearing vulnerable to someone or taking on an academic challenge— our emotions will warn us that such a step is risky. In these cases, we need to acknowledge the message we are receiving, yet we can still choose to take the values-based action.

HÉCTOR: I guess that makes sense. I certainly knew that moving away from my family and starting medi- cal school was risky. I felt a lot of fear, but I did it anyway, because it is important to my family that I succeed. My abuela [grandmother] always says courage is acting with heart. Being afraid, but doing something anyway, because of love or passion.

However, Héctor also struggled a bit as he tried to determine the function of his emotions in some other contexts.

HÉCTOR: I can see how emotions sometimes can serve a function. But other times the function seems much less clear to me. For example, I know a little test anxiety can be helpful and motivating, but why do I feel terrified some nights when I am studying. I get so scared and anxious that I become paralyzed. My problem is that most of the time I am confused by my emotions and their intensity.

THERAPIST: We make the distinction between what we call “clear” and “muddy” emotions. Clear emotions refer to when we have a very strong emotional re- sponse to a particular situation; for instance, we feel strong fear when a car approaches us on the street, which is what we might call a “clear” emotional re- sponse. Emotions that are complex, confusing, or too intense and long-lasting for the situation are what we call “muddy.”

Together, Héctor and his therapist reviewed how fail- ures in self-care (e.g., not getting enough sleep or eating well, not exercising regularly) increase the likelihood of muddy emotions. They also considered ways that worry (which involves the ability to imagine things that have not yet happened) and rumination (which involves re- peatedly remembering past events) both can elicit emo- tions that are not at all related to whatever is unfolding in the present moment. Finally, they discussed the way our “reactions to our reactions” can muddy our emo- tional responses.

202 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

“Another thing that can make our emotions confusing and muddied is that often when we have an emotion- al response, we don’t just have that one response—we have a series of responses that are triggered by that first emotion. For instance, we may feel scared, then angry that we got scared, then afraid the feeling will grow stronger, then ashamed that we are afraid, and so on. We may also have thoughts that come up as responses to a clear emotion, such as ‘I shouldn’t feel this way,’ ‘This is a sign that I am a weak person.’ One reaction that we often have is to try to control emotional responses. We will talk more about that in the next session. Finally, emotional responses can also seem much more intense when we start to feel defined by our emotions—when we see them as stable traits that represent our personality rather than natural human responses to events that come and go.”

Normally, Session 3 would end with a review of the first completed writing assignment (i.e., writing about how anxiety and worry interferes with relationships, work–school–household management, and self-nour- ishment and community involvement). However, Héc- tor admitted that he had not finished it. He noted that it had been a busy week with exams and that he found it hard to set aside time for himself. Together, Héctor and his therapist brainstormed ways he could schedule in the values writing. However, she also noted that sitting down and considering the ways that anxiety is interfer- ing with the things that matter most could be a very painful exercise. The therapist suggested that Héctor recognize that the pain served a function (letting Héc- tor know that changes were needed for him to live a more personally fulfilling life), and she pointed out that seeking therapy was a sign that he acknowledged that pain and was willing to make some changes. The thera- pist also gave Héctor new monitoring forms that added a column for emotions, so he could begin to monitor his emotional responses in addition to his worry.

Session 4

Héctor presented to Session 4 visibly upset. He had just returned from a visit back home to Miami, and he was extremely upset over his interactions with his brother. As he began to describe the situation, the therapist gen- tly interrupted.

“Excuse me for interrupting you, Héctor, but I have an important question. I can tell this visit was very

upsetting for you, and we will be sure to devote a good part of today’s session to talking about it. But if you are willing, I would like us to start out our ses- sion as we always do, with a brief mindfulness prac- tice. It can really be challenging to practice when you are experiencing a lot of emotions and thoughts, yet it can also be extremely helpful. If you are willing, I would like us to start by becoming aware of the physical sensations we are currently experiencing. I would like to hear about your visit, and then there is another mindfulness exercise that might help us fur- ther explore what you are feeling right now. Would that be all right with you?”

Héctor agreed, and the therapist introduced a mind- fulness exercise that involved increasing awareness of physical sensations. During the debriefing of the prac- tice, Héctor admitted that he found it particularly chal- lenging to keep redirecting his attention from images of his visit to his physical sensations in the moment. However, he noted that it became easier over time. The therapist remarked that Héctor seemed more centered than he had when he first walked in. Héctor replied that he did feel more present and ready to discuss his concerns.

THERAPIST: Did you use your monitoring sheet this weekend to help you work through some of the chal- lenges that arose during your visit home?

HÉCTOR: Absolutely, I was so upset that I needed to get my thoughts down on paper. As I wrote here, on Saturday, when I was at my parent’s house but only my brother and his sons were home, I was flooded with worries. My nephews used to be such sweet little boys, but now they will barely make eye contact with me when I greet them. They spend all their time glued to their electronic devices playing violent video games. And my brother completely ignores them— all he wants to do is talk to me about his latest dating adventures.

THERAPIST: Did you notice the specific worries you were experiencing?

HÉCTOR: Yes, I wrote I am worried that my brother and nephews are too much for my mother to handle. I am worried that they are draining her health and finances. I am worried that my nephews will not get a good education, and that they will get involved in the wrong crowd. And I am worried my brother is drinking too much and that he is too selfish.

Generalized Anxiety Disorder 203

THERAPIST: Good job observing your responses. How about your emotions? Were you able to identify what emotion or emotions were present?

HÉCTOR: I was very upset. Mostly angry, I think. I don’t know—this is one of those situations where I felt confused about my feelings.

The therapist suggested that Héctor try a mindful- ness practice aimed at observing his emotional respons- es. She asked him to close his eyes and vividly imagine his interaction with his brother, and she instructed him to notice visual and auditory stimuli, to focus on the physical sensations in his body, to bring his attention to the thoughts running through his mind and finally to his emotions. She reminded him simply to notice his experience, bringing curiousness and compassion to what he was experiencing, observing what happened when he was feeling strong emotions, without altering or judging them. She reminded him to notice whether more than one emotion was present, and to observe any rise and fall in his emotions. After several moments, she asked him to open his eyes.

THERAPIST: What did you notice? HÉCTOR: At first, all I felt was angry. Then I noticed

I was feeling afraid. But what really surprised me is that I felt extremely sad. It’s interesting because at the time I thought I was just straight up angry, but thinking back on it I noticed that my emotions seemed to ebb and flow. I guess another thing that was interesting is that I started out just feeling the emotions. But throughout the exercise I started to notice I was observing them. It was really helpful to get some distance—before that I think I just felt con- sumed with emotion.

THERAPIST: Great observations. Tell me a bit more about your responses to those emotions. And any thoughts you have about their function.

HÉCTOR: I think I felt angry, because I disagree with how my brother is raising his sons. But then I got mad at myself for feeling angry. My brother hasn’t had the opportunities that I have. Thinking about that made me feel guilty.

THERAPIST: Did you notice any responses to your feel- ings of guilt?

HÉCTOR: I hate feeling guilty. It feels like a tremendous weight on my chest. I think I tried to distract myself from that feeling and then I just started imagining

all the problems that could result from my brother’s screwups and I got consumed with fear and worry. But then, when you prompted me, I returned back to observing my emotions. And then the more I focused on my emotions, I started to realize I felt really, re- ally sad. But what was interesting was I think I just accepted it was a sad situation. Usually I can’t stand feeling sad. I am afraid it means I am going to get depressed and retreat into my own world. But I think I recognized that this is just a sad situation. I miss my family. I wish I could fix my brother’s problems, but I can’t.

The therapist tied Héctor’s experience to the topic of clear and muddy emotions. She pointed out that anger is a natural response that arises when someone acts against your wishes. And sadness is a normal re- sponse to a painful situation. She also helped Héctor identify why his anger was initially so intense. In addi- tion to being angry about the situation on Saturday, he was also having anger about the many times in the past when his brother upset him. Héctor was also imagining that his brother would continue to “screw up,” which further fueled his anger. The “reactions to reactions” Héctor experienced also increased the intensity of his response. For example, when Héctor judged the feeling of anger as unacceptable, he started to feel guilty. And when the feeling of guilt was too painful, he distracted himself with multiple worries about the future.

Next, the therapist spent some time on the main concept of the session—the limits and consequence of internal control efforts. She asked Héctor to engage in a number of experiential exercises aimed at demonstrat- ing the often paradoxical effects of efforts to control internal experiences such as thoughts, emotions, and images. For example, the therapist asked Héctor to imagine that he “had to get a good night’s sleep” before a big test. She asked him what might happen if, alarmed by the late hour, he purposefully tried to induce a state of sleepiness. Héctor noted that this frequently hap- pened, and the more he tried, the more distressed and awake he became.

Finally, the therapist spent some time going over Héctor’s values assignment. Héctor easily identified many ways in which his anxiety was interfering with school and work. He noted that it was harder and hard- er to concentrate both during class and while doing his homework, because his mind was consumed with wor- ries—worries about failing class, about letting down his family, and about his family’s health and well-being.

204 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Héctor also noted that when his anxiety about his fam- ily became too intense, he would call or plan a visit with them. But he found that when he did make the time to talk with or be with his family, he was consumed with worry about the time he was taking away from his schoolwork. Héctor wrote about his fear that he would never find a life partner. He was far too busy with school and his family to date, and he believed it was his destiny to end up alone. He was terrified about this possibility because he described himself as extremely family-oriented.

As the session ended, the therapist gave Héctor a monitoring form that added a column for “efforts to control,” so that he could begin to notice these as they occurred throughout the week. She also provided for Héctor a second values assignment to complete for the next session. The therapist noted that often our at- tempts to avoid anxiety, worry, and stress cause us to make subtle shifts in our behavior, so that we begin doing whatever we are “supposed” to be doing and lose track of what we want to be doing, or what personally matters to us as individuals. She reviewed the distinc- tion between values and goals, emphasizing the impor- tance of identifying the direction that Héctor wants to move in rather than solely the goals to achieve. The therapist noted that this next assignment was aimed at further exploring three areas of living to see what changes might be necessary to improve Héctor’s quality of life.

“Choose two or three relationships that are important to you. You can either pick actual relationships (your relationship with your brother) or relationships you would like to have (“I would like to be part of a cou- ple,” “I would like to make more friends”). Briefly write about how you would like to be in those rela- tionships. Think about how you would like to com- municate with others (e.g., how open vs. private you would like to be, how direct vs. passive you would like to be in asking for what you need and in giving feedback to others). Think about what sort of sup- port you would like from other people and what sort of support you can give without sacrificing your own self-care. I also would like you to write briefly about the sort of work you would like and why that appeals to you. Next write about the student you would like to be with respect to your work habits and your re- lationships with your professors and peers. What is important to you about the product of your work/ studies? How would you like to communicate to others

about your work? How would you like to respond to feedback? What additional challenges would you like to take on? Finally, I would like you to briefly write about the ways in which you would like to spend your free time. What would you like to do to better nourish yourself (e.g., nutrition, exercise, spirituality) or contribute to your community?”

Sessions 5–7

In Sessions 5–7 of treatment, the focus is on encourag- ing the client to consider moving from a stance of re- sistance and avoidance to one of willingness. A number of mindfulness and other experiential exercises are used to help clients practice observing their thoughts, emo- tions, and physical sensations as transient events. For example, Héctor practiced imagining that his thoughts and feelings were going by on a movie screen in front of him. Once clients are able to defuse or decenter from their internal experiences, and they no longer feel de- fined or threatened by them, they are often more will- ing to approach and engage in a variety of activities.

Like many clients, Héctor initially struggled a bit with the concept of willingness. At first Héctor thought the therapist was suggesting that he should come to view his anxiety in a more positive light. Or that he should learn to accept his anxiety because it was what a “strong man” needed to do. Using a metaphor adapted from ACT, his therapist tried to clarify the concept of willingness, likening it to one’s willingness to wade through a swamp on a journey to a beautiful mountain.

“Taking a stance of willingness suggests that you will accept and move forward with the thoughts and feel- ings (rational or irrational) that appear as you make your way through life, taking the actions that will help you obtain the things in life that you value. For instance, let’s say that you want to ask your class- mates if you can join their study group. To do so will likely elicit feelings of fear, thoughts about possible rejection. However, you can be willing to experience those thoughts and feelings, if they are what arise when you take actions consistent with your value to engage in your schoolwork. You may not like the feelings, you may wish it could be another way, but you can be willing to experience whatever comes up in order to take a values-based action.

“It is as if you are on a journey to a beautiful mountain. But along the way you come to a disgust- ing, murky swamp. You don’t want to walk through

Generalized Anxiety Disorder 205

the swamp, and it may not seem fair that you need to do so. But you can choose to walk through if you decide that the journey to the mountain is worth it to you.

“Now if the swamp is to the side of your path, you do not necessarily need to go through it. And, you don’t have to dive into the swamp and roll around in it. And you can put on boots, or walk across a plank, in an effort to avoid getting dirty. Yet you might still trip and fall in the swamp, and willingness means you accept that possibility as you move forward on the journey of your choosing.”

Several values assignments are used to help clients set their course or mountain “journey.” As noted earlier, Héctor was asked to write about his values in three spe- cific domains. This can be a challenging assignment, and often clients confuse values with goals, describe values that suggest the need for control or perfection, or focus on what they perceive to be insurmountable obstacles to living consistently with their values. Thus, often, several sessions are devoted to discussing the values assignment, and it is not uncommon for clients to revise their values multiple times in session and for homework. For example, Héctor’s initial writing assign- ment produced some values that could have been prob- lematic for him to pursue.

HÉCTOR: My value in the schoolwork domain is to achieve the highest grades in all of my coursework. I want to be the top student in my graduating class, so that I can make my family proud.

THERAPIST: Would aiming to receive a perfect score on an exam be an example of a value or a goal?

HÉCTOR: Right, grades are outcomes, so I guess those are goals.

THERAPIST: Imagine that you are working as a physi- cian. You are surfing the Internet and you stumble upon a webpage where patients rate, and leave com- ments about, their doctor. What would you want the page to say? My doctor scores well on standardized tests?

HÉCTOR: (chuckling) Well, no. I guess I would want them to say that I was caring and compassionate. And that I was willing to stick with a health problem until I came up with the right diagnosis and the best treatment I could provide.

THERAPIST: Great, those sound a bit more like values.

So, would it be fair to say you want to be engaged with the material you are learning? And that you want to be bring kindness and compassion to your interactions with patients and commit to learning what you can to help improve their health?

HÉCTOR: Yes, that is what I value. I keep thinking my grades matter most, but I know in my heart that is not why I am in medical school. I am not here to impress my instructors and classmates. I want to be a doctor who brings care and commitment to improv- ing the health of my patients.

Héctor also struggled a bit with articulating his rela- tionship values:

HÉCTOR: I wrote that I always wanted to be available to my mother, whenever she needed me. I want to be her rock. I get so angry at myself when I am too tired to return her phone calls at night. Or when she needs something to be fixed, like the leaky faucet in the kitchen, and I can’t take care of it because I am here in Boston and she is in Miami. Also, I feel bad when she is lonely. I want to prevent her from having to experience any more pain than she already has.

THERAPIST: I know you care deeply for your mother. And I can completely understand your desire to do all you can for her. And yet, much like it is humanly impossible to prevent yourself from feeling emo- tions, I think it is humanly impossible to ensure that our loved ones are never in pain or in need. Even if you dropped out of medical school and moved back home, there are limits to what you can do for her. And that can be a very difficult and painful thing to accept. It sounds to me like the value is that you want to maintain a strong, caring relationship with your mother. Would you agree?

HÉCTOR: Absolutely. THERAPIST: And fixing a faucet and returning a call

are actions that are consistent with those values. Are there other actions you can take that reflect your val- ues? In other words, if you are in Boston and she is in Miami, can you care for her without fixing her faucet?

HÉCTOR: Well, I could talk to her about it. She appre- ciates when I listen to her vent about her problems.

THERAPIST: Great, what else? HÉCTOR: I guess I could call a repair person for her. Or

ask my brother to help.

206 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: Wonderful. The point is, there are many actions one can take that are consistent with a value. If we define values-based action as just one or two responses, and for whatever reason, we can’t respond in those ways, we can end up feeling stuck and mis- erable. Living consistently with one’s values means flexibly considering multiple options to act in ways that are meaningful to us.

Héctor also struggled with articulating his values in relation to his brother and nephews:

HÉCTOR: I want to be close to my brother and his sons, but I can’t. It doesn’t matter how I treat them, they are selfish, and they never want to spend time with me.

THERAPIST: One of the most complicated things about relationship values is that we only have control over half of the relationship. You cannot control how your brother acts; you can only choose how you want to approach him.

HÉCTOR: Are you saying I should just let my brother live his life the way he currently does? Allow him to raise his sons to be disrespectful and rude?

THERAPIST: It is so painful for you to watch your brother make choices that are inconsistent with your values. And I know if you could control his behavior, you would. It seems like you keep trying and try- ing to figure out how to control a situation that just might be out of your control. Sometimes mindful- ness skills can help us to clearly accept the reality of a situation. And by “accept” I mean recognize the real- ity of the situation—I don’t mean that you should like or support his approach. But you may need to accept the reality that you only have control over some parts of this very painful situation. It seems to me that you can control how you choose to define your values regarding how you relate to your brother. But you can’t control his behavior. If you act lovingly toward him and try to establish a close relationship, your brother may respond in kind. And that bond might allow you to talk with him about your par- enting concerns. Or you might end up with a closer relationship and he could continue with his current habits. Or he may completely reject your efforts to become closer. Choosing our actions is like aiming an arrow. We can make choices about how we aim and when we release the arrow. We don’t have control over where the arrow lands. However, we may notice

where it lands and use that information to inform the way we aim or when we shoot the next time. In a similar way, we can choose the actions we want to take repeatedly, although we don’t have control over the consequences of our actions.

Héctor continued to work on defining his values, until he felt that he could clearly articulate what mat- tered to him in the domains of relationship, school- work, self-nourishment, and community involvement. Although it is necessary for clients to achieve this mile- stone, so that they can move into the next phase of treatment, it is important to recognize that values artic- ulation is a dynamic process. Having defined values is helpful in guiding the final nine sessions of treatment, but what is most important is for clients to adopt the general perspective that valuing can provide a compass for directing behavior and improving quality of life.

During these sessions, Héctor was given a final ver- sion of the monitoring form that represented an ap- plication of the full model. This included columns for date/time, situation, first reactions (thoughts, feelings, sensations), second reactions (efforts to control, mud- diness, willingness, acceptance), and actions/responses (e.g., avoidance, values-based actions, application of mindfulness skills).

Sessions 8–12

The goal of Sessions 8–12 was to personalize the con- cepts introduced in the first phase of treatment and help Héctor to apply mindfulness and engagement in valued activities to his daily life. At the beginning of each ses- sion, Héctor and the therapist worked together to pick a mindfulness practice. Each week they purposely chose exercises, including ones that Héctor found particularly challenging, those he found most useful, and those that seemed to best fit his needs given the particular struggle he was facing (see Table 5.1).

The bulk of these sessions used the mindfulness and acceptance strategies introduced during Phase I to in- crease Héctor’s willingness to engage in his personally articulated values-based actions. Héctor continued to monitor values-based actions taken, missed opportuni- ties, mindfulness, and obstacles to willingness (see Fig- ure 5.1).

For example, in Session 10, Héctor shared that he had missed an opportunity to engage in a valued ac- tion. Specifically, one of his favorite instructors had offered to meet with Héctor to discuss the process of

Generalized Anxiety Disorder 207

TABLE 5.1. Choosing a Mindfulness Practice

Title Focus of attention How it can be helpful Where to find it

Mindfulness of Breath Breath • Portable • Can be centering • Great introduction to the habits of the mind

(busy, judgmental)

MP3 available onlinea; Kabat-Zinn (1990); Roemer & Orsillo (2020); Orsillo & Roemer (2011)

Mindfulness of Sounds Sounds • Helps us to notice our tendency to categorize/ judge

• Allows us to practice “beginner’s mind”— seeing things fully as they are, not as we imagine they will be

MP3 available online; Segal et al. (2002); Orsillo & Roemer (2011)

3-Minute Breathing Space

Physical sensations (including breath), thoughts, emotions

• Helps us get centered and present when moving from one activity to another

• Useful when we want to “check in” with ourselves

Segal et al. (2002); Roemer & Orsillo (2020); Orsillo & Roemer (2011)

Mindfulness of Physical Sensations

Physical sensations • Good practice for bringing curiosity and compassion to physical sensations that are typically feared and avoided

• Brings awareness to sensations in the body, without judgment or avoidance

MP3 available online; Orsillo & Roemer (2011)

Mindful Progressive Relaxation

Muscle tension/ relaxation

• Increases awareness of the sensations of tension and relaxation

• Concrete way to practice “letting go” • May elicit a relaxed state

MP3 available online; Orsillo & Roemer (2011)

Mindfulness of Emotions and Physical Sensations

Emotions and/ or accompanying physical sensations

• Increases awareness of the full range of emotions present

• Helpful when generally distressed or confused • Useful for evaluating clear and muddy

emotions

MP3 available online; Orsillo & Roemer (2011)

Mindfulness of Clouds and Sky

Thoughts and feelings, imagery

• Allows practice of viewing thoughts and feelings as transient and separate from self

• Helps with decentering/defusion

MP3 available online; Roemer & Orsillo (2020); Orsillo & Roemer (2011)

Inviting a Difficulty In and Working It through the Body

Physical sensations related to painful experience

• Helps to cultivate willingness to experience painful emotions

• Useful first step when a client is struggling against accepting a painful reality

MP3 available online; Williams et al. (2007); Roemer & Orsillo (2020); Orsillo & Roemer (2011)

Your Personal Experience with Self-Compassion/ Mindful Observation of Self-Critical Thoughts

Self-critical thoughts • Brings awareness to experiences of criticism in the past and the present

• Helps to identify barriers to self-compassion

MP3 available online; Orsillo & Roemer (2011)

Mountain Meditation Mountain imagery—transience of events external to the mountain

• Uses the image of a mountain to promote the experience of thoughts, feelings, and emotions as changing and impermanent

• Particularly helpful for cultivating a sense of inner strength or stability, even in the face of distress and reactivity

MP3 available online; Kabat-Zinn (1995); Orsillo & Roemer (2011)

aAt www.mindfulwaythroughanxiety.com.

208 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

selecting rotations, but Héctor had cancelled the ap- pointment.

THERAPIST: What did you notice about your response to his offer?

HÉCTOR: At first, I was excited, but as time went on, I became more and more anxious.

THERAPIST: Can you identify the clear emotions that arose?

HÉCTOR: I actually used the mindfulness of emotion exercise to sort this out a bit. I felt excited about tak- ing the next step in my education, happy that my instructor singled me out, and nervous about the challenges that lie ahead for me in my career.

THERAPIST: Excellent. Were you also able to observe your reaction to your reactions?

HÉCTOR: Honestly, not until today. I think at the time I just got caught up in my reactions rather than observ- ing them. But during the mindfulness practice today,

I noticed some of the same old responses I always have. I was afraid to feel good about myself, and my pros- pects for the future. I had that same sense that worry- ing about what could go wrong was what I needed to do to ensure that I don’t mess up. I also became pretty critical and judgmental about my anxiety.

THERAPIST: What do you think you could have done differently?

HÉCTOR: I have become kind of lax when it comes to filling out the monitoring forms. But I was think- ing about what you said last week. I do think that the process of physically completing the form in the midst of my distress can help me to take a pause . . . and remember some of my skills.

Session 11 brought a more challenging issue into therapy. Héctor was extremely distressed over an inter- action he had with a university security officer. Héctor was on his way back home from a long night studying when he was approached by a security officer and asked

VALUED ACTIVITY LOG

Please complete this form at the end of each day.

This week, at the end of each day we would like you to think about an action that you took that was consistent with one of your values or an opportunity that you missed to take an action consistent with your value. Briefly describe the action and mark T for taken or M for missed.

On a scale of 0–100 rate how mindful you were during the action or the missed opportunity.

Note any obstacles that you noticed that stopped you from taking action (or could have).

There are no right or wrong answers to this assignment—we all choose not to engage in valued actions for a variety of reasons. This is just a way for us to start to get a better sense of what may be getting in the way for you so that you can make choices as to how you would like to proceed.

Date Action Taken (T) or missed (M)

Mindfulness (0–100) Obstacles

FIGURE 5.1. Values Monitoring Form.

Generalized Anxiety Disorder 209

to produce his university identification card. Although it was close to midnight, Héctor observed at least five other students crossing the campus, yet he was the only one who was questioned. Héctor was already sensitive to the fact that he had been the only person of color in the library that night. He was stressed out over exams, missing his family and friends, and frankly tired of dealing with the subtle and obvious discrimination he encountered on a daily basis. Thus, he refused to pro- duce his identification card and reported that he “lost” it, and he shouted at the officer. Although the situation was eventually sorted out, Héctor was angry, embar- rassed over his behavior in the situation, and confused.

HÉCTOR: I am really struggling with this incident. My mind is racing, I feel tense all over, and I can’t sort out what is clear and what is muddy and, more im- portantly, what valued action I could have chosen.

THERAPIST: It is natural to experience a rush of con- flicting thoughts and emotions in such a painful en- counter. I am so sorry that given the racism inherent in our society, you are subjected to differential treat- ment because of how you look. This structural prob- lem exists outside of you and isn’t your fault. And I really understand how the pain and the anger can build up when you have to deal with things like this all the time. I certainly don’t want to suggest that you have to change who you are, when the system needs changing. However, if you think it would be helpful, I would like to try to work with you to find the least painful, most effective, values consistent way for you to respond when you are confronted with racism, be- cause, unfortunately, it is something you encounter in your daily life. If you are willing, a mindfulness practice might help us gain some clarity.

HÉCTOR: I don’t feel very open right now, but I do think it’s important for me to work on this. “Invit- ing a Difficulty In and Working with It through the Body” [see Figure 5.2] could be a first step.

Following the exercise, Héctor appeared more set- tled, although he also had tears in his eyes.

THERAPIST: What did you notice? HÉCTOR: It was pretty easy to locate the tension—it

was in the pit of my stomach. But I really struggled with opening up to it. My first response was “I don’t want to let go off the struggle against racism. Why

should I accept it?” But then I remembered the last time we did this exercise. And I reminded myself that I only had to be open to the present moment. I remembered that acceptance didn’t mean resigning myself to a situation. Instead, I focused on accepting that the incident had occurred and that I was rigidly holding tension in my body.

THERAPIST: I am really impressed that you were able to do that. What happened next?

HÉCTOR: I continued to breathe into my stomach and I worked on letting go of my tension. Once my body became more relaxed, I turned my attention to my thoughts about the incident.

THERAPIST: And what did you observe? HÉCTOR: I had thoughts about racism and how unjust

it is for people to be treated differently based on their appearance. I felt angry, which I think was a clear emotion, but then I started to feel ashamed of my behavior.

THERAPIST: Was that reaction clear or muddy? HÉCTOR: Well, I think a bit of both. I definitely was

able to bring some compassion to myself. No one wants to be treated differently based on their appear- ance.

THERAPIST: That is great. I know it is not easy for you to take a compassionate stance toward your thoughts and actions. What do you think was clear about the response?

HÉCTOR: I am ashamed of my behavior. It is inconsis- tent with my values to treat anyone the way I treated that officer, even if they deserve it. Frankly, I don’t care what he thinks of me, but I care what I think about myself.

THERAPIST: It sounds like you said and did some things that were inconsistent with your values and you were able to bring some compassion to yourself for that. This was a highly charged situation, and you were vulnerable going into it. In this moment, are there any values-based actions that come to mind?

HÉCTOR: This incident made me realize that my values have been a bit too off balance lately. I have been pay- ing a lot of attention to the schoolwork domain and a pretty good amount of attention to the relationship domain, but I think I need to take some actions con- sistent with my values regarding self-nourishment and community. At the beginning of the semester I

210 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

grabbed a flyer for the Latinx Medical Student As- sociation, and I think I am going to contact them to see if there are some activities I can get involved with.

THERAPIST: That sounds great. HÉCTOR: I also think I might try and meet with some-

one from campus security. I think I want to apolo- gize for my behavior, but I also want to talk to them about cultural sensitivity training. And don’t worry, I didn’t forget about the arrow thing we talked about a few weeks ago. I can only aim the arrow; I can’t control where it lands. I know I might not change their practices, but these actions are consistent with my values.

Sessions 13–16

Héctor completed a treatment reflection writing assign- ment that set the stage for the final four sessions of thera- py. He identified a few specific values-based actions that he wanted to take before the end of therapy. He also rec- ognized that although he was maintaining a pretty steady formal mindfulness practice, he had paid less attention to informal mindfulness. Héctor also had made great gains in increasing his self-compassion, but he felt that he need- ed more practice while he still had the support of therapy.

Thus, Sessions 13–15 continued to follow the struc- ture of Sessions 8–12, but with added attention to is- sues of maintenance. The therapist became less and less

Before you begin this exercise, think of a difficulty you’re experiencing right now. It doesn’t have to be a significant difficulty, but choose something that you find unpleasant, something that is unresolved. It may be something you are worried about, an argument or misunderstanding you’ve had, something you feel angry, resentful, guilty, or frustrated about. If nothing is going on right now, think of some time in the recent past when you felt scared, worried, frustrated, resentful, angry, or guilty, and use that. Noticing the way you are sitting in the chair or on the floor. Noticing where your body is touching the chair or floor. Bringing you attention to your breath for a moment. Noticing the in-breath . . . and the out- breath. . . . Now gently widening your awareness, take in the body as a whole. Noticing any sensations that arise, breathing with your whole body. When you are ready, bringing to mind whatever situation has been bringing up difficult emotions for you. Bringing your attention to the specific emotions that arise and any reactions you have to those emotions. And as you are focusing on this troubling situation and your emotional reaction, allowing yourself to tune in to any physical sensations in the body that you notice are arising . . . becoming aware of those physical sensations . . . and then deliberately, but gently, directing your focus of attention to the region of the body where the sensations are the strongest in the gesture of an embrace, a welcoming . . . noticing that this is how it is right now . . . and breathing into that part of the body on the in-breath and breathing out from that region on the out-breath, exploring the sensations, watching their intensity shift up and down from one moment to the next. Now, seeing if you can bring to this attention an even deeper attitude of compassion and openness to whatever sensations, thoughts, or emotions you are experiencing, however unpleasant, by saying to yourself from time to time, “It’s OK. Whatever it is, it’s already here. Let me open to it.” Staying with the awareness of these internal sensations, breathing with them, accepting them, letting them be, and allowing them to be just as they are. Saying to yourself again, if you find it helpful, “It’s here right now. Whatever it is, it’s already here. Let me be open to it.” Softening and opening to the sensation you become aware of, letting go of any tensing and bracing. If you like, you can also experiment with holding in awareness both the sensations of the body and the feeling of the breath moving in and out as you breathe with the sensations moment by moment. And when you notice that the bodily sensations are no longer pulling your attention to the same degree, simply return 100% to the breath and continue with that as the primary object of attention. And then gently bringing your awareness to the way you are sitting in the chair, your breath, and, when you are ready, opening your eyes.

FIGURE 5.2. Inviting a difficulty in and working with it through the body. Adapted from Williams, Teasdale, Segal, and Kabat-Zinn (2007, pp. 151–152). Copyright © 2007 The Guilford Press. Adapted by permission.

Generalized Anxiety Disorder 211

directive throughout this time, allowing Héctor to ad- dress obstacles and experience success himself. During this time, Hector began to date and expand his social network, feel more satisfied with his relationships with his family members, and find more success and satisfac- tion in his schoolwork.

During the final session, the therapist predicted that there would be times when Héctor would feel over- whelmed by emotion, drift away from his mindfulness practice, and lose sight of his values, despite all the no- table gains he reported. She described these “lapses” as a natural part of the process of life and helped Héctor to make plans for how to cope. Specifically, she sug- gested that he review the handouts in his binder, begin self-monitoring again, increase or reengage in mindful- ness practice, and consider doing some values writing. The therapist and Héctor collaboratively developed a personalized list of elements that were particularly help- ful for him and added that list to his binder. Héctor expressed sadness at saying good-bye to his therapist, and also excitement at feeling able to continue his prog- ress on his own and use the time allocated to therapy to engage in other values-based actions moving forward.

CONCLUSION

Evidence suggests that this ABBT for GAD can target symptoms of GAD, comorbid presenting problems, and proposed mechanisms that underlie these clinical pre- sentations, while helping clients to engage in their lives in satisfying ways. We have presented in this chapter a conceptual basis for this treatment, as well as guidelines for its flexible application, while remaining responsive to the specific context of a given client. More research is needed to better understand mechanisms and processes of change, as well as how to disseminate this treatment in community and primary care settings.

ACKNOWLEDGMENTS

We thank the therapists, students, and clients we have worked with over the years for all they have taught us, as well as Na- tional Institutes of Health for funding our work (Grant No. MH074589). We also thank Dave Barlow, Tim Brown, Bon- nie Brown, and the staff at the Center for Anxiety and Re- lated Disorders for supporting our treatment research. We dedicate this chapter to Tom Borkovec, whose seminal work in the treatment of GAD is the sturdy foundation on which our work stands.

NOTE

1. Audio recordings of this exercise, as well as other mind- fulness exercises we use, are available at www.mindfulway- throughanxiety.com. Scripts for many of these mindfulness exercises are available in Orsillo and Roemer (2011, 2016) and Roemer and Orsillo (2020).

REFERENCES

American Psychiatric Association. (2013). Diagnostic and sta- tistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Andrews, G., Hobbs, M. J., Borkovec, T. D., Beesdo, K., Craske, M. G., Heimberg, R. G., et al. (2010). Generalized worry disorder: A review of DSM-IV generalized anxiety disorder and options for DSM-V. Depression and Anxiety, 27(2), 134–147.

Arbid, N. (2020, November). A culturally adapted mindfulness and acceptance-based stress management prevention work- shop for Latinx students. Paper presented at the 54th annual meeting of the Association for Behavioral and Cognitive Therapies, Philadelphia, PA.

Arch, J. J., Eifert, G. H., Davies, C., Vilardaga, J. C. P., Rose, R. D., & Craske, M. G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disor- ders. Journal of Consulting and Clinical Psychology, 80(5), 750–765.

Baldwin, D. S., Allgulander, C., Bandelow, B., Ferre, F., & Pallanti, S. (2012). An international survey of reported prescribing practice in the treatment of patients with gen- eralized anxiety disorder. World Journal of Biological Psy- chiatry, 13(7), 510–516.

Baldwin, D. S., Hou, R., Gordon, R., Huneke, N. T. M., & Garner, M. (2017). Pharmacotherapy in generalized anxi- ety disorder: Novel experimental medicine models and emerging drug targets. CNS Drugs, 31(4), 307–317.

Ballenger, J. C., Davidson, J. R. T., Lecrubier, Y., Nutt, D. J., Borkovec, T. D., Rickels, K., et al. (2001). Consensus statement on generalized anxiety disorder from the Inter- national Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry, 62, 53–58.

Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of gen- eralized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23(8), 1011–1023.

Belanger, L., Ladouceur, R., & Morin, C. M. (2005). Gen- eralized anxiety disorder and health care use. Canadian Family Physician, 51(10), 1362–1363.

Berger, A., Edelsberg, J., Bollu, V., Alvir, J. M., Dugar, A., Joshi, A. V., et al. (2011). Healthcare utilization and costs in patients beginning pharmacotherapy for generalized

212 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

anxiety disorder: A retrospective cohort study. BMC Psy- chiatry, 11, 193.

Blevins, D., Roca, J. V., & Spencer, T. (2011). Life guard: Evaluation of an ACT-based workshop to facilitate rein- tegration of OIF/OEF veterans. Professional Psychology: Research and Practice, 42(1), 32–39.

Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., et al. (2011). Preliminary psy- chometric properties of the Acceptance and Action Ques- tionnaire–II: A revised measure of psychological inflex- ibility and experiential avoidance. Behavior Therapy, 42, 676–688.

Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoid- ance theory of worry and generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.), Gen- eralized anxiety disorder: Advances in research and practice (pp. 77–108). New York: Guilford Press.

Borkovec, T. D., & Costello, E. (1993). Efficacy of applied relaxation and cognitive-behavioral therapy in the treat- ment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 61(4), 611–619.

Borkovec, T. D., & Hu, S. (1990). The effect of worry on cardiovascular response to phobic imagery. Behaviour Re- search and Therapy, 28(1), 69–73.

Borkovec, T. D., & Roemer, L. (1995). Perceived functions of worry among generalized anxiety disorder subjects: Dis- traction from more emotionally distressing topics? Journal of Behavior Therapy and Experimental Psychiatry, 26(1), 25–30.

Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. Journal of Clinical Psychiatry, 62, 37–42.

Borkovec, T. D., & Sharpless, B. (2004). Generalized anxiety disorder: Bringing cognitive-behavioral therapy into the valued present. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp.  209–242). New York: Guilford Press.

Brown, L. A., Forman, E. M., Herbert, J. D., Hoffman, K. L., Yuen, E. K., & Goetter, E. M. (2011). A randomized controlled trial of acceptance-based behavior therapy and cognitive therapy for test anxiety: A pilot study. Behavior Modification, 35(1), 31–53.

Brown, T. A., & Barlow, D. H. (2014). Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5)—Adult Version: Client Interview Schedule 5-Copy Set. New York: Oxford University Press.

Bruce, S. E., Machan, J. T., Dyck, I., & Keller, M. B. (2001). Infrequency of “pure” GAD: Impact of psychiatric comor- bidity on clinical course. Depression and Anxiety, 14(4), 219–225.

Calloway, A., Hayes-Skelton, S. A., Roemer, L., & Orsillo, S. (2017, April). Working alliance over time across an ac- ceptance-based behavioral therapy and applied relaxation for

clients with generalized anxiety disorder. Paper presented at the annual meeting of the Anxiety and Depression Asso- ciation of America, San Francisco, CA.

Chodron, P. (2007). Practicing peace in times of war. Boston: Shambhala.

Cisler, J. M., & Koster, E. H. W. (2010). Mechanisms of attentional biases towards threat in anxiety disorders: An integrative review. Clinical Psychology Review, 30(2), 203–216.

Covin, R., Ouimet, A. J., Seeds, P. M., & Dozois, D. J. A. (2008). A meta-analysis of CBT for pathological worry among clients with GAD. Journal of Anxiety Disorders, 22(1), 108–116.

Crouch, T. A., Lewis, J. A., Erickson, T. M., & Newman, M. G. (2017). Prospective investigation of the contrast avoid- ance model of generalized anxiety and worry. Behavior Therapy, 48(4), 544–556.

Cuijpers, P., Sijbrandij, M., Koole, S. Huibers, M., Berking, M., & Andersson, G. (2014). Psychological treatment of generalized anxiety disorder: A meta-analysis. Clinical Psy- chology Review, 34, 130–140.

Dahlin, M., Andersson, G., Magnusson, K., Johansson, T., Sjögren, J., Håkansson, A., et al. (2016). Internet-delivered acceptance-based behavior therapy for generalized anxiety disorder: A randomized controlled trial. Behavior Research and Therapy, 77, 86–95.

Danitz, S. B., & Orsillo, S. M. (2014). The mindful way through the semester: An investigation of the effective- ness of an acceptance-based behavioral therapy program on psychological wellness in first-year students. Behavior Modification, 38(4), 549–566.

Danitz, S. B., Suvak, M. K., & Orsillo, S. M. (2016). The mindful way through the semester: Evaluating the impact of integrating an acceptance-based behavioral program into a first-year experience course for undergraduates. Be- havior Therapy, 47(4), 487–499.

de Almeida Sampaio, T. P., Jorge, R. C., Martins, D. S., Gandarela, L. M., Hayes-Skelton, S., Bernik, M. A., et al. (2020, April 25). Efficacy of an acceptance-based group behavioral therapy for generalized anxiety disorder. De- pression and Anxiety. [Epub ahead of print]

Dugas, M. J., Brillon, P., Savard, P., Turcotte, J., Gaudet, A., Ladouceur, R., et al. (2010). A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. Behavior Thera- py, 41(1), 46–58.

Etkin, A., & Schatzberg, A. F. (2011). Common abnormali- ties and disorder-specific compensation during implicit regulation of emotional processing in generalized anxiety and major depressive disorders. American Journal of Psy- chiatry, 168(9), 968–978.

Eustis, E. H., Hayes-Skelton, S., Orsillo, S. M., & Roemer, L. (2016). Reductions in experiential avoidance as a media- tor of change in symptom outcome and quality of life in

Generalized Anxiety Disorder 213

acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder. Behaviour Research and Therapy, 87, 188–195.

Eustis, E. H., Hayes-Skelton, S. A., Orsillo, S. M., & Ro- emer, L. (2018). Surviving and Thriving During Stress: A randomized clinical trial comparing a brief web-based therapist assisted acceptance-based behavioral interven- tion versus waitlist control for college students. Behavior Therapy, 49, 889–903.

Eustis, E. H., Krill Williston, S., Morgan, L. P., Graham, J. R., Hayes-Skelton, S. A., & Roemer, L. (2017). Devel- opment, acceptability, and effectiveness of an acceptance- based behavioral stress/anxiety management workshop for university students. Cognitive and Behavioral Practice, 24, 174–186.

Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disor- ders, 22(4), 716–721.

Fuchs, C., Lee, J. K., Roemer, L., & Orsillo, S. M. (2013). Using mindfulness- and acceptance-based treatments with clients from nondominant and/or marginalized back- grounds: Clinical considerations, meta-analysis findings, and introduction to the special series. Cognitive and Behav- ioral Practice, 20(1), 1–12.

Fuchs, C. H., Haradhvala, N., Evans, D. R., Nash, J. M., Weisberg, R. B., & Uebelacker, L. A. (2016). Implemen- tation of an acceptance-and mindfulness-based group for depression and anxiety in primary care: Initial outcomes. Families, Systems, and Health, 34(4), 386–395.

Fuchs, C. H., West, L. M., Graham, J. R., Kalill, K. S., Mor- gan, L. P. K., Hayes-Skelton, S. A., et al. (2016). Reactions to an acceptance-based behavior therapy for GAD: Giv- ing voice to the experiences of clients from marginalized backgrounds. Cognitive Behavioral Practice, 23, 473–484.

Gámez, W., Chmielewski, M., Kotov, R., Ruggero, C., & Watson, D. (2011). Development of a measure of expe- riential avoidance: The Multidimensional Experiential Avoidance Questionnaire. Psychological Assessment, 23(3), 692–713.

Gentes, E. L., & Ruscio, A. M. (2011). A meta-analysis of the relation of intolerance of uncertainty to symptoms of gen- eralized anxiety disorder, major depressive disorder, and obsessive–compulsive disorder. Clinical Psychology Review, 31(6), 923–933.

Germer, C. K. (2005). Anxiety disorders: Befriending fear. In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mind- fulness and psychotherapy (pp. 152–172). New York: Guil- ford Press.

Gomez, A. F., Barthel, A. L., & Hofmann, S. G. (2018). Comparing the efficacy of benzodiazepines and seroto- nergic anti-depressants for adults with generalized anxiety disorder: A meta-analytic review. Expert Opinion on Phar- macotherapy, 19(8), 883–894.

Gratz, K. L., & Roemer, L. (2004). Multidimensional as- sessment of emotion regulation and dysregulation: De- velopment, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psy- chopathology and Behavioral Assessment, 26(1), 41–54.

Gross, J. J. (2002). Emotion regulation: Affective, cognitive, and social consequences. Psychophysiology, 39(3), 281–291.

Gross, J. J., & Levenson, R. W. (1997). Hiding feelings: The acute effects of inhibiting negative and positive emotion. Journal of Abnormal Psychology, 106(1), 95–103.

Hall, G. C. N., Hong, J. J., Zane, N. W. S., & Meyer, O. L. (2011). Culturally-competent treatment for Asian Ameri- cans: The relevance of mindfulness- and acceptance-based psychotherapies. Clinical Psychology: Science and Practice, 18, 215–231.

Hanrahan, F., Field, A. P., Jones, F. W., & Davey, G. C. L. (2013). A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clinical Psychology Review, 33, 120–132.

Harrell, S. P. (2018). Soulfulness as an orientation to contem- plative practice: Culture, liberation, and mindful aware- ness. Journal of Contemplative Inquiry, 5(1), 9–40.

Hayes, S. A., Orsillo, S. M., & Roemer, L. (2010). Changes in proposed mechanisms of action during an acceptance- based behavior therapy for generalized anxiety disorder. Behaviour Research and Therapy, 48(3), 238–245.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Ac- ceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press.

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychol- ogy, 64(6), 1152–1168.

Hayes-Skelton, S. A., Calloway, A., Roemer, L., & Orsillo, S. M. (2015). Decentering as a potential common mechanism across two therapies for generalized anxiety disorder. Jour- nal of Consulting and Clinical Psychology, 83(2), 395–404.

Hayes-Skelton, S. A., Roemer, L., & Orsillo, S. M. (2013). A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anx- iety disorder. Journal of Consulting and Clinical Psychology, 81(5), 761–773.

Hayes-Skelton, S. A., Usmani, A., Lee, J. K., Roemer, L., & Orsillo, S. M. (2012). A fresh look at potential mecha- nisms of change in applied relaxation for generalized anxi- ety disorder: A case series. Cognitive and Behavioral Prac- tice, 19(3), 451–462.

Hays, P. A. (2016). Addressing cultural complexities in practice: Assessment, diagnosis and therapy (3rd ed.). Washington, DC: American Psychological Association.

He, H., Xiang, Y., Gao, F., Bai, L., Gao, F., Fan, Y., et al. (2019). Comparative efficacy and acceptability of first-line drugs for the acute treatment of generalized anxiety disor-

214 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

der in adults: A network meta-analysis. Journal of Psychiat- ric Research, 118, 21–30.

Heatherington, L., Harrington, N. T., Harrington, J., Nei- meyer, K. F., Weinberg, S. C., & Friedlander, M. L. (2014). Applying group cognitive behavior therapy for anxiety disorders in community settings: Retention, out- come, and clinical considerations. Journal of Cognitive Psy- chotherapy, 28(2), 117–133.

Heuzenroeder, L., Donnelly, M., Haby, M. M., Mihalopou- los, C., Rossell, R., Carter, R., et al. (2004). Cost-effec- tiveness of psychological and pharmacological interven- tions for generalized anxiety disorder and panic disorder. Australian and New Zealand Journal of Psychiatry, 38(8), 602–612.

Hoffman, D. L., Dukes, E. M., & Wittchen, H. (2008). Human and economic burden of generalized anxiety dis- order. Depression and Anxiety, 25(1), 72–90.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wis- dom of your body and mind to face stress, pain, and illness. New York: Delta.

Kabat-Zinn, J. (1995). Wherever you go there you are: Mindful- ness meditation in everyday life. New York: Hyperion.

Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Sci- ence and Practice, 10(2), 144–156.

Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernist- ed, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, post- traumatic stress and obsessive–compulsive disorders. BMC Psychiatry, 14(Suppl. 1), S1.

Kennedy, B. L., & Schwab, J. J. (1997). Utilization of medi- cal specialists by anxiety disorder patients. Psychosomatics, 38(2), 109–112.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the Na- tional Comorbidity Survey Replication. Archives of Gen- eral Psychiatry, 62(6), 593–602.

Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. (2012). Twelve-month and life- time prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21(3), 169–184.

Kocovski, N. L., Fleming, J. E., Hawley, L. L., Huta, V., & Antony, M. M. (2013). Mindfulness and acceptance- based group therapy versus traditional cognitive behav- ioral group therapy for social anxiety disorder: A random- ized controlled trial. Behaviour Research and Therapy, 51, 889–898.

Ladouceur, R., Gosselin, P., & Dugas, M. J. (2000). Ex- perimental manipulation of intolerance of uncertainty: A study of a theoretical model of worry. Behaviour Research and Therapy, 38(9), 933–941.

Lee, J. K., Orsillo, S. M., Roemer, L., & Allen, L. B. (2010).

Distress and avoidance in generalized anxiety disorder: Exploring the relationships with intolerance of uncertainty and worry. Cognitive Behaviour Therapy, 39(2), 126–136.

Levine, J. C., Fleming, R., Piedmont, J. I., Cain, S. M., & Chen, W. J. (2016). Heart rate variability and general- ized anxiety disorder during laboratory-induced worry and aversive imagery. Journal of Affective Disorders, 205, 207–215.

Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy, 35(4), 747–766.

Linehan, M. M. (1993). Cognitive-behavioral treatment of bor- derline personality disorder. New York: Guilford Press.

Logue, M. B., Thomas, A. M., Barbee, J. G., & Hoehn-Saric, R. (1993). Generalized anxiety disorder patients seek eval- uation for cardiological symptoms at the same frequency as patients with panic disorder. Journal of Psychiatric Re- search, 27(1), 55–59.

Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales. Sydney: Psychology Foun- dation of Australia.

Marten, P. A., Brown, T. A., Barlow, D. H., Borkovec, T. D., Shear, M. K., & Lydiard, R. B. (1993). Evaluation of the ratings comprising the associated symptom criterion of DSM-III-R generalized anxiety disorder. Journal of Ner- vous and Mental Disease, 181(11), 676–682.

Martinez, J. H., & Roemer, L. A. (2019, November). A brief mindfulness- and acceptance-based intervention for coping with race-related stress. Paper presented at the annual meet- ing of the Association for Behavioral and Cognitive Thera- pies, Atlanta, GA.

Mennin, D. S., & Fresco, D. M. (2014). Emotion regulation therapy. In J. J. Gross (Ed.), Handbook of emotion regula- tion (2nd ed., pp. 469–490). New York: Guilford Press.

Mennin, D. S., Fresco, D. M., O’Toole, M. S., & Heimberg, R. G. (2018). A randomized controlled trial of emotion regulation therapy for generalized anxiety disorder with and without co-occurring depression. Journal of Consult- ing and Clinical Psychology, 86(3), 268–281.

Mennin, D. S., Holaway, R. M., Fresco, D. M., Moore, M. T., & Heimberg, R. G. (2007). Delineating components of emotion and its dysregulation in anxiety and mood psy- chopathology. Behavior Therapy, 38(3), 284–302.

Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28(6), 487–495.

Michelson, S. E., Lee, J. K., Orsillo, S. M., & Roemer, L. (2011). The role of values-consistent behavior in gener- alized anxiety disorder. Depression and Anxiety, 28(5), 358–366.

Millstein, D. J., Orsillo, S. M., Hayes-Skelton, S. A., & Ro-

Generalized Anxiety Disorder 215

emer, L. (2015). Interpersonal problems, mindfulness, and therapy outcome in an acceptance-based behavior therapy for generalized anxiety disorder. Cognitive Behaviour Ther- apy, 44(6), 491–501.

Mussell, M., Kroenke, K., Spitzer, R. L., Williams, J. B. W., Herzog, W., & Löwe, B. (2008). Gastrointestinal symp- toms in primary care: Prevalence and association with depression and anxiety. Journal of Psychosomatic Research, 64(6), 605–612.

Najmi, S., & Wegner, D. M. (2008). Thought suppression and psychopathology. In A. J. Elliot (Ed.), Handbook of ap- proach and avoidance motivation (pp. 447–459). New York: Psychology Press.

Neff, K. D. (2003). The development and validation of a scale to measure self-compassion. Self and Identity, 2(3), 223–250.

Newman, M. G., Castonguay, L. G., Borkovec, T. D., Fisher, A. J., Boswell, J. F., Szkodny, L. E., et al. (2011). A ran- domized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies. Journal of Consulting and Clinical Psychology, 79(2), 171–181.

Newman, M. G., & Llera, S. J. (2011). A novel theory of ex- periential avoidance in generalized anxiety disorder: A re- view and synthesis of research supporting a contrast avoid- ance model of worry. Clinical Psychology Review, 31(3), 371–382.

Nhat Hanh, T. (1992). Peace is every step: The path of mindful- ness in everyday life. New York: Bantam Books.

Nordahl, H. M., Borkovec, T., Hagen, R., Kennair, L. E. O., Hjemdal, O., Solem, S., et al. (2018). Metacognitive therapy versus cognitive-behavioural therapy in adults with generalized anxiety disorder. BJPsych Open, 4(5), 393–400.

Olatunji, B. O., & Wolitzky-Taylor, K. B. (2009). Anxiety sensitivity and the anxiety disorders: A meta-analytic re- view and synthesis. Psychological Bulletin, 135(6), 974– 999.

Orsillo, S. M., & Roemer, L. (2011). The mindful way through anxiety: Break free from chronic worry and reclaim your life. New York: Guilford Press.

Orsillo, S. M., & Roemer, L. (2016). Worry less, live more: The mindful way through anxiety workbook. New York: Guil- ford Press.

Orsillo, S. M., Roemer, L., & Barlow, D. H. (2003). Integrat- ing acceptance and mindfulness into existing cognitive- behavioral treatment for GAD: A case study. Cognitive and Behavioral Practice, 10(3), 222–230.

Orsillo, S. M., Roemer, L., & Salters-Pedneault, K. (2008, November). Acceptance-based behavioral therapy for GAD: Predictors of change. Paper presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, Orlando, FL.

Proulx, J., Croff, R., Oken, B., Aldwin, C. M., Fleming, C.,

Bergen-Cico, D., et al. (2018). Considerations for research and development of culturally relevant mindfulness inter- ventions in American minority communities. Mindfulness, 9(2), 361–370.

Przeworski, A., Newman, M. G., Pincus, A. L., Kasoff, M. B., Yamasaki, A. S., Castonguay, L. G., et al. (2011). In- terpersonal pathoplasticity in individuals with generalized anxiety disorder. Journal of Abnormal Psychology, 120(2), 286–298.

Renna, M. E., Quintero, J. M., Fresco, D. M., & Mennin, D. S. (2017). Emotion regulation therapy: A mechanism- targeted treatment for disorders of distress. Frontiers in Psychology, 8, 98.

Revicki, D. A., Travers, K., Wyrwich, K. W., Svedsäter, H., Locklear, J., Mattera, M., et al. (2012). Humanistic and economic burden of generalized anxiety disorder in North America and Europe. Journal of Affective Disorders, 140(2), 103–112.

Roemer, L., & Borkovec, T. D. (1994). Effects of suppressing thoughts about emotional material. Journal of Abnormal Psychology, 103(3), 467–474.

Roemer, L., Lee, J. K., Salters-Pedneault, K., Erisman, S. M., Orsillo, S. M., & Mennin, D. S. (2009). Mindfulness and emotion regulation difficulties in generalized anxiety dis- order: Preliminary evidence for independent and overlap- ping contributions. Behavior Therapy, 40(2), 142–154.

Roemer, L., Molina, S., & Borkovec, T. D. (1997). An in- vestigation of worry content among generally anxious in- dividuals. Journal of Nervous and Mental Disease, 185(5), 314–319.

Roemer, L., & Orsillo, S. M. (2020). Acceptance-based behav- ioral therapy: Treating anxiety and related challenges. New York: Guilford Press.

Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based behavior therapy for gen- eralized anxiety disorder: Evaluation in a randomized con- trolled trial. Journal of Consulting and Clinical Psychology, 76(6), 1083–1089.

Romera, I., Fernández-Pérez, S., Montejo, Á. L., Caballero, F., Caballero, L., Arbesú, J. Á., et al. (2010). Generalized anxiety disorder, with or without co-morbid major depres- sive disorder, in primary care: Prevalence of painful so- matic symptoms, functioning and health status. Journal of Affective Disorders, 127(1–3), 160–168.

Ruscio, A. M., Hallion, L. S., Lim, C. C. W., Aguilar-Gaxio- la, S., Al-Hamzawi, A., Alonso, J., et al. (2017). Cross-sec- tional comparison of the epidemiology of DSM-5 general- ized anxiety disorder across the globe. JAMA Psychiatry, 74(5), 465–475.

Sagon, A. L., Danitz, S. B., Suvak, M. K., & Orsillo, S. M. (2018). The Mindful Way through the Semester: Evalu- ating the feasibility of delivering an acceptance-based be- havioral program online. Journal of Contextual Behavioral Science, 9, 36–44.

216 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Sauer-Zavala, S., Boswell, J. F., Gallagher, M. W., Bentley, K. H., Ametaj, A., & Barlow, D. H. (2012). The role of negative affectivity and negative reactivity to emotions in predicting outcomes in the unified protocol for the trans- diagnostic treatment of emotional disorders. Behaviour Research and Therapy, 50(9), 551–557.

Segal, Z. V., Williams, J. M., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press.

Serowik, K. L., Roemer, L., Suvak, M., Liverant, G., & Or- sillo, S. M. (2020). A randomized controlled pilot study evaluating Worry Less, Live More: The Mindful Way through Anxiety Workbook. Cognitive Behaviour Therapy, 49(5), 412–424.

Siev, J., & Chambless, D. L. (2007). Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders. Journal of Consulting and Clinical Psychology, 75(4), 513–522.

Sobczak, L. R., & West, L. M. (2013). Clinical considerations in using mindfulness- and acceptance-based approaches with diverse populations: Addressing challenges in service delivery in diverse community settings. Cognitive and Be- havioral Practice, 20(1), 13–22.

Stapinski, L. A., Abbott, M. J., & Rapee, R. M. (2010). Fear and perceived uncontrollability of emotion: Evaluating the unique contribution of emotion appraisal variables to pre- diction of worry and generalised anxiety disorder. Behav- iour Research and Therapy, 48(11), 1097–1104.

Stöber, J., & Bittencourt, J. (1998). Weekly assessment of worry: An adaptation of the Penn State Worry Question- naire for monitoring changes during treatment. Behaviour Research and Therapy, 36(6), 645–656.

Sue, D. W., & Sue, D. (2016). Counseling the culturally di- verse: Theory and practice (7th ed.). New York: Wiley.

Thayer, J. F., Friedman, B. H., & Borkovec, T. D. (1996). Autonomic characteristics of generalized anxiety disorder and worry. Biological Psychiatry, 39(4), 255–266.

Treanor, M., Erisman, S. M., Salters-Pedneault, K., Roemer, L., & Orsillo, S. M. (2011). Acceptance-based behavioral therapy for GAD: Effects on outcomes from three theo- retical models. Depression and Anxiety, 28(2), 127–136.

Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Twelve-month use of mental health services in the United States: Results from the Na- tional Comorbidity Survey Replication. Archives of Gen- eral Psychiatry, 62(6), 629–640.

Waters, A. M., & Craske, M. G. (2005). Generalized anxiety disorder. In M. M. Antony, D. R. Ledley, & R. G. Heim- berg (Eds.), Improving outcomes and preventing relapse in cognitive-behavioral therapy (pp. 77–127). New York: Guil- ford Press.

Wells, A. (2005). The metacognitive model of GAD: Assess- ment of meta-worry and relationship with DSM-IV gen- eralized anxiety disorder. Cognitive Therapy and Research, 29(1), 107–121.

Whisman, M. A. (2007). Marital distress and DSM-IV psy- chiatric disorders in a population-based national survey. Journal of Abnormal Psychology, 116(3), 638–643.

Williams, J. M. G., Teasdale, J. D., Segal, Z. V., & Kabat- Zinn, J. (2007). The mindful way through depression: Free- ing yourself from chronic unhappiness. New York: Guilford Press.

Williams, K. E., Chambless, D. L., & Ahrens, A. (1997). Are emotions frightening?: An extension of the fear of fear construct. Behaviour Research and Therapy, 35(3), 239–248.

Wilson, K. G., & Murrell, A. R. (2004). Values work in ac- ceptance and commitment therapy: Setting a course for behavioral treatment. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 120–151). New York: Guilford Press.

Wilson, K. G., Sandoz, E. K., Kitchens, J., & Roberts, M. (2010). The Valued Living Questionnaire: Defining and measuring valued action within a behavioral framework. Psychological Record, 60(2), 249–272.

Zargar, F., Farid, A. A. A., Atef-Vahid, M. K., Afshar, H., Maroofi, M., & Omranifard, V. (2012). Effect of accep- tance-based behavior therapy on severity of symptoms, worry and quality of life in women with generalized anxi- ety disorder. Iranian Journal of Psychiatry and Behavioral Sciences, 6(2), 23–32.

217

In this chapter we describe the Unified Protocol for Transdiagnostic Treatment of Emotional Dis- orders, one of the first treatment protocols of its kind, which has now been adopted worldwide and is translated into over 10 different languages. Developed through the Center for Anxiety and Related Disorders at Boston University, this “unified” transdiagnostic protocol distills therapeutic principles common to psychological treatment of the various emotional disorders and integrates these princi- ples into a single protocol that is, in theory, applicable to the full range of emotional disorders. What is unique about this approach is the systematic manner in which the treatment components are applied across disorders, as well as theoretical developments leading to reconceptualization of the principal target of treatment as a common, higher-order temperament undergirding disorders of emotion rather than specific DSM-defining system clusters. The protocol is deeply rooted in emotion science and, in particular, the evolutionarily adaptive function of emotions. The major advantage of a transdiagnostic approach, of course, in addition to greatly simplifying dissemination by eliminating numerous over- lapping single-disorder protocols, is that this approach also takes into consideration the extensive comorbidity often found among emotional disorders. In this chapter, we illustrate the unified protocol through a case study of the treatment of “Marianne.” —D. H. B.

The first edition of this book was published in 1985, in the dawn of evidence-based psychological treat-

ments. Descriptions of only those treatments with suf- ficient empirical support that were broadly applicable to large numbers of individuals with various forms of psychopathology at that time were included. Over suc- ceeding editions of this book some new treatment ap- proaches with wide appeal and strong empirical support have been added, whereas others have been deleted. In addition, the field has matured to the point that pub- lic health services around the world have directed that evidence-based psychological treatments become an

integral part of health care delivery systems due to their effectiveness, efficiency, and durability (Clark, 2012; Nathan & Gorman, 2007; Ruzek, Karlin, & Zeiss, 2012). It is also a sign of the maturity of a field to examine closely the limitations of existing evidence. Obviously, a considerable number of patients still do not respond as well as would be desirable to our current arsenal of psychological (or drug) treatments, and there is plenty of room for improvement.

Another problem that has become apparent, particu- larly in the context of emotional disorders, is that there now exists a plethora of treatment protocols for each

C H A P T E R 6

emotional Disorders A Unified Protocol for Transdiagnostic Treatment

Laura A. Payne Kristen K. Ellard Todd J. Farchione David H. Barlow

218 CliniCal Handbook of PsyCHologiCal disorders

of the discrete anxiety and mood disorders. Although these protocols, by and large, have proven useful and been well received, it takes a significant amount of training to become sufficiently familiar with the dis- tinct protocols to integrate them into clinical practice (Barlow, Bullis, Comer, & Ametaj, 2013). Unless these treatments become more “user-friendly” as recom- mended, clinicians are less likely to have a sufficient understanding of, or access to, these evidence-based treatments for the emotional disorders (McHugh & Barlow, 2012). In this chapter, we present a Unified Protocol (UP) for the transdiagnostic treatment of emotional disorders. “Emotional disorders” in our con- ception include not only the anxiety, depressive, obses- sive–compulsive, and trauma-related disorders but also other classes of disorders in which the experience and regulation of emotion plays a prominent role, such as the somatic disorders, dissociative disorders, and, to some extent, the eating disorders. Borderline personal- ity disorder can also be conceptualized as a disorder of extreme emotional dysregulation (Sauer-Zavala & Bar- low, 2014; Neacsiu, Zerubavel, Nylocks, & Linehan, Chapter 10, this volume) and may fit within our UP conceptualization (e.g., Lopez et al., 2015). Our science and practice have advanced sufficiently that there are now several strong arguments for this approach, in ad- dition to the very practical advantage of substantially reducing the number of existing protocols. We touch on these arguments here before describing the treatment components of the UP in some detail, in keeping with the long-standing format of this book.

RATIONALE FOR A UNIFIED APPROACH

Perhaps the strongest argument for a unified transdiag- nostic treatment approach to emotional disorders is an emerging body of evidence supporting commonalities in the etiology of these disorders that we have summa- rized in the form of an etiological model referred to as “triple vulnerability” (Barlow, 1991, 2000, 2002; Bar- low, Ellard, Sauer-Zavala, Bullis, & Carl, 2014; Suárez, Bennett, Goldstein, & Barlow, 2009). Since the time the UP first appeared in this volume, interest and re- search into transdiagnostic processes has grown expo- nentially, from 43 studies published between 2004 and 2009, to over 2,000 studies published between 2010 and 2020. Most notably, in 2010, the National Insti- tute of Mental Health launched the Research Domain Criteria (RDoC) initiative to promote research into

transdiagnostic dimensions of functioning across mul- tiple levels of analysis, from genes to molecules, neuro- circuits, behavior, and self-report, in an effort to more clearly elucidate and define etiology and markers of psychopathology beyond the bounds of DSM-defined diagnostic categories (Insel et al., 2010). Although re- search in this area is still in its early stages and shared etiological pathways or pathophysiological processes are not yet firmly established, emerging evidence on shared pathological processes is sufficiently strong at present to justify a transdiagnostic treatment approach, a point to which we return below.

A second argument focuses on conceptions of the major emotional disorders that emphasize their com- monalities rather than their differences. The “spec- trum” approach is one manifestation of this concep- tion. For example, high rates of comorbidity suggest considerable overlap among disorders. The observed effects of current psychological treatments on comorbid conditions also point to at least a partial nonspecificity of treatment response. From a phenomenological per- spective, emerging research on the latent structure of dimensional features of emotional disorders reveals a hierarchical structure that can accommodate these dis- orders. The sections to follow briefly review evidence relevant to these arguments.

Etiology

We have described in some detail a set of interacting vulnerabilities or diatheses relevant to the development of anxiety, anxiety disorders, and related emotional dis- orders. This “triple-vulnerability” theory encompasses a generalized biological vulnerability, a generalized psychological vulnerability, and a specific psychologi- cal vulnerability emerging from early learning (Barlow, 2000, 2002; Barlow, Ellard, et al., 2014; Sauer-Zavala & Barlow, 2021). Much of the research on generalized biological and psychological vulnerabilities has focused on a temperament labeled, variously, “neuroticism,” “negative affect,” “behavioral inhibition,” or “trait anxi- ety.” Although the relationships among these closely related traits and temperaments have yet to be worked out fully, it seems that they substantially overlap and represent a common theme associated with a biological vulnerability to develop emotional disorders (Barlow, 2000, 2002; Campbell-Sills, Liverant, & Brown, 2004; Suárez et al., 2009). We have come to refer to this tem- perament by its most traditional label, “neuroticism” (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014;

Emotional Disorders 219

Eysenck, 1947; Sauer-Zavala & Barlow, 2021). A gener- alized biological vulnerability involves nonspecific ge- netic contributions to the development of neuroticism. Additionally, early life experiences fostering a sense that events, particularly negative events, are unpredictable or uncontrollable, contribute to a generalized psycho- logical vulnerability, or diathesis, to develop neuroti- cism later on. If a generalized biological and a general- ized psychological vulnerability happen to line up and are potentiated by the influence of life stress, the likely result is a development of the two closely related clinical syndromes of generalized anxiety disorder (GAD) and/ or depressive disorders. Notice that false alarms (panic attacks) may also occur as a function of stressful life events, facilitated by high levels of baseline anxiety. But these false alarms seem to have a different heritability than anxiety and are not necessarily implicated in a clinical disorder. For that to occur, an additional layer of a more specific psychological vulnerability must be considered.

We know from emotion science that learned asso- ciations between strong emotions and certain contexts, cues, or “meanings” become encoded into memory and serve to drive our behaviors in an automatic, reflexive way. Over time, we learn that “when I feel this, it means this about me and the world, and I respond in this way.” From an evolutionary standpoint, encoding these as- sociations in memory allows us to develop a unique “blueprint” of the world to guide our behaviors, so that we can respond to cues quickly and are not tasked with constantly reinterpreting meaning and reinventing re- sponses. However, this evolutionarily adaptive process can become maladaptive when associations among emotions, meanings, and responses are no longer help- ful or accurate. Thus, a psychological vulnerability to develop specific anxiety disorders can occur when the biological propensity to experience strong emotions is coupled with maladaptive learned associations. Certain learning experiences seem to focus anxiety on specific life circumstances, and these circumstances or events are associated with a heightened sense of threat or dan- ger. For example, specific early learning experiences seem to determine whether individuals may view so- matic sensations, intrusive thoughts, or social evalua- tion as specifically dangerous (Barlow, 2002; Bouton, Mineka, & Barlow, 2001); that is, to take one example, individuals with social anxiety often have in their back- ground admonitions from parents or family to always to be on their best behavior and to look their best, to avoid the dreaded consequence of being negatively eval-

uated or “disapproved of” by others. Children raised in environments in which the behavior of caregivers is unpredictable may learn to associate ambiguous social cues with threat, leading to the development of social anxiety, or with danger, leading to the development of GAD. It is this specific psychological vulnerability that, when coordinated with the generalized biological and psychological vulnerabilities mentioned earlier, seems to contribute to the development of discrete anxiety disorders such as social anxiety disorder, panic disor- der, and specific phobias. In other words, the specific symptom presentations that align with DSM diagnos- tic categories may in fact reflect circumstantial surface manifestations of underlying biological and psychologi- cal vulnerabilities. This model is also applicable to ob- sessive–compulsive, trauma-, and stressor-related dis- orders. For instance, in obsessive–compulsive disorder (OCD), individuals often report learning from author- ity figures that having a thought is as bad as engaging in the action (i.e., having the thought about shaking a newborn infant to quiet it is as bad as actually shaking the infant). Existing evidence for this triple-vulnerabili- ty model has been reviewed in detail elsewhere (Bouton et al., 2001; Chorpita & Barlow, 1998; Sauer-Zavala & Barlow, 2021) and is consistent with the overriding im- portance of common factors in the genesis and presen- tation of emotional disorders.

Latent Structure of the Emotional Disorders

Whereas the fourth and fifth editions of the Diagnos- tic and Statistical Manual of Mental Disorders (DSM- IV-TR and DSM-5; American Psychiatric Association, 2000, 2013) highlight a “splitting approach” to nosolo- gy in an attempt to achieve high rates of diagnostic reli- ability, this achievement may have come at the expense of diagnostic validity; that is, the current system may be highlighting categories that are minor variations of more fundamental underlying syndromes. Quantitative approaches such as structural equation modeling, prin- cipal component analyses, and machine learning are now capable of examining the full range of anxiety and mood disorders, and their interrelationships, without the constraints of existing (possibly) artificial categories (Brown, Chorpita, & Barlow, 1998; Chorpita, Albano, & Barlow, 1998; Clark, 2005; Clark & Watson, 1991; Grisanzio et al., 2018; Watson, 2005). We have been studying this question for a number of years. For exam- ple, Brown and colleagues (1998), using a sample of 350 patients with DSM-IV anxiety and mood disorders,

220 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

confirmed a hierarchical structure to the emotional dis- orders. In this structure, trait negative affect and trait positive affect were identified as crucial higher-order factors to the DSM-IV disorder factors, with significant paths from negative affect to each of the five DSM-IV disorder factors (GAD, social phobia, panic disorder, OCD, and major depression). Interestingly, low positive affect emerged with significant paths to major depres- sion and social phobia only. In this model, autonomic arousal represents the phenomenon of panic, and this arousal emerges as a lower-order factor with significant paths from panic disorder and GAD (where the rela- tionship was negative).

In a separate study that followed 606 patients with DSM-IV anxiety and mood disorders over the course of 2 years, Brown (2007) found further support for this hierarchical model. Replicating earlier cross-sectional findings, the two higher-order temperament dimen- sions of neuroticism/behavioral inhibition/negative affectivity and behavioral activation/positive affectiv- ity accounted for virtually all of the covariance among DSM-IV disorder constructs (GAD, social phobia, and major depression). Furthermore, the rate of change in neuroticism/behavioral inhibition over the study period accounted for virtually all of the covariance among the rate of change in DSM-IV disorder constructs.

Computational approaches, such as machine learn- ing and graph-theoretical network-based analyses, have further confirmed underlying dimensions that cut across traditional DSM diagnostic categories. For ex- ample, a recent study used principal component analy- sis on the 21-item Depression Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995) to identify dimensional clusters in a sample of 248 patients diag- nosed with a range of anxiety and mood disorders and 249 healthy controls. Three stable clusters emerged, identified by the authors as tension, anxious arousal, and anhedonia, which are constructs that overlap with high negative affect, low positive affect, and autonom- ic arousal (Grisanzio et al., 2018). Unsupervised ma- chine learning was then used to classify patients and controls within these three dimensions, resulting in six subtypes, defined as normative mood, tension, anxious arousal, general anxiety, anhedonia, and melancholia. Importantly, similar to our findings, the identified sub- types did not align with DSM diagnoses but instead cut across DSM diagnostic boundaries.

Findings such as these suggest that commonalities among emotional disorders outweigh the differences. We have concluded from this research that DSM emo-

tional disorder categories are best considered as use- ful concepts or constructs that emerge as “blips” on a general background of neuroticism/behavioral inhibi- tion but may not be the best way to organize nosology (Brown & Barlow, 2009).

Overlap among Disorders

At the diagnostic level, the overlap among the emo- tional disorders is most evident in the high rates of cur- rent and lifetime comorbidity (e.g., Brown, Campbell, Lehman, Grisham, & Mancill, 2001; Kessler et al., 1996; Roy-Byrne, Craske, & Stein, 2006; Tsao, Myst- kowski, Zucker, & Craske, 2002, 2005). Results from Brown, Campbell, and colleagues (2001) indicate that 55% of patients with a principal anxiety disorder had at least one additional anxiety or depressive disorder at the time of assessment. But if one examines for the presence of a disorder over the lifetime of the patient, whether it is present or not at the time of interview, this rate increases to 76%. To take one example, 60% of 324 patients diagnosed with panic disorder with or without agoraphobia (PD/A) were determined to meet criteria for either an additional anxiety or mood disorder, or both. Specifically, 47% presented with an additional anxiety disorder and 33%, with an additional mood disorder. When lifetime diagnoses are considered, the percentages rise to 77% experiencing any anxiety or mood disorder, breaking down to 56% for any anxiety disorder and 60% for any mood disorder. If posttrau- matic stress disorder (PTSD) or GAD was the principal (most severe) diagnosis, comorbidity rates were high- est. Merikangas, Zhang, and Aveneoli (2003) followed almost 500 individuals for 15 years and found that relatively few people suffer from anxiety or depression alone. When a single disorder did occur at one point in time, the additional mood state would almost certainly emerge later.

Several possible explanations for these high rates of comorbidity have been reviewed extensively elsewhere (Brown & Barlow, 2002). Among these are relatively trivial issues with overlapping definitional criteria; arti- factual reasons, such as differential base rates of occur- rence in our setting; and the possibility that disorders are sequentially related, and that the features of one dis- order act as risk factors for another disorder. For exam- ple, depression seems to follow PD/A, and PD/A seems to follow PTSD. But the more intriguing explanation, for our purposes, first offered by individuals such as Gavin Andrews and Peter Tyrer (Andrews, 1990, 1996;

Emotional Disorders 221

Tyrer, 1989; Tyrer et al., 1998), is that this pattern of comorbidity argues for the existence of what has been called a “general neurotic syndrome” (Barlow, Ellard, et al., 2014; Sauer-Zavala & Barlow, 2021). Andrews and Tyrer have suggested that the difference in the ex- pression of emotional disorder symptoms (individual variation in the prominence of social anxiety, panic at- tacks, anhedonia, etc.) is simply a trivial variation in the manifestation of a broader syndrome. This, in turn, is consistent with “triple vulnerability” models mentioned earlier, that anxiety (and mood) disorders emerge from shared psychosocial and biological/genetic diatheses. If this is the case, then a unified treatment protocol cut- ting across current diagnostic categories to address core features of the anxiety and mood disorders could be a more parsimonious and, perhaps, powerful option.

We have reviewed the genetic and neurobiological evidence on the commonalities among anxiety and de- pressive states in some detail elsewhere (Barlow, 2002, Chaps. 3, 6–8; Bouton, 2005; Brown, 2007; Suárez et al., 2009). For example, most work on genetic contri- butions to anxiety and depression supports the early dictum of Ken Kendler (1996; Kendler et al., 1995), “same genes, different environment” (Hettema, Neale, & Kendler, 2001; Rutter, Moffit, & Caspi, 2006). Consistent with a theory of an underlying genetic vul- nerability, genetic variations have been linked to both trait anxiety and negative emotionality (or neuroti- cism) (Montag, Fiebach, Kirsch, & Reuter, 2011; Stein, Campbell-Sills, & Gelernter, 2009; Tabak et al., 2020), and have been found to influence the later development of psychopathology following life stressors (Caspi et al., 2003). Recently, a growing body of literature in genet- ics has observed links between genetic polymorphisms and both the function and structure of neural pathways implicated in emotional processing, suggesting an asso- ciation between a genetic predisposition, inefficient or maladaptive emotion processing, and the development of emotional disorders. For example, genetic variations have been associated with hyperactivation in neural structures implicated in emotion generation (Drabant et al., 2012; Lonsdorf et al., 2011; Munafò, Brown, & Hariri, 2008; Tabak et al., 2020), reduced gray mat- ter volume in limbic regions, and reduced functional connectivity between emotion-generating regions and structures implicated in their inhibitory control (Mc- Teague et al 2020; Pezawas et al., 2005; Sharp, Miller, & Heller, 2015).

Increased perceptions of emotions as uncontrollable and intolerable, increased avoidant processing, and in-

creased attempts at emotional control have also been demonstrated across disorders (Campbell-Sills, Barlow, Brown, & Hofmann, 2006a, 2006b; Sloan et al., 2017; Weinberg & Hajcak, 2010; Weiser, Pauli, Weyers, Alp- ers, & Mühlberger, 2009). Intolerance of uncertainty and distress has been demonstrated across a full range of disorders, including depression, GAD, social anxi- ety, and OCD (Boelen, Vrinssen, & van Tulder, 2010; Boswell, Thompson-Holland, Farchione, & Barlow, 2013; Lee, Orsillo, Roemer, & Allen, 2010). In ad- dition, a growing number of studies have shown that individuals with anxiety and mood disorders tend to use maladaptive emotion regulation strategies, includ- ing attempts to avoid or dampen the intensity of un- comfortable emotions that ultimately backfire and contribute to the maintenance of their symptoms (e.g., Campbell-Sills et al., 2006a, 2006b; Liverant, Brown, Barlow, & Roemer, 2008; Mennin, Heimberg, Turk, & Fresco, 2005; Sloan et al., 2017; Tull & Roemer, 2007). Taken together, the evidence from genetics, neurosci- ence, behavioral studies, and psychopathology research suggests that a common, overlapping feature across disorders is the propensity toward increased emotional reactivity and inefficient or deficient regulatory con- trol that is coupled with a heightened tendency to view these experiences as aversive and is manifest in attempts to alter, avoid, or control emotional responding.

In summary, the existing literature supports several arguments for stepping back from individual DSM diagnostic categories and associated disorder-specific psychological protocols and considering a more unified transdiagnostic approach based on new findings on the nature of psychopathology and from the emerging field of emotion science. In addition, current evidence- based cognitive-behavioral therapy (CBT) protocols for emotional disorders have much in common and reduce to three broad principles of change: altering emotion- based misappraisals of salient events; preventing avoid- ance of negative, emotionally charged internal or exter- nal triggers, as well as modifying emotional behaviors (action tendencies) and facilitating extinction of fear; and reducing anxiety and distress over the experience of intense emotion (Mennin, Ellard, Fresco, & Gross, 2013).

EVIDENCE FOR THE EFFICACY OF THE UP

Since its inception in the early 2000s, the UP has amassed considerable empirical support as a treat-

222 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

ment for a wide range of presenting problems. In 2020, Cassiello-Robbins, Southward, Tirpak, and Sauer- Zavala systematically reviewed 77 treatment outcome studies using the UP across 11 different countries and with numerous adaptations. In these studies, the UP was delivered in a variety of formats (i.e., group, indi- vidual, digital), across several different clinical settings (i.e., outpatient, intensive outpatient, inpatient) and for a wide range of diagnostic presentations. Overall, the authors concluded that the UP is acceptable to both patients and therapists and can be flexibly applied to a range of DSM-IV and DSM-5 diagnoses, as well as nondiagnosable problems such as nonsuicidal self-inju- ry, subclinical presentations, and sexual minority stress. However, they also noted that as the majority of stud- ies focused on patients with primary anxiety disorders or closely related conditions (i.e., OCD); thus, findings outside of anxiety and depressive disorders should be considered more preliminary. Sakiris and Berle (2019) conducted a meta-analysis examining the efficacy of the UP across a subset of 15 outcome studies (N = 1,244) described in the review by Cassiello-Robbins et al. (2020). Consistent with Cassiello-Robbins and col- leagues’ conclusions, the UP was associated with large effect size improvements across anxiety and depressive disorders, OCD, and borderline personality disorder. In addition, findings suggest that the UP led to increased use of adaptive and decreased use of maladaptive emo- tion regulation strategies and improvements in func- tioning and quality of life. This meta-analytic review included a number of randomized controlled trials, in- cluding one of the largest trials of the UP to date (N = 223) in which we compared effectiveness of the UP to established single-disorder protocols for panic disorder, social anxiety disorder, OCD, and GAD (Barlow et al., 2017). In that particular study, relative to the single- disorder protocols, the UP was associated with lower rates of attrition and led to similar improvements across a range of outcomes, including diagnostic severity, anx- iety and depressive symptoms, work/social adjustment, hope, quality of life, positive affect, and number of co- morbid disorders (Barlow et al., 2017; Gallagher et al., 2020; Steele et al., 2018; Wilner Tirpak et al., 2019), both at the end of treatment and at 6-month follow- up. These data support the efficacy of the UP when applied in a variety of populations and symptoms. A full explanation of this protocol and a description of its application with a patient with a complex, yet common, presentation follows.

TREATMENT VARIABLES

Setting

The UP has been administered in a number of different settings, including medical centers, inpatient units, and even homeless shelters, but the most common venue is an outpatient setting. Our own outpatient setting is the Center for Anxiety and Related Disorders (CARD) at Boston University. Our clinic receives over 600 new admissions per year, with many patients being offered treatment after their initial intake assessments. CARD, in addition to housing staff psychologists and psychia- trists, is also a training center for doctoral students and psychiatric residents. At any given time, numer- ous National Institutes of Health (NIH)-funded treat- ment and research studies are ongoing at the Center. Regarding diagnostic breakdown of treatment-seeking patients, the most common diagnosis assigned is GAD, followed by social phobia, PD/A, specific phobia, OCD, and PTSD, but the full range of “neurotic spectrum” disorders is assessed and treated. A small percentage of patients are assigned “coprincipal diagnoses,” which re- fers to cases in which two separate diagnoses are judged to be of equal severity.

Prior to the intake evaluation, each patient is mailed a packet of questionnaires to complete and bring to the assessment, which are scored and interpreted sub- sequent to the interview. The majority of the intake appointment comprises administration of the Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5; Brown, Di Nardo, & Barlow, 2014). Following comple- tion of the entire assessment process, consensus diagno- ses are determined during a weekly staff meeting, after which the patient is provided diagnostic feedback and treatment recommendations. Based on the information from the interview, the patient may be offered one of several treatment options at the Center, referral to a clinical trial if the patient qualifies where treatment is always free of charge, or a referral in the community.

Format

Treatment with the UP is typically conducted in an in- dividual format, although it has been successfully con- ducted in a group format with patients with mixed prin- cipal emotional disorder diagnoses (Bullis et al., 2015; de Ornelas Maia, Nardi, & Cardoso, 2015; Reinholt et al., 2017). The treatment described in this chapter re- flects the individual treatment protocol, which allows

Emotional Disorders 223

for greater attention to the description and application of treatment components during each session. How- ever, when administered in a group setting, patients are easily able to see the commonalities among their diverse presenting complaints, and this understanding often creates a strong bond among group members; therefore, it may be useful to adapt the protocol for group treat- ment as we have done at CARD.

Therapist Variables

The UP has been administered by therapists with vary- ing degrees of clinical experience and expertise with the protocol. To our knowledge, both junior therapists (even therapists who have never had experience with cognitive-behavioral treatments) and senior therapists (i.e., therapists with at least 4 or more years of treat- ment experience) have been able to adapt to the UP without significant difficulty. Certainly, a background in cognitive-behavioral techniques may be helpful when utilizing the protocol (e.g., facilitating cognitive reappraisal, and designing and conducting exposures). Evidence suggests some benefit to therapist experience, at least when treating PD/A with a highly structured CBT protocol (Huppert et al., 2001).

The UP comprises five core modules that target shared mechanisms associated with neuroticism and resulting emotion dysregulation, specifically, negative evaluation and avoidance of intense emotional experi- ence (Sauer-Zavala et al., 2012) underlying all anxiety, depressive, and related disorders (Barlow, Sauer-Zavala, et al., 2014). Across these core modules, and the proto- col more generally, treatment exercises focus on elicit- ing and changing responses to a variety of emotions and emotional cues. Perhaps one of the most challenging aspects for the therapist is to be able to create and utilize emotion-provoking exposures effectively, which begin early in treatment and continue throughout its course. Most importantly, the therapist must have a sense of when a patient is avoiding the process of experiencing, expressing, or accepting emotions, and this is often sig- naled by very subtle behavioral cues, such as avoiding eye contact, changing the topic of discussion, arriving late for a session, and not completing (or “overdoing”) homework assignments. Each of these behaviors rep- resents attempts to control uncomfortable emotions through either direct avoidance or overcontrol. It is es- sential that the therapist be able to recognize and ad- dress such behaviors when they occur, thereby allowing

the opportunity for an effective emotion exposure and discussion of avoidance to facilitate emotional process- ing.

A second challenge for the therapist is to be able to tolerate and experience the expression of emotion by the patient. It is common for less experienced therapists to quickly “rationalize away” the patient’s emotional reac- tions; however, this only feeds into the cycle of emo- tions and avoidance. At every step, the therapist should encourage the expression and acceptance of emotion, while guiding the patient in how to “examine” it, with- out letting the emotion “take over.” In such cases, mod- eling from a senior therapist and/or extensive supervi- sion may be helpful instruction for less experienced therapists.

Client Variables

As previously mentioned, the rate of comorbidity among patients with a principal anxiety or mood dis- order is approximately 55% (Brown, Campbell, et al., 2001), depending on the principal diagnosis. In most CBT protocols, comorbid diagnoses are never a focus of treatment, although successful treatment of a principal anxiety disorder often results in decreases in comorbid- ity (e.g., Allen et al., 2010; Brown, Antony, & Barlow, 1995; Davis, Barlow, & Smith, 2010). In a recent study by our research group, the UP and single-disorder pro- tocols were equally efficacious in reducing symptoms of comorbid emotional disorders immediately follow- ing treatment (Steele et al., 2018). One advantage of a unified treatment approach is that symptoms related to comorbid diagnoses can be discussed in treatment ses- sions and may even be the focus of an emotion expo- sure. For example, a patient with GAD who experiences chronic worry about daily matters may also feel anxious in social situations. Therefore, that patient’s in-session emotion exposure might comprise a conversation with a stranger or giving a speech to a small group of people. Contrary to traditional protocols, the experience of any emotion that is the target of treatment may be particu- larly beneficial for patients with significant comorbid- ity or for those who would like to address multiple con- cerns during the course of treatment.

Concurrent Drug Treatment

Many patients who present for treatment are also tak- ing some form of psychoactive medication. At CARD,

224 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

patients are required to have stabilized on the dosage of medication prior to the intake interview, so that the therapist has a clear picture of actual symptoms (as op- posed to symptoms that may be caused by the initial addition or removal of a medication). Whereas concur- rent use of medications such as selective serotonin reup- take inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) does not appear to have a negative impact on treatment outcome initially, once the medications are removed, evidence suggests that patients who received medication alone or CBT in ad- dition to medication are more likely to relapse (e.g., Barlow, Gorman, Shear, & Woods, 2000; Heimberg et al., 1998; Liebowitz et al., 1999). The exact mecha- nisms underlying the return of symptoms are unclear, although some authors have suggested that patients may attribute the success of the treatment to the use of medication and, once it is withdrawn, no longer believe they have the ability to manage their symptoms. How- ever, in an investigation using data from a multisite comparative study for the treatment of panic disorder, results indicated that patients who received CBT plus pill placebo were equally likely to believe they had re- ceived medication as patients who had actually received the medication (Raffa et al., 2008). Yet those in the CBT plus placebo condition were less likely to relapse compared to those who had received either CBT plus medication or medication alone. Therefore, it appears unlikely that the higher relapse rates in the medication conditions were due solely to this “attribution hypoth- esis.” One other possible explanation for greater rates of relapse in patients receiving psychopharmacological treatment is that the medication provides an unintend- ed “protective” effect against increased physiological arousal and anxiety. Since eliciting anxiety and panic is a core component of CBT protocols, patients taking medication (1) may have experienced greater physical sensations when the medication was removed and/or (2) were never able fully to confront the physiological arousal and panic during the course of treatment. How- ever, these hypotheses have yet to be fully investigated.

One additional consideration frequently raised is the use of benzodiazepines on a prn (“as-needed”) basis during the course of treatment. Following conceptions outlined in the UP, any strategy used to reduce the intensity of emotions in the moment is considered an emotional avoidance strategy, and ultimately contrib- utes to increasing levels of anxiety and emotional reac- tivity. Therefore, the use of benzodiazepines (or other fast-acting medications) is discouraged, particularly if

the medications are carried with the person as a “safety signal.”

ASSESSMENT

Case Study

“Marianne” was a 43-year-old, single woman who had been unemployed for 8 months. She previously worked as a supervisor for a large biotech company but was laid off due to significant changes in the company and had been unable to find work since. Marianne came to our Center seeking help for not only the recent significant emotional distress she was experiencing but also a life- long history of depression and anxiety that she saw as interfering with her career and relationships, particular- ly romantic relationships, over the course of her life. Al- though she had never sought treatment previously, the recent unexpected loss of her job intensified her feelings of both depression and anxiety. She recently suffered from an unexpected panic attack on a bus, which she had never experienced before. Marianne then realized she could no longer ignore her symptoms.

During her intake interview, Marianne stated that she had been feeling increasingly depressed over the last several months. She described feeling very lethar- gic and having trouble motivating herself to look and apply for new jobs. This was due, in part, to her dif- ficulty concentrating on tasks, which was necessary for both reviewing job descriptions and completing appli- cations. She also found it hard to watch television or read books, as she had trouble staying focused on the information and felt very “restless.” Marianne reported that she spent a lot of time inside her apartment and was avoiding activities she previously enjoyed, such as spending time with her two close friends and garden- ing. This change was particularly significant for Mari- anne, as she did not have an extensive social circle and was distant from her family; her two friends were her primary sources of social support. Similarly, gardening had been an activity that always boosted her mood, but she had not felt motivated to tend to her garden. She felt guilty about avoiding these activities, although she was unable to push herself to be more active. Marianne also reported that she slept late into the morning be- cause she had trouble falling asleep at night. Waking up late further exacerbated her feelings of worthlessness, thereby creating a continuous cycle of disrupted sleep and low mood. Marianne stated that symptoms of de- pression had been a part of her life for as long as she

Emotional Disorders 225

could remember, although she could never recall feeling as badly as she did now. She had experienced chronic feelings of hopelessness and low-self-esteem, as well as low energy since childhood. She attributed her experi- ence of lifelong depression to a dysfunctional and cha- otic family environment growing up. Her father strug- gled with alcoholism, and one of her sisters was born with a serious heart condition that required significant care and management throughout her childhood. Her parents were rarely emotionally available for Marianne, and Marianne learned to suppress her needs so as to not create additional stress for her parents. Additionally, her father’s alcoholism created anxiety due to his unpredict- able moods. When drinking alcohol, he could become angry and verbally lash out at Marianne and her sister, although he was never physically violent.

Marianne also described a lifelong history of anxi- ety and worry that accompanied her feelings of depres- sion. She worried about the health and relationships of her family members, as well as her future. In school, she was an excellent student but stated she was often paralyzed with anxiety about upcoming tests or assign- ments. Currently, Marianne avoided reading newspa- pers or online news stories, as it would further trigger her worries about climate change and the “state of the world.” Unable to stop worrying, Marianne found that avoiding triggers was her only strategy for managing anxiety. She stated she was restless, although also fa- tigued much of the time. She also had chronic muscle tension. Marianne described worrying so frequently, particularly in the last 8 months, that tasks easily be- came overwhelming, which interfered with taking the steps to find a new job. She also reported interference in social relationships due to worry and anxiety because many of her friends were highly successful, which left Marianne worrying that they did not want to be friends with her anymore because she was not “good enough” for them.

Last, Marianne also described experiencing frequent headaches, and occasionally migraine headaches, in the last several years. She stated that on most days, she woke up with a mild headache that would get progres- sively worse throughout the day, making it difficult to concentrate on what she was doing. She stated the pain would be worse on days near the start of her menstrual cycle, and she had not been able to sufficiently treat her symptoms with medications prescribed by a neurologist she was seeing. The headaches were present 90% of the days and were causing her to further avoid activities and friends.

Objective assessment of Marianne’s emotional state via self-report questionnaires resulted in a score of 53 on the Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996), reflecting severe depression and a score of 65 on the Penn State Worry Question- naire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990), reflecting moderate levels of worry. Her scores of 18 on the Overall Depression Severity and Impair- ment Scale (ODSIS; Bentley, Gallagher, Carl, & Bar- low, 2014) and 12 on the Overall Anxiety Severity and Impairment Scale (OASIS; Campbell-Sills et al., 2009; Norman, Cissell, Means-Christensen, & Stein, 2006) were consistent with these other measures, suggesting severe levels of depression and moderate-to-severe lev- els of anxiety, respectively. A diagnostic interview using the Anxiety and Related Disorders Interview Schedule for DSM-5—Lifetime Version (ADIS-5L; Brown & Barlow, 2014) revealed a principal diagnosis of major depressive disorder (MDD), single episode, severe at a clinical severity rating (CSR; described below) of 7, on a 0- to 8-point scale (see below) and additional diagnosis of persistent depressive disorder, early onset (CSR = 5). Marianne was not given a separate diagnosis of GAD, as the symptoms of anxiety and worry had been present for as long as the persistent depressive disorder and were therefore subsumed under that diagnosis.

Interviews

A number of structured and semistructured clinical in- terviews may be appropriate for diagnosing emotional disorders. The Structured Clinical Interview for DSM-5 (SCID-5; First, Williams, Karg, & Spitzer, 2016) is widely used and assesses diagnoses. Because this inter- view is highly structured and focuses only on current symptom count, it achieves a high degree of interrater reliability for many diagnoses. However, this interview does not include dimensional ratings of frequency and severity of symptoms, so it may be less useful for more detailed profiling of emotional disorders.

The ADIS-5 (Brown et al., 2014), a semistructured, diagnostic clinical interview, focuses on DSM diagno- ses of anxiety, OCD and related disorders, and trauma- and stressor-related disorders and their accompanying mood states, as well as somatic symptoms and dissocia- tive disorders, and substance and addictive disorders. The information derived from the interview using the ADIS allows clinicians to determine differential diag- noses and gain a clear understanding of the level and severity of each diagnosis. Principal and additional di-

226 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

agnoses are assigned a CSR on a scale from 0 (No symp- toms) to 8 (Extremely severe symptoms), with a rating of 4 or above (Definitely disturbing/disabling) passing the clinical threshold for DSM diagnostic criteria. Inqui- ries about suicidal ideation are part of this interview. A previous version of the ADIS based on DSM-IV criteria has demonstrated excellent to acceptable interrater reli- ability for the anxiety and mood disorders (Brown, Di Nardo, Lehman, & Campbell, 2001).

Two additional clinician-rated measures that provide a wider range of scores are the (1) Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH- A; Shear, Vander Bilt, & Rucci, 2001) and the (2) Struc- tured Interview Guide for the Hamilton Depression Rating Scale (SIGH-D; Williams, 1988). The SIGH-A was developed to create a structured format for admin- istering the Hamilton Anxiety Rating Scale (HARS; Hamilton, 1959). Respondents are asked to indicate the presence and severity of a number of symptoms that may have been present over the past week, including anxious mood, tension, sleep problems, irritability, and so forth. The rater is also asked to rate the interview behavior of the patient. The SIGH-A includes specific instructions on administration and anchor points for assigning severity ratings. This measure demonstrated good interrater and test–retest reliability (Shear et al., 2001). In addition, scores are similar to (although con- sistently higher than) the HARS.

Similar to the SIGH-A, the SIGH-D was developed to provide more specific instructions for administra- tion and scoring of the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960). Again, patients are questioned about the presence and severity of a range of depressive symptoms over the past week, including depressed mood, suicidal ideation, fatigue, feelings of hopelessness, weight loss, and so forth. The SIGH-D also demonstrated good interrater and test–retest reli- ability, and produces scores similar to the HDRS (Wil- liams, 1988).

Medical Evaluations

Medical evaluations are generally recommended prior to assignment of diagnoses and initiation of treatment to rule out organic causes for symptoms of emotional disorders. Some conditions, such as hypothyroidism, hyperthyroidism, hypoglycemia, mitral valve prolapse, or alcohol or substance withdrawal, may elicit symp- toms similar to those associated with GAD or PD/A. Although the diagnosis of such medical conditions does

not preclude the need for a psychological treatment, it is generally recommended that such conditions be evalu- ated medically, because an alternative treatment may be clinically indicated.

Self‑Monitoring

Self-monitoring forms are an important part of the treatment protocol for several reasons. First, the thera- pist is able to discuss specific situations or events that occurred over the past week and may have contributed to emotional reactions. Such records can facilitate dis- cussions of concepts presented during the treatment sessions and help the therapist integrate the general treatment components into the patient’s specific symp- toms. Second, some evidence suggests that patients’ retrospective recall of past episodes of anxiety may be inflated, particularly when recalling panic attacks (Margraf, Taylor, Ehlers, Roth, & Agras, 1987; Rapee, Craske, & Barlow, 1990). Self-monitoring forms allow for a prospective, and possibly more accurate, account of anxiety episodes and may therefore be more useful therapeutically. In addition, consistent with the themes outlined in the UP, practicing awareness of emotions in the present moment is believed to be an important com- ponent of changing maladaptive patterns of emotional responding. The very nature of self-monitoring requires patients to disengage, even briefly, from the habitual anxious process to write down concrete thoughts, feel- ings, and behaviors, helping them to begin to adopt a more objective stance toward their own emotional ex- periences. Developing this skill ultimately aids patients in beginning to change emotional reactions and result- ing behaviors.

Treatment forms used in the UP include self- monitoring forms for tracking emotional experiences, automatic appraisals, and emotion avoidance, as well as forms for conducting interoceptive and situationally based emotion exposure. Figure 6.1 illustrates the Fol- lowing Your ARC Form, which was designed to help patients track their emotional experiences during the initial phases of treatment (see description of the ARC below). As new skills are introduced for responding to emotions in a more adaptive manner, other self- monitoring forms are also used. For instance, patients are asked to monitor situations, identify emotional behaviors and alternative actions, as well as the short- and long-term consequences of alternative action on the Countering Emotional Behaviors Form (see Figure 6.2).

227

A A A

R R R

C C C

D at

e/

tim e

A nt

ec ed

en t

R es

po ns

e C

on se

qu en

ce

W

ha t t

rig ge

re d

yo ur

em

ot io

na l r

es po

ns e?

Th ou

gh ts

Ph

ys ic

al S

en sa

tio ns

Be

ha vi

or s

Lo ng

-te rm

H

ow m

ig ht

th is

re sp

on se

le

ad to

m or

e ne

ga tiv

e em

ot io

ns in

th e

fu tu

re ?

Sh or

t-t er

m

H ow

is th

is re

sp on

se

w or

ki ng

fo r y

ou ?

F IG

U R

E 6

.1 .

Fo llo

w in

g Yo

ur A

RC F

or m

. R ep

rin te

d w

ith p

er m

iss io

n fr

om O

xf or

d U

ni ve

rs ity

P re

ss .

228

F IG

U R

E 6

.2 .

C ou

nt er

in g

Em ot

io na

l B eh

av io

rs F

or m

. R ep

rin te

d w

ith p

er m

iss io

n fr

om O

xf or

d U

ni ve

rs ity

P re

ss .

U se

th is

fo rm

to h

el p

yo u

th in

k of

A lte

rn at

iv e

A ct

io ns

fo r

th e

em ot

io na

l b eh

av io

rs y

ou w

ou ld

li ke

to c

ha ng

e. U

se th

e fir

st c

ol um

n to

id en

tif y

si tu

at io

ns

th at

b rin

g up

s tr

on g

em ot

io ns

, a nd

u se

th e

se co

nd c

ol um

n to

n ot

e th

e em

ot io

ns th

at ty

p ic

al ly

c om

e up

in th

at s

itu at

io n.

In th

e th

ird c

ol um

n, w

rit e

d ow

n th

e em

ot io

na l b

eh av

io r(

s) y

ou u

su al

ly u

se . F

in al

ly , u

se th

e la

st tw

o co

lu m

ns to

b ra

in st

or m

a lte

rn at

iv e

ac tio

ns a

nd to

c on

si d

er th

e sh

or t-

te rm

an

d lo

ng -t

er m

c on

se q

ue nc

es o

f e ng

ag in

g in

a n

ew b

eh av

io r.

S it

u at

io n

/T ri

g g

er E

m o

ti o

n( s)

E m

o ti

o n

al B

eh av

io r

A lt

er n

at iv

e A

ct io

n( s)

C o

n se

q u

en ce

s o

f A

lt er

n at

iv e

A ct

io n

s

S ho

rt te

rm :

Lo ng

te rm

:

S ho

rt te

rm :

Lo ng

te rm

:

S ho

rt te

rm :

Lo ng

te rm

:

Emotional Disorders 229

Several problems may arise with the introduction and completion of self-monitoring forms. First, some patients may not be compliant with completion of monitoring forms and homework assignments, which is an important issue to be addressed in the therapy ses- sion. Adopting a motivation enhancement approach, eliciting reasons underlying the patient’s ambivalence regarding completing the homework or monitoring can be a valuable technique (i.e., eliciting reasons why the patient might not wish to complete the homework and perceived benefits to not completing it). This process is crucial, as it allows the therapist to identify maladaptive cognitive appraisals and emotional reasons contributing to the lack of completion of monitoring forms. Once such reasons are identified, therapeutic strategies such as cognitive reappraisal may also be used to increase patients’ willingness to complete homework forms. Furthermore, selectively reflecting the benefits of com- pleting the homework and the costs associated with noncompliance can help to build motivation to com- plete homework forms. In some cases, especially when patient self-efficacy for completion is low, completion of homework forms themselves may become an emo- tion exposure, and progress toward this goal should be reinforced accordingly.

Another common problem with the completion of self-monitoring may be the tendency for some patients (particularly those with more obsessive or “perfection- istic” features, commonly seen in GAD and OCD) to “overdo” the homework forms; that is, the patient may write an extremely long and involved description of a situation and his/her reactions to it. This is common with patients who feel a need to “unload” every piece of information about the event. Although the patient is doing the homework, his/her overengagement may also be facilitating the anxious/worry process. If this becomes evident, the therapist may want to discuss the tendency to overengage in the homework as an emo- tional behavior and encourage monitoring situations and events using one- or two-word descriptions, or even implement a time limit to help ensure that patients do not spend lengthy periods of time generating their de- scriptions.

Questionnaires

In our research trials, we employ a number of self- report questionnaires over the course of treatment. We describe most of them here, realizing that for purely clinical purposes only a subset would be needed. Two

general (diagnosis-nonspecific) questionnaires designed to measure symptoms and impairment associated with those symptoms are administered weekly prior to ses- sion to track symptoms and impairment across the course of treatment. A larger questionnaire battery is administered pre-, mid-, and posttreatment, in order to gain a more comprehensive picture of patients’ present- ing concerns, overall functioning, and quality of life. This battery comprises general questionnaires (mea- sures designed to assess a range of symptoms associated with anxiety and mood disorders, as well as disorder- specific measures designed to track symptoms associ- ated with specific disorders).

Weekly General Measures

The OASIS (Campbell-Sills et al., 2009; Norman et al., 2006), a brief, five-item questionnaire developed as a continuous measure of anxiety-related symptom se- verity and impairment, can be used across anxiety dis- orders, with multiple anxiety disorders, and with sub- threshold anxiety symptoms. This measure has good internal consistency, excellent test–retest reliability, and convergent and divergent validity (Campbell-Sills et al., 2009; Norman et al., 2006). The ODSIS (Bentley et al., 2014), a direct adaptation of the OASIS, is modified to be applicable for depression. It is a brief, five-item questionnaire that assesses dimensional depression- related symptom severity and impairment that can be used across depressive disorders, with varied comorbid presentations, and with subthreshold depressive symp- toms. Both measures focus on severity of and impair- ment associated with particular symptoms over the past week, offering a general, diagnosis-nonspecific measure designed to track changes as they occur over the course of treatment.

Optional General Measures

In the Positive and Negative Affect Schedule—Trait version (PANAS; Watson, Clark, & Tellegen, 1988), a brief, reliable, and valid measure of positive and nega- tive affect, individuals rate how frequently they ex- perience 20 feeling or emotion words in general. The PANAS assesses core negative affect and deficits in positive affect in those disorders with this characteristic (i.e., agoraphobia, social anxiety disorder, depression) and is useful in determining changes in positive and negative affect over the course of treatment. In an effort to establish degree of interference from symptoms in

230 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

various domains of living, the Work and Social Adjust- ment Scale (WSAS; Hafner & Marks, 1976) includes five items that ask participants to rate the degree of interference caused by their symptoms in work, home management, private leisure, social leisure, and fam- ily relationships. The WSAS, a descriptive measure of subjective interference in various domains of living, has been successfully used in previous studies (e.g., Brown & Barlow, 1995).

Quality of Life and Well‑Being Measures

The Quality of Life and Enjoyment Satisfaction Ques- tionnaire (QLESQ; Endicott, Nee, Harrison, & Blu- menthal, 1993), a 14-item measure that assesses enjoy- ment and satisfaction across different life areas in the past week, is widely used and has been validated for use in clinical populations and shown to be sensitive to change. The Mental Health Continuum—Short Form (MHC-SF; Keyes, 2005, 2006; Keyes et al., 2008; Lamers, Westerhof, Bohlmeijer, ten Klooster, & Keyes, 2011; Westerhof & Keyes, 2009) is a 14-item measure designed to assess social, emotional, and psychological well-being. The measure has shown excellent internal consistency and discriminant validity in both adoles- cents and adults in the United States, the Netherlands, and South Africa (Keyes, 2005, 2006; Keyes et al., 2008; Lamers et al., 2011; Westerhof & Keyes, 2009).

Diagnosis‑Specific Measures

In addition to the general (diagnosis nonspecific) mea- sures, it is important to assess symptoms specific to the individual’s specific diagnostic presenting concerns. We use the following measures that assess symptom sever- ity over the past week and can be administered both as self-report and clinician-rated measures, increas- ing their clinical utility. The Yale–Brown Obsessive– Compulsive Scale–II (Y-BOCS-II; Storch et al., 2010) is a revised version of the Y-BOCS (Goodman et al., 1989), designed to assess the presence and severity of OCD symptoms.

The Panic Disorder Severity Scale (PDSS; Shear et al., 1997), a seven-item scale, provides ratings of the core features of panic disorder (panic frequency, dis- tress during panic, anticipatory anxiety, panic-related avoidance of situations and sensations) and the degree of work and social impairment/interference due to PD/A.

The Liebowitz Social Anxiety Scale (LSAS; Liebow- itz, 1987) is a widely used 24-item scale designed to as- sess the range of social interaction and performance sit- uations that patients with social anxiety may fear and/ or avoid (Heimberg et al., 1999; Safren et al., 1999).

The Generalized Anxiety Disorder Severity Scale (GADSS; Shear, Belnap, Mazumdar, Houck, & Roll- man, 2006) is a six-item assessment that evaluates the core features of GAD.

The PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993), a 17-item measure designed to as- sess DSM-IV symptoms of PTSD, with each item cor- responding to the symptoms of PTSD, comprises one brief question that is rated from 0 (Not at all) to 3 (5 or more times per week/Very much). This measure yields a total PTSD severity score, as well as Reexperiencing, Avoidance, and Arousal subscores (Foa & Tolin, 2000).

Functional Analysis

Regardless of the diagnosis, a functional understand- ing of the processes that contribute to and maintain an individual’s psychopathology provides an essential foundation for case conceptualization and personaliza- tion of the intervention. Several components are impor- tant to consider when diagnosing a patient based on a functional analysis. These include a close examination of symptom topography (including duration of illness, physical sensations, level of distress, and interference from symptoms), triggers (situations, physical symp- toms, places, thoughts, etc.), cognitions (beliefs about symptoms and misappraisals), behavioral responses to emotions (including avoidance of situations, places, people, or triggers, as well as escape behaviors), and the consequences of behavioral reactions (limiting qual- ity of life, reduced “comfort zone,” etc.). The UP Case Conceptualization Worksheet is presented in Figure 6.3; for a detailed description of transdiagnostic as- sessment and case conceptualization, see Boettcher and Conklin (2018).

Marianne, at the diagnostic level, met criteria for what is often referred to as “double depression,” in that she experienced persistent depressive disorder her whole life but now was also experiencing a major depressive episode. Her primary concern involved significant feelings of depression, fatigue, trouble concentrating, and anhedonia, and Marianne clearly met criteria for MDD, single episode. However, feelings of low self- esteem, hopelessness, and fatigue had also been present

Emotional Disorders 231

FIGURE 6.3. UP Case Conceptualization Worksheet. Reprinted with permission from Oxford University Press.

Patient:_______________

PRESENTING PROBLEMS:

STRONG UNCOMFORTABLE EMOTIONS:

AVERSIVE REACTIONS:

AVOIDANT COPING

SITUATIONAL AVOIDANCE/ESCAPE

SUBTLE BEHAVIORAL AVOIDANCE:

COGNITIVE AVOIDANCE:

SAFETY SIGNALS:

TREATMENT PLAN: FOCUS/APPLICATION OF CORE MODULES

MODULE 3:

MODULE 4:

MODULE 5:

MODULE 6:

MODULE 7:

232 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

since childhood, although Marianne was able to cope with the symptoms despite the significant distress and interference in her relationships. Thus, a diagnosis of persistent depressive disorder was also warranted. Mari- anne also presented with significant anxiety and un- controllable worry about her family and their health, the state of the world, and her relationships. These wor- ries, although clearly significant, were only experienced during the course of the persistent depressive disorder. Thus, even though Marianne met diagnostic criteria for GAD, an additional diagnosis was not assigned.

Whereas Marianne’s symptoms merited the assign- ment of multiple co-occurring disorders, it is impor- tant to note that at the phenomenological level, these diagnosis-specific symptoms shared significant overlap. This was an important consideration for treatment, and it provided a strong argument for a unified, transdiag- nostic approach. For example, Marianne’s low self-es- teem, driven by her depressogenic ruminations, resulted in significant anxiety and worry when she confronted situations in which she was being evaluated by others. This anxiety focused on negative evaluation in turn in- creased Marianne’s negative beliefs about herself and her life, then fueled her emotional behaviors, for example, isolating herself, which was an attempt to avoid feel- ing worse about herself. Without any social contact or experiences outside her apartment, she became heavily focused on physical symptoms, particularly headaches, which then created anxiety and additional obstacles to improve her functioning (i.e., applying for jobs). By avoiding job applications and other anxiety-provoking activities Marianne unintentionally reinforced the neg- ative belief that she was incompetent and would not be able to make changes in her life. Marianne attributed this negative cycle to her experiences growing up, when her inability to effect change in her family dynamics, particularly with her father, created a sense that she had little ability to modify her circumstances. Thus, all of these beliefs, behaviors, and physiological responses were interacting in Marianne’s emotional experiences, regardless of their specific diagnostic classification, and affecting her ability to function in an adaptive way. Treatment of Marianne’s symptoms with the UP, which focuses on how the interactions of thoughts, feelings, and behaviors at any given moment influence overall emotional experiences and subsequent actions, allowed us to target Marianne’s phenomenological patterns of dysfunction directly rather than focus on one diagno- sis-specific cluster of symptoms at a time.

COMPONENTS OF TREATMENT

The structure of the UP outlines five core treatment modules and three additional modules, designed to be delivered in 12–18, 50- to 60-minute individual treat- ment sessions, held on a weekly basis. Final sessions may be held every other week to allow patients to con- solidate gains and to provide somewhat of a “taper” off the weekly therapy. This format for the final sessions is not a requirement, though, and it may be more ben- eficial for the patient to continue to have weekly ses- sions if he/she might potentially have trouble using the treatment concepts consistently without the weekly re- inforcement of sessions. Therefore, spacing of the final sessions is determined by the therapist, who takes into consideration the patient’s progress and any anticipated difficulties after treatment.

The five core treatment modules designed to target aspects of emotion processing and regulation are as follows: (1) Mindful Emotion Awareness (Module 3); (2) Cognitive Flexibility (Module 4); (3) Countering Emotional Behaviors (Module 5); (4) Understanding and Confronting Physical Sensations (Module 6); and (5) Emotion Exposures (Module 7). Preceding these core components is a module focused on enhancing motivation and readiness for change and treatment en- gagement (Module 1—Setting Goals and Maintaining Motivation), as well as an introductory module pro- viding psychoeducation about the nature of emotions and a framework for understanding emotional experi- ences (Module 2—Understanding Emotions). A final module reviews progress over treatment and develops relapse prevention strategies (Module 8—Recognizing Accomplishments and Looking to the Future). This treatment, which takes place in the context of provok- ing emotional expression (emotion exposure) through situational, internal, and somatic (interoceptive) cues, as well as through standard mood induction exercises, differs from patient to patient only in the situational cues and exercises utilized. In addition, “exposure” is not conceptualized as a mechanism of action. Rather, successfully provoking emotions creates a setting condi- tion to implement the essential treatment components. Emotion exposures begin with general stimuli (e.g., mood induction and interoceptive provocation) and are later tailored to address each patient’s particular con- cerns and symptoms. Although each session addresses a specific component of the protocol, the expectation is that patients then “carry through” the strategies they

Emotional Disorders 233

learn to future sessions (e.g., patients learn cognitive reappraisal strategies in Module 4 but are expected to continue to use this strategy throughout the remainder of treatment).

Module 1: Setting Goals and Maintaining Motivation

In this initial treatment module, which is grounded in the principles and therapeutic techniques utilized in motivational interviewing (MI; Miller & Rollnick, 2013), therapists work to increase the patient’s readi- ness and motivation for behavior change, and to foster a sense of self-efficacy, or the patient’s belief in his/her ability to change. This module was included in the pro- tocol in response to research by Westra and colleagues (Westra, Arkowitz, & Dozois, 2009; Westra & Dozois, 2006) suggesting that MI may enhance the efficacy of CBT for anxiety disorders. This module utilizes two specific motivational exercises: (1) a decisional balance exercise, in which the therapist works with the patient to identify and weigh the pros and cons of changing versus staying the same; and (2) a treatment goal-setting exer- cise that helps patients more clearly articulate achiev- able and concrete goals for treatment. This module, and the principles and techniques contained therein, are primarily used to help “set the stage” for subsequent learning that takes in the core modules. However, the principles can also be applied throughout the course of treatment to enhance treatment engagement and main- tain patient motivation for behavior change.

Module 2: Understanding Emotions

Following the initial motivation enhancement session, patients are provided with psychoeducation about the nature and function of emotions, including anxiety, anger, sadness, shame/guilt, and fear. In this module (which typically occurs over the course of one to two sessions), patients are provided information about the cognitive, physiological, and behavioral sequelae of emotional reactions and how these three components interact. It is important that the patient begin to con- sider that his/her reactions are functional and serve the purpose of providing information about the environ- ment, in addition to protection from harm. This three- component model is then applied to a recent situation or event that the patient experienced, so that he/she may better understand the aspects of each component and how they interact. Patients also learn how to care-

fully monitor and track their emotional responses and, as a result, are expected to develop greater awareness of their own patterns of emotional responding, including potential maintaining factors (e.g., common triggers and/or environmental contingencies).

As noted earlier, the UP uses the acronym ARC to describe the sequence of events around emotions. Emotions are always triggered by an event, situation, or experience known as an antecedent (the A in the ARC). Often there are multiple antecedents, and may include recent and distal events. One’s response to the emotional experience (the R of ARC) corresponds to all cognitions, somatic sensations, and behaviors from the three-component model. Finally, short- and long-term outcomes of emotional responding are referred to as consequences, or the C of the ARC. During this expla- nation, the therapist clearly works through an example with the patient.

Another important aspect of psychoeducation is the concept of negative reinforcement. This involves a detailed discussion of how the patient’s behavioral re- sponse to an emotional episode (usually escape or some form of emotional avoidance) is problematic, because it reduces the emotion in the short term (i.e., by removing the person from the emotional stimulus) but reinforces the cycle of emotions in the long term (i.e., by teach- ing the person that escape/avoidance is the only way to manage these feelings in the future). It is extremely important that the patient understand the connection between behavioral responses and reinforcement of emotion, so that he/she is better able to appreciate the purpose and function of emotion exposures introduced in future sessions.

Module 3: Mindful Emotion Awareness

The first core module (which typically occurs over the course of one to two treatment sessions) is designed to help patients further identify how they are reacting and responding to their emotions by promoting a more non- judgmental, present-focused approach to the experience of emotions. Often, patients report feeling that their emotions are confusing, or that they seem to just hap- pen “automatically” and/or in such way that they are outside of the patient’s immediate awareness (i.e., “un- consciously”). Through this module, patients learn to become more aware of the interaction among thoughts, feelings, and behaviors, and to view their emotions in a more objective and present-focused manner. This

234 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

occurs within the specific context of the situation in which the emotional experience is unfolding. The focus on present-moment experiences is important and is be- lieved to put the patient in a better position to more clearly identify patterns of emotional responding and/ or the emotion regulation strategies being employed in the particular situation. In turn, this renders the patient better able to modify the emotional response adaptively to make it more consistent or compatible with ongoing situational or motivational demands. Furthermore, the therapist introduces the idea that it is not the emotions per se that are problematic, but rather how the patient reacts to the emotions. As these reactions tend to be judgment-laden (e.g., seeing anxiety as a sign of one’s inability to cope an indication of weakness, or a sign of failure) and are often not based on information from the present-moment context, they can prevent the pro- cessing of potentially corrective information that would allow for a change in the emotional response. It is ex- pected that as patients develop a more nonjudgmental stance toward their emotions, they are better able to identify the specific thoughts, physical sensations, and behaviors that may be contributing to their distress, and thus be in a better position to implement strate- gies for adaptively altering their emotional response. Mindful emotion awareness also allows for the pos- sibility of attending to positive emotions, should they arise. These skills are developed through the practice of a brief mindfulness meditation, emotion induction exercises, and a “three-point check” that utilizes emo- tion awareness in the context of an emotion-provoking situation. Emotion awareness thereby also serves to fa- cilitate extinction of reactivity to and distress associated with emotion experiences.

Module 4: Cognitive Flexibility

Cognitive therapy, initially developed by Aaron T. Beck to treat depression (Beck, 1967; Beck, Rush, Shaw, & Emery, 1979; also discussed in depth in Young, Ward- Ciesielski, Rygh, Weinberger, & Beck, Chapter 7, this volume), has become a fundamental part of psychologi- cal treatments. Individuals with emotional disorders are likely to have appraisals and interpretations of external events that are characterized by cognitive biases, such as the tendency to overestimate the likelihood of the occurrence of negative events and to underestimate the ability to cope with these events. Thus, the aim of cog- nitive therapy is to evaluate objectively the likelihood of these negative appraisals and to incorporate more

realistic, evidence-based appraisals of the outcome of a situation. On the surface, this technique may appear to be a way to suppress or control negative thoughts by “rationalizing” them, and occasionally, this is how cog- nitive therapy is incorrectly used, as noted by Hayes, Strosahl, and Wilson (1999). However, this strategy can also be conceptualized from an emotion regulation per- spective, especially if reappraisals are considered one of many possible interpretations of a situation.

The primary aim of this module is to foster greater flexibility in thinking (this module is typically admin- istered in one or two sessions). This is accomplished first by helping patients develop an understanding of how they interpret or appraise situations, and how their appraisals influence patterns of emotional responding, then by teaching them to generate numerous alternative attributions and appraisals when experiencing strong emotional experiences. As their initial interpretations are typically more negative or anxious, patients are encouraged to be more flexible in their thinking (i.e., to generate alternative appraisals) and are taught reap- praisal strategies.

As adapted in our usage, the UP focuses on correct- ing two fundamental misappraisals often found in in- dividuals with emotional disorders: the probability of a negative event happening (probability overestimation) and the consequences if the negative event does happen (catastrophizing) (Barlow & Craske, 2007; Craske & Barlow, 2006). Although a number of other misapprais- als are noted in other, traditional CBT protocols, most misappraisals can be condensed into one of the two ap- praisals listed here.

Module 5: Countering Emotional Behaviors

Module 5 generally comprises one to two sessions. This module focuses on the behavioral component of emo- tion. Specifically, patients are taught skills to evaluate and prepare to change “emotional behaviors,” which are behaviors that occur in anticipation of or in response to emotion. Emotional behaviors fall into two general categories: behaviors that prevent the full experience of emotion (avoidance) or as behaviors driven by the emotion itself (emotion-driven behaviors [EDBs]). The concept of emotion avoidance is likely to be particu- larly important for patients who do not physically avoid or escape situations but still experience high levels of anxiety without much relief. The therapist should con- vey that even if the person stays physically in the situ- ation, he/she is likely to engage in a number of other

Emotional Disorders 235

subtle behaviors to prevent full emotional arousal. Any technique or strategy the patient uses to reduce or to down-regulate emotions, or any behavior that occurs in response to an emotion, may be conceptualized as an emotional behavior, and it is essential that emotion- al behaviors be identified and eliminated as much as possible prior to engagement in emotion exposures, to allow for full emotional processing. Therefore, a very detailed description of individual emotional behaviors must be obtained for each patient. Common examples of emotional behaviors associated with different emo- tions are presented in Figure 6.4.

Within the emotional behaviors, we have identified four general categories of emotional behaviors that serve as avoidance strategies: (1) overt avoidance, (2) subtle behavioral avoidance, (3) cognitive avoidance, and (4) safety signals. Overt avoidance refers to directly avoiding a situation, task, person, or place because of the anticipated emotion it will trigger. Subtle behavioral avoidance strategies may include a number of differ- ent behaviors, with certain behaviors occurring more frequently with particular disorders. For example, the avoidance of caffeine in panic disorder or social phobia (prior to a social engagement) is an attempt to keep physiological symptoms from becoming strong in anx- iety-provoking situations. Patients with social phobia may also avoid eye contact or wear sunglasses when in- teracting in social settings. Individuals with GAD may excessively plan, prepare, or write “to do” lists in an at- tempt to control potentially negative outcomes. At the same time, procrastination is also a form of subtle be- havioral avoidance, if a particular task or project seems too emotionally arousing or distressing for the patient. It is very important to conduct a functional analysis of the subtle behaviors to determine which ones are avoid- ance strategies, that is, behaviors that serve to reduce or avoid emotional experience, and which are functional responses to situations. And, notably, what may be an avoidance strategy for one person may be a functional response for another. Cognitive avoidance strategies are typically more difficult to identify, because they tend to occur outside of the patient’s awareness. Some of these strategies include distraction, “tuning out,” and mentally checking lists or reviewing past conversations. However, data also suggest that worry and rumination actually function as a way to down-regulate and avoid emotions (e.g., Borkovec, 1994). The function of worry is to enable the person to prepare for a possible threat. However, when someone experiences chronic worry and associated anxiety, his/her attention is focused on

the future as opposed to the present moment. Research has shown that when confronted with an emotionally arousing event, chronic worriers do not experience the full emotional impact of that event because (1) they have been “bracing” themselves for something bad to happen, and (2) their focus has already shifted to other, future negative outcomes (Borkovec, Hazlett- Stevens, & Diaz, 1999). Therefore, the worry functions as a cognitive avoidance strategy and only serves as a maladaptive attempt to gain control over seemingly uncontrollable future events. Obsessions, common to individuals with OCD, may also function in a similar manner.

Safety signals are most common to patients with PD/A, although may also be present in individuals with GAD, OCD, or other emotional disorders. Safety sig- nals include any object that the patient carries to feel more safe or “comfortable,” particularly if he/she is en- tering an emotionally arousing situation. Safety signals can range from actual medication (e.g., benzodiaze- pines for reducing physiological arousal or medications for gastrointestinal distress) to empty medication bot- tles, to “lucky” objects (a talisman, teddy bear, “lucky” pen, etc.). Regardless of the object itself, if its function is to help the patient reduce emotional arousal in the moment, then it also is problematic, because it feeds into the cycle of negative reinforcement.

In addition to changing patterns of avoidance, this module also focuses on helping patients identify and subsequently change EDBs. Data and hypotheses from emotion science suggest that the most efficient and effective way to change emotions is by changing the behavior the emotion is driving (Barlow, 1988; Izard, 1971); thus, it is conceivable that the mechanism of change during an exposure is to prevent the action ten- dency associated with a particular emotional experience. Over the past several decades, research has focused on these action tendencies, and changing action tenden- cies has become an important treatment component for anxiety, as well as other emotional disorders (Bar- low, 1988; Linehan, 1993). For example, Beck and col- leagues (1979) based a large part of their treatment for depression on changing the action tendencies of their patients to behave in a “passive, retarded, and apathetic manner” (p. 312). More recently, behavioral activation strategies have become a central feature of newer treat- ments for depression (Dimidjian et al., 2006; Jacobson, Martell, & Dimidjian, 2001); for a more in-depth dis- cussion, see Dimidjian, Martell, Herman-Dunn, and Hubley (Chapter 9, this volume).

236 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Emotion Emotional Behavior Type

Anxiety Walk instead of taking public transit Overt Avoid talking to attractive individuals Overt Text at parties to avoid small talk Subtle behavioral Say “I don’t know” Subtle behavioral Listen to music when walking Cognitive Worry about tomorrow’s to-do list Cognitive Engage in checking behavior (locks, stove, etc.) EDB Ask for reassurance EDB

Sadness Decline offers to see friends Overt Avoid physical exercise Overt Speak in a low tone of voice Subtle behavioral Make minimal eye contact Subtle behavioral Watch television Cognitive Sleep excessively Cognitive Think about all the things you’ve done wrong EDB Engage in self-injurious behaviors EDB

Anger Refuse to drive during rush hour Overt Avoid talking to provoking people Overt Make snide comments Subtle behavioral Make deprecating jokes Subtle behavioral Silently curse Cognitive Ruminate Cognitive Insult someone EDB Yell or hit someone EDB

Guilt Not say “no” to tasks Overt Not express one’s opinion Overt Fidget Subtle behavioral Speak quietly Subtle behavioral Worry Cognitive Ruminate Cognitive Overapologize EDB Do “extra” things to “make up for doing something wrong” EDB

Happiness Avoid pleasurable activities Overt Avoid contact with enjoyable people Overt Make comments that undercut the enjoyment of a situation Subtle behavioral Remind oneself that the good feelings can’t last Subtle behavioral Worry Cognitive Ruminate Cognitive Do something that makes one feel bad EDB Overengage in pleasurable activities to try to “hold on” to the good feelings EDB

FIGURE 6.4. Examples of emotional behaviors. Reprinted with permission from Oxford University Press.

Emotional Disorders 237

Whereas the function of emotional avoidance strat- egies is to down-regulate or suppress emotions, EDBs include a specific set of “reactive” behaviors associated with each emotion. For example, the EDB for a panic attack is escape (fight or flight), whereas that for anxi- ety is hypervigilance. Similarly, the emotion of anger elicits an EDB of attacking–defending, and the EDB for sadness is cognitive, emotional, and physical slow- ing and withdrawal. It is important to note, however, that the therapist must focus on helping the patient engage in alternative actions for all emotional behav- iors, from changing EDBs to preventing all types of avoidance. For example, a patient with social phobia may be able to maintain eye contact and fully engage in social situations but escape the situation when his/ her anxiety rises to the level of panic. On the contrary, this same patient may be able to stay in the situation as long as needed, but he may be distracting him/herself the whole time or avoiding conversations with people. Clearly, both scenarios are problematic, because the pa- tient is preventing him/herself from learning that he/ she can experience emotions at their fullest without leaving the situation.

After reviewing and identifying emotional behaviors in session, patients identify several emotional behaviors they might engage in, then generate possible alternative actions to these emotional behaviors. An alternative ac- tion is any behavior that is different than the emotional behavior. The potential short- and long-term conse- quences of engaging in the alternative actions are also highlighted and reviewed in session.

Module 6: Understanding and Confronting Physical Sensations

This module (typically one session) was designed to increase patients’ awareness of the role of physical sen- sations as a core component of emotional experiences and to promote increased tolerance of these sensations. In this module, patients are asked to engage in a se- ries of interoceptive exposure (IE) exercises designed to induce physical sensations analogous to those typically associated with naturally occurring feelings of anxiety and emotional distress (e.g., shortness of breath, heart palpitations, dizziness), which themselves often become cues for anxiety through interoceptive conditioning (Barlow, 2002). Examples of IE exercises include hy- perventilation, spinning (while standing and/or in a chair), running in place, and breathing through a thin straw). The use of IE has largely been confined to the

treatment of PD/A, and has been shown to be effec- tive in reducing panic attack frequency and the fear of physical sensations that occur as a primary feature of the disorder (e.g., Barlow et al., 2000; Craske, Rowe, Lewin, & Noriega-Dimitri, 1997). However, given the fact that heightened physiological arousal and sensitiv- ity to physical sensations are observed in other emotion- al disorders, IEs are applied across diagnoses, regardless of whether the physical sensations represent a specific focus of the patient’s anxiety.

Module 7: Emotion Exposures

In this final core module, treatment concepts are prac- ticed and extended during in-session emotion expo- sures created by the therapist and individually tailored to the patient’s presenting symptoms (this module is the longest; typically lasting four to six sessions). Through exposure to both internal and external cues, patients ul- timately increase their tolerance of intense and uncom- fortable emotional experiences. In-session exposures can range from an imaginal exposure to a past emo- tional event (for PTSD or GAD), a conversation with a stranger (for social phobia), going into a dirty bathroom (for OCD), or watching a sad movie or movie clip (for MDD or persistent depressive disorder). Furthermore, for some patients, continued engagement in IEs may be indicated to promote greater tolerance of uncomfort- able physical sensations. The goal of the exposures is gradually to introduce situations and experiences that serve as external triggers for emotional experiences. By eliciting the emotions that patients have been avoiding, they have the opportunity to practice the techniques learned in treatment (present-focused awareness, cogni- tive reappraisal, and engaging in alternative action). In this sense, exposure to the emotion itself is the neces- sary mechanism of action for change. Thus, the actual situational context of the exposure becomes less impor- tant. Therapists must be creative in the design of the exposure to maximize the emotion provocation for each patient.

Module 8: Recognizing Accomplishments and Looking to the Future

Treatment concludes with a general review of treatment principles and a discussion of the patient’s progress (usu- ally one session). In this module, therapist and patient identify specific strategies for maintaining and extend- ing treatment gains and for responding to future dif-

238 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

ficulties that may arise. For instance, it is emphasized that a return of anxiety and/or mood difficulties does not reflect relapse and, instead, may be a more natural fluctuation of emotions that can be addressed using the skills developed in treatment.

DETAILED DESCRIPTION OF PROTOCOL

The following session descriptions and accompanying transcripts are from the case of “Marianne,” described earlier, treated by one of the authors (L. A. P.).

Session 1: Functional Assessment and Introduction to Treatment

During the introductory session, the goals of the treat- ment program are identified and reviewed. The UP aims to help clients become aware of and better under- stand emotional experiences and reactions, and to coun- ter maladaptive responses to uncomfortable emotions. Modifying maladaptive responses can help reduce the intensity and frequency of uncomfortable emotions, while still allowing clients to experience them in an adaptive way. It is also important to emphasize that modifying these responses can be challenging, and that change often does not occur in a linear fashion.

Following this introduction to treatment is a detailed review of the presenting complaint. In this review, the therapist focuses on the emotions that result in the most distress and/or interference in the patient’s life, the situ- ations and contexts in which those emotions occur, and how the patient has attempted to manage these emo- tions. Below, Marianne describes how depression has interfered with finding a new job:

THERAPIST: Marianne, you have said that feelings of depression have made it difficult for you to find a new job. Can you tell me more about that?

MARIANNE: Well, when I lost my previous job, I just felt so awful about myself. Even though I knew it didn’t really have much to do with my performance. And since then, I just feel like I’m such a loser. Whenever I think about looking for a new job, I just don’t want to do it.

THERAPIST: Why is that? MARIANNE: Every time I see a job listing that would be

relevant to my qualifications, I automatically think, “They would never want me. I’m not smart enough,

I am not very organized, and I’m just completely in- competent.” Even just thinking about this now gives me a pit in my stomach.

THERAPIST: And so, what do you do when you feel this way?

MARIANNE: I just go lie down in bed usually. Some- times I will try to watch TV if I’m able to concen- trate. But it’s really hard to do anything! I don’t want to keep looking for jobs, but then I just sit there and feel miserable. Then I start thinking about how I’m feeling, and my headache gets worse. After that, I’m useless for the rest of the day.

THERAPIST: So, it sounds like the stress of looking for a new job has also been making your physical symp- toms worse, particularly headaches?

MARIANNE: Yes. THERAPIST: Have you found any strategy that has

helped you? MARIANNE: Not really. I’m just completely paralyzed.

I can’t escape feeling badly, no matter what I do.

Note that in this early exchange, the therapist has already obtained important information about the pa- tient’s emotional experiences and the ways she copes with uncomfortable emotions. In this case, Marianne is experiencing very low self-esteem and intense self- criticism whenever she begins the process of looking for a job. The therapist is able to gather information about some of Marianne’s negative automatic apprais- als (e.g., Marianne’s belief that she is incompetent and not smart), anxiety-related physical sensations (e.g., a “pit” in her stomach and headaches), and maladaptive behaviors (e.g., worry, rumination, avoidance, procras- tination). The therapist is also able to elicit information about whether the patient’s current ways of responding to uncomfortable emotions are actually helpful. In this case, Marianne is aware that avoidance of looking for a job is not a solution to her difficulties, but she is so para- lyzed by emotion that she does not know what else to do.

Although the therapist spends a significant portion of the session reviewing Marianne’s presenting com- plaints and gathering additional information about her responses to emotions, this process will continue across the first several treatment sessions. As the thera- pist obtains more details about strategies (adaptive or maladaptive) for managing emotions, emotional or situational avoidance, and engagement in EDBs, this is then integrated into the patient’s UP Case Concep-

Emotional Disorders 239

tualization Worksheet, and the treatment plan may be adjusted accordingly.

Module 1: Setting Goals and Maintaining Motivation

This module focuses on achieving the goals of prepar- ing and developing each patient’s willingness to make identified behavioral changes, based on the MI princi- pals and techniques developed by Miller and Rollnick (2013). Specifically, the principles of (1) expressing empathy, (2) developing discrepancy, (3) rolling with resistance, and (4) supporting self-efficacy are used in this module and throughout the course of treatment to support behavior change. In this module, the therapist explores motivational issues with the patient through exercises designed to build motivation (through the Decisional Balance Worksheet) and to enhance self- efficacy (using the Treatment Goals Form). The aim of these exercises is both to highlight potential obstacles to change and to identify the patient’s top problems and specific, concrete goals, respectively.

THERAPIST: Let’s take a look at your Treatment Goals Form. We filled out some of this in our last session, and you were going to keep working on it at home. I remember we specifically talked about your top problems last time, which you identified as “I can’t find a job” and “I don’t have many friends.” What concrete goals did you identify for the problem of “I can’t find a job”?

MARIANNE: Well, one goal is to actively look for jobs. This could mean looking on the internet or reaching out to previous co-workers. Another goal would be to actually apply to jobs that seem to match my skills.

THERAPIST: That’s great! Those are two good goals to help you work toward this top problem. What steps did you come up with for each?

MARIANNE: For the goal of looking for jobs, one pos- sibility would be to reach out to previous coworkers and bosses to let them know I’m on the job market, but I’ll need to update my resumé. I guess that could be another step, too. I can also look on the Internet. But I already know I should be doing that—it’s just that I can’t do it!

THERAPIST: Absolutely. If you could just do these steps on your own, you would have done them! But it’s still helpful for us to write them down so that we can refer back to them later on in treatment and to make sure

you and I are on the same page about what you are working toward. That way, I can better help you get there. What are the concrete goals you had for your other top problem of “I don’t have many friends.”

MARIANNE: I don’t know. I really couldn’t come up with anything. Maybe a goal of having more friends?

THERAPIST: Yes, it does sound like having more friends is the outcome you want, but let’s try to stay focused on something clear and concrete that has to do with your own behavior. How about a goal of developing closer relationships with the friends you have?

MARIANNE: Yes, I suppose that would be a good goal. And maybe another goal would be to work on meet- ing new people.

THERAPIST: That’s great. What are some steps for each of those goals? Remember, you’re not expected to be able to take those steps right now.

MARIANNE: One step for trying to have closer relation- ships with my existing friends would be to actually participate in their weekly potluck dinners. I don’t like to go to those, because everyone always asks whether I’ve found a new job. But I think they do have a lot of fun at those dinners and maybe they would bring us closer.

THERAPIST: OK, that’s a good step for that goal. What about for the other goal of meeting new people?

MARIANNE: I suppose I could join some sort of club or group activity of some kind.

THERAPIST: That’s a very good idea. OK, now that you have the hang of this, can you work on some addi- tional steps for these goals over the next week?

MARIANNE: Yeah, I could do that.

Module 2: Understanding Emotions

Understanding Your Emotions: What Is an Emotion?

The therapist begins this module by providing psycho- education about the nature of emotions and how they become disordered. It is important to highlight the functional, adaptive nature of emotions at the onset of this discussion for two reasons: (1) so the patient can understand why he/she would not simply want to elimi- nate emotions and (2) to explore the potentially impor- tant information provided by adaptive emotions.

Next, the three-component model of emotional ex- periences is described as a framework for examining emotions by dividing them into components (cognitive,

240 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

physiological, and behavioral), thereby making them more manageable. The therapist guides the patient in identifying each component in a relevant personal ex- ample and presents the model as the structural basis for treatment. Each component is addressed over the course of treatment as contributing to the overall emo- tion and interacting with the other components. For homework in this section of the module, the patient is asked to complete a three-component model example in which he/she is asked to break down an emotion from the week into the three-component model presented in session, by recording the thoughts, behaviors, and physiological sensations specific to that example.

THERAPIST: When they are functioning in an adaptive way, emotions give us some really helpful informa- tion about the environment. Anxiety lets us know when there could be a possible threat—it makes us “hypervigilant” (or hyperaware) of our surround- ings. This is good, because then we can be prepared if we might be in a dangerous situation. Anger lets us know when we’ve been wronged in some way and encourages us to either get back something that was taken from us by attacking or to defend ourselves. So, when functioning adaptively, all of our emotions are really important to our survival, and that’s why we would not want to get rid of them. But it’s pos- sible for our emotions to start becoming maladap- tive, meaning they are happening too frequently or intensely or in situations that don’t warrant the emo- tion. Because an emotion can also trigger all sorts of associated thoughts, memories, physical sensations, and behaviors, often from other experiences in our lives, we can get overwhelmed and caught up in our emotional responses. It feels like something we can’t cope with, that we have to get away from. So, the sadness you feel about losing your job isn’t function- ing as a helpful way to let you know that you’ve lost something that is important to you and motivating you to change the situation, which is, at its core, the adaptive function of sadness. Instead, the sadness can trigger anxiety and become paralyzing, not let- ting you take the right steps to move forward.

MARIANNE: I guess that’s true, but I don’t feel very sad about losing that particular job. It was OK, but I was thinking of leaving it in a year or two anyway.

THERAPIST: Yes, but I wonder if there is sadness about something else? Maybe not the loss of this specific job, but maybe you felt a sense of rejection? The rea-

son I say that is because I think anyone would feel that to some degree in this situation. It’s natural and adaptive to want to be accepted by others, so feeling rejected can make us sad. But for you, that feeling of rejection and sadness might be associated with many other thoughts and feelings from your life experienc- es, so it quickly becomes overwhelming and intoler- able. So, to help us better understand exactly what’s going on, we need to break down these emotional experiences into their component parts to help make them less overwhelming, and to help us identify how an emotion like sadness goes from something adaptive and useful to something that makes you “paralyzed.” As I mentioned, emotional experiences are made up of three main parts: thoughts, physi- cal sensations, and behaviors. What we need to do is help you recognize each of these parts, to make you a better observer of your emotional experiences. Then, throughout treatment, we’ll take a closer look at each of these components individually, to see how specific thoughts, feelings or physical sensations, and behav- iors might be influencing your overall experience and causing the experience to go from something helpful and useful to something uncomfortable and unwanted.

Understanding Your Emotions: Following the ARC

An important step to gaining greater understanding of emotional experiences involves more closely monitoring when, where, and why the emotions are occurring. This is done through illustration of the ARC of emotions. In this illustration, it is critical that the therapist clearly work through an example with the patient, particu- larly short- and long-term consequences of emotional responding. Consequences are often negative, but it is important that the therapist point out potential positive consequences of emotional responding (e.g., reduction in anxiety after escaping a difficult situation), as this process of negative reinforcement is usually maintain- ing the cycle of emotions. The positive experiences are typically short term, and negative outcomes are usually experienced in the longer term.

Expanding on this discussion, the therapist now in- troduces the concept of learned behaviors, essentially focusing on how the patient has learned responses to emotions that are usually an attempt to manage or con- trol the emotions and may briefly lead to feeling better, but often end up leading the patient to feeling worse. Habitually responding to emotions prevents any new

Emotional Disorders 241

learning from taking place (i.e., that a situation is not as dangerous as it appears during the experience of a panic attack) and disables the patient from developing a way of coping. It also undermines the patient’s sense of self- efficacy for dealing with negative emotions. This entire process is what makes adaptive emotions and emotional responses maladaptive. Yet knowing that the habitual responses provide some relief, even minimally, can help the patient understand why he/she continues to engage in the behaviors.

Module 3: Mindful Emotion Awareness

The goal of this module is to introduce the patient to the concept of mindful emotion awareness and begin developing a regular practice of this skill. The thera- pist must convey that the mindful emotion awareness skill is different than the patient’s current awareness of his/her emotions. This skill allows the patient to see an emotion from an objective and nonjudgmental perspec- tive in order to better identify and alter maladaptive thoughts and behaviors, and process the emotion more fully instead of avoiding it. During this introduction, the therapist reviews the concept of nonjudgmental emo- tion awareness. The therapist discusses how it is easy to judge and critique emotional experiences, either by tell- ing oneself that one “should” or “shouldn’t” be feeling certain emotions or by holding on to beliefs that cer- tain thoughts or emotions are “bad” or “harmful.” Both of these approaches are associated with being anxious about emotions, which makes the patient want to sup- press or avoid those emotional experiences. As discussed in the previous module and in more detail in Module 5, trying to control emotions in this way is precisely what leads to emotions becoming increasingly maladaptive. Nonjudgmental emotion awareness focuses on accep- tance of emotions as they come and go, regardless of the quality or intensity of the emotion. It’s taking a “hands-off” approach to emotional experiences in an effort to interrupt the cycle of emotional avoidance and maladaptive emotions. The therapist must also com- municate to the patient that this is not an endorsement of “giving up” or accepting that he/she will always feel depressed or anxious. Rather, it is an effort to gain more control and confidence by observing emotions instead of reacting to them.

The next component of mindful emotion awareness is present-focused emotion awareness, which is the skill of repeatedly bringing attention back to the present mo- ment and to what is happening in the “here and now” as

opposed to allowing thoughts to focus on past experi- ences or future concerns. Learning to stay in the pres- ent moment can also be very helpful for determining the most adaptive responses to a situation, as well as make it more manageable. Also, focusing on the pres- ent moment can be helpful for connecting with positive emotions, with which many patients may struggle. This new approach to emotions is likely very different from how the patient typically experiences emotions, so de- veloping this skill takes practice.

When practicing mindful emotion awareness, it is important that the therapist remind the patient of sev- eral points. First, this type of practice may feel awk- ward or uncomfortable at first. The goal is not to be “perfect” at the exercise; rather, the patient should focus on becoming an objective observer of emotional experience and start developing the ability to pay at- tention mindfully and in the moment. It is also natu- ral for patients to judge or criticize their experiences during this practice, possibly because they find it dif- ficult to stay focused or remain calm. The mind being judgmental is a natural process, and the value of the exercise comes from the simple act of practicing it, not from feeling calm or staying focused. The goal is the behavior of practicing, not having a specific experience during the practice.

Mindful Emotion Awareness Meditation

Developing the skill of mindful emotion awareness typically begins with the practice of a formal medita- tion exercise. In session, the therapist can read the script detailed in the protocol. The patient may choose to au- dio-record this reading or read the script at home and audio-record it for practice during the week.

Mindful Mood Induction

After the patient has had a chance to practice the mind- ful emotion awareness skill during a formal medita- tion, the next practice involves using the skill to notice slightly stronger emotional experiences. It is often help- ful to have the patient identify a salient piece of music to listen to in session; otherwise, the therapist can select a piece of music. At the conclusion of the music, the therapist helps the patient elicit thoughts, feelings, or other reactions, and practice discussing this experience in an objective and nonjudgmental way. The following excerpt describes Marianne’s reaction to listening to a piece of music:

242 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: What did you notice when you were listen- ing to the music?

MARIANNE: I noticed that I thought of a friend I had when I was in college. I remembered what it was like to spend time together. Then I thought of all the job applications I should be working on right now and how successful my friends are. I couldn’t stay focused on the music.

THERAPIST: It sounds like you were able to notice a number of different thoughts during this exercise, and your mind seemed to jump from one topic to another. Since the goal of this exercise is to practice observing, just noticing your thoughts have taken you somewhere else, even after it has already hap- pened, counts. What about physical sensations—did you notice any of those?

MARIANNE: No, I didn’t notice any physical sensa- tions. I just felt how I usually feel.

THERAPIST: I was observing you a bit, and I did notice that, at one point, both your fists were clenched. Did you notice that?

MARIANNE: No, I didn’t realize that. But now that you say it, I also notice that my jaw feels tight and hurts.

THERAPIST: And what about behaviors? Did you notice any behaviors, or any urges to do something?

MARIANNE: Well, I noticed a couple of times just feeling uncomfortable and sort of wanting to move around.

THERAPIST: And what about the music itself? Were you able to notice the music itself?

MARIANNE: I think I was more lost in my head. But there was one moment where I thought of my sister. Some parts of the music reminded me of some songs she liked.

THERAPIST: This is what our emotions can do. An emotion can trigger all sorts of associated thoughts, feelings, and behaviors that may have very little to do with what is happening “in the room,” yet the initial- ly triggered emotion itself is connected to something occurring in the present moment, just like the music you were listening to, which was really just sounds happening in the present moment. Getting better at observing our reactions to the trigger (in this case, the music), can help us to see how many of our asso- ciated thoughts, feelings, and behaviors actually “fit” with the current context, and how many of them are

just associations, which may or may not fit the cur- rent context at all.

Anchoring in the Present

Informal mindful emotion awareness practice is also a useful skill for the patient to practice, as this can be used at any time. The therapist can help the patient find a “cue” (e.g., the breath) to shift focus to the pres- ent moment, particularly in times of distress. The goal of this more informal practice is repeatedly to pair the patient’s chosen cue with a shift in attention and aware- ness to the present moment, by focusing on a sight, sound, or other sensation, so that engaging this cue will eventually be automatically paired with present- moment awareness. It is important for the therapist to note that the breath (or other cue) should not be used as distraction—it should only be used as a cue to re- mind the patient to be mindful of the present moment. Eventually, once the patient has successfully associated this cue with refocusing on the present moment, the patient can learn to follow this with a brief “three-point check” of thoughts, physical sensations, and behaviors. By observing what is occurring in the moment within these three domains, the patient can begin to identify how responses in any of these domains may be affecting the overall emotional experience, to compare what is happening in these domains with information from the current context, and ultimately to identify and alter any maladaptive patterns of responding.

Module 4: Cognitive Flexibility

Cognitive appraisal first involves discussing the concept that interpretations depend, in large part, on which of the numerous aspects (or stimuli) a person chooses to focus on in any given situation. Focusing only on limit- ed or specific aspects of a situation is critical for our sur- vival. We would be overwhelmed by information if we focused on all stimuli wherever we went. This process helps us quickly evaluate situations for risk and danger, allows us to estimate what might happen in the future, and usually happens outside of awareness. Importantly, the information we focus on and what we perceive as risky or dangerous tends to be the result of learned as- sociations between specific information or stimuli and the affective or threat value of those stimuli. For exam- ple, if negative evaluation by others has been associated with threat in the past, an increase in vigilance for nega-

Emotional Disorders 243

tive evaluation may result. Importantly, appraisals can have a powerful impact on our feelings or mood states, and vice versa. The therapist can illustrate this concept by inquiring how appraisals might vary depending on whether the patient was feeling joyful, sad, or angry.

An in-session exercise is used to demonstrate the many possible different appraisals that can be gener- ated from a situation. The therapist shows the patient an “ambiguous” picture to which many cognitive ap- praisals can be assigned, instructs the patient to look at the picture for approximately 30 seconds, then elicits both the patient’s initial appraisal and at least two or three alternative appraisals. Additionally, the patient is asked what specifically may have contributed to the au- tomatic appraisal (e.g., memories of similar situations, specific details in the picture). This exercise is used to demonstrate the way that situations can be interpreted in many ways, if all available information is considered.

Automatic appraisals, interpretations of situations that happen very quickly, are often negative or pes- simistic in nature. Core automatic appraisals (e.g., “I am a failure”) are appraisals that may be driving many emotional responses. It is helpful if the therapist can identify one or more core automatic appraisals by using the downward arrow technique instead of focusing only on surface-level appraisals related to a specific situation.

Automatic appraisals can lead to a habitual and pow- erful heuristic that begins to exclude other, possibly more appropriate or realistic appraisals of a situation or event. These automatic appraisals are called “thinking traps,” because, over time, a patient may get “stuck” in this way of thinking. As described earlier, two common thinking traps, probability overestimation (jumping to conclusions), or the tendency to assume a high likeli- hood of the occurrence of a negative event, and cata- strophizing (thinking the worst), or assuming that the consequences of an event will be beyond one’s ability to cope, are presented as two cognitive biases common to all emotional disorders. The therapist guides the patient in beginning to identify these biases in the context of his/her experience. Below, the therapist discusses both of these cognitive biases based on a recent situation in which Marianne felt rejected by a friend.

THERAPIST: Tell me what happened when you felt like your friend was ignoring you.

MARIANNE: Well, I had tentatively made plans with my friend Carly to go to the movies. This is pretty

unusual for me, because I hardly ever want to go out, but there was a movie playing locally and Carly asked me to go.

THERAPIST: And what happened next? MARIANNE: I hadn’t talked to her for a while, so on the

day we were supposed to go, I texted her and asked her if we were still going. She didn’t get back to me until several hours later and said she was too busy with work, and asked if we could reschedule.

THERAPIST: Can you remember any of your thoughts at the time?

MARIANNE: Yeah, I remember thinking that it’s pretty clear she doesn’t want to spend time with me any- more. I haven’t been a good friend and, like all my relationships, I really screwed this up.

THERAPIST: You mentioned that you thought she didn’t want to spend time with you anymore—is this what she said?

MARIANNE: No, not exactly. But she canceled at the last minute with the excuse that she was busy with work.

THERAPIST: So you don’t think she was busy with work?

MARIANNE: Well, I don’t know. She did just start a new job and has some pretty crazy hours, but it still felt bad. Like I said, I always mess up my relation- ships.

THERAPIST: And what about the other people in your group of friends?

MARIANNE: Well, I don’t have a big group of friends— really just one or two other good friends. But I haven’t seen them in a while. In my group of coworkers from my previous job, we’re still friends but we don’t hang out very much.

THERAPIST: OK, so it sounds like you still have those relationships, but they’re not as close as you want them to be? Is that the same as “messing them up”?

MARIANNE: I guess not. THERAPIST: What evidence did you have to suggest

that you “mess up” your relationships? MARIANNE: Well, I mean, my dad and I don’t have

a great relationship. We’re not close at all, and we argue when we see each other.

THERAPIST: Yes, I remember you telling me that your relationship with your dad has been hard, often be-

244 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

cause he is under the influence of alcohol and loses his temper. So, given this evidence, do you know for certain that you “mess up” all your relationships?

MARIANNE: Well, not for certain. THERAPIST: Exactly, because even though not all your

relationships are how you would like them to be, we don’t know for sure that it is you who caused that. In fact, it sounds like your friendships are good but maybe not as close as you want them to be, and your difficult relationship with your dad might at least in part be due to his alcohol use. So one possibility is that you caused all these problems in your relation- ships, but can you think of any other possibilities? If you were talking to someone who was expressing the same concerns as you, what would you say?

MARIANNE: I guess I would say that it’s not all your fault. Your friendships aren’t too bad, and your dad acts in a way that makes it hard for anyone to get along with him.

THERAPIST: So, how likely do you think that it is that you are the one who messed up all your relationships?

MARIANNE: I guess not very likely. A bunch of them aren’t even really messed up.

THERAPIST: But for you, at that moment when you felt your friend rejected you, how much did it feel like you ruined your relationships, on a scale of 0% meaning not at all to 100% meaning you’re absolutely certain.

MARIANNE: At that moment? I was convinced com- pletely. 100%.

THERAPIST: And sitting here now, how likely do you actually think it is that you ruined your relation- ships, using the same percentage scale?

MARIANNE: I don’t know, maybe 10%? THERAPIST: And at the time, what emotions were you

experiencing? MARIANNE: Sadness, shame, and maybe a little bit of

anger. THERAPIST: Can you remember any physical sensa-

tions? MARIANNE: My stomach dropped, and I remember

feeling a little nauseous. THERAPIST: So when you were experiencing sadness,

shame, and anger, and all of the associated physical sensations, the thoughts that came with that were that you had done something terribly wrong. And at the time, these thoughts felt like they were true.

Now, sitting here, without the experience of those emotions or the associated physical symptoms, how likely do those thoughts feel?

MARIANNE: Well, sitting here now, I can see how I might have jumped to conclusions a bit. And maybe catastrophized the situation, too.

The therapist discusses the importance of monitor- ing and recording automatic appraisals, in order to in- crease the patient’s awareness that these interpretations are occurring, and reminds the patient that using the present-focused awareness skills learned in the previ- ous module can help aid in this process—by anchoring in the present moment using the patient’s chosen cue (i.e., taking a deep breath and focusing attention on a sound or sensation occurring in the present moment), the patient can use the “three-point check” to observe what thoughts are occurring at that moment. The goal is to notice the thoughts, then, using information from the current situation, consider other possible interpreta- tions of what is occurring within the current context. In this way, the patient can more flexibly apply informa- tion from learned associations (i.e., memory) and infor- mation from the current context toward more adaptive appraisals.

As the patient begins to record automatic thoughts, the therapist can help him/her begin to identify pat- terns in the nature of those thoughts. The therapist provides guidance on identifying thinking traps and tries to focus the patient’s attention on the “core” ap- praisal through the use of “downward arrow” Socratic questioning. The excerpt below is from a discussion of Marianne’s fears of not being qualified to find another job.

THERAPIST: You’ve talked about how you are concerned that you are not qualified to find another job. What specifically concerns you about your qualifications?

MARIANNE: I just don’t have as much experience as some other people. I was only in management for a few years, and then my company let me go. I clearly wasn’t as valuable as some other people, so I must not have what it takes to have a good job like that.

THERAPIST: And what concerns you about not “having what it takes”?

MARIANNE: Well, I just think that I don’t have the skills and inherent abilities to be successful at a good job. I’ll just be stuck in a dead-end position for the rest of my life.

Emotional Disorders 245

THERAPIST: And then what will happen? MARIANNE: I won’t be successful, and I’ll be unhappy

forever. THERAPIST: And what does that mean? MARIANNE: That I’m just useless. That there is some-

thing really wrong with me that I won’t ever be able to change.

THERAPIST: Now that is what we want, the real core of it, what is driving this interpretation. A lot of these negative, self-critical thoughts you’ve recorded often do come down to the belief that there is something wrong with you. So you think, “If I lose my one job, that means my life will be miserable and will be an in- dicator that there is something wrong with me” or “If I do something to make a friend dislike me, it means I will never be able to have friends and will be proof that there is something wrong with me.” Of course, anyone would be constantly feeling badly if every time something did not go as planned or expected, it would be an indicator of his/her inherent deficiencies.

As demonstrated earlier, the therapist then engages the patient in a more detailed discussion of this core belief, focusing on flexible thinking. Countering prob- ability overestimation and decatastrophizing strategies are presented as a way to generate alternative thoughts and to place less focus on the core appraisal. Counter- ing probability estimation involves drawing on past evidence to examine how realistic the patient’s estima- tion is when experiencing an emotion. The therapist guides the patient in making concrete estimations and comparing the original estimation to a more realistic one. Decatastrophizing involves helping the patient to identify his/her ability to cope with the feared situation using past evidence and specific examples (e.g., similar experiences in the past). It is important to communicate that these strategies do not eliminate negative thoughts, but they provide greater flexibility and allow the pa- tient to gain perspective on the feared situations, using more accurate information as a guide rather than being caught up in overlearned automatic appraisals.

Module 5: Countering Emotional Behaviors

Emotional Behaviors

The therapist now introduces the concept of emotion- al behaviors, which are behaviors people engage in to manage emotions. As reviewed earlier, while engaging

in these responses can be harmful in the long term, they typically provide some short-term relief, which is why the behaviors are maintained. Types of emotional be- haviors, including overt avoidance (e.g., not going to an event), subtle behavioral avoidance (e.g., avoiding eye contact), cognitive avoidance (e.g., distraction), safety signals (e.g., carrying a water bottle), and EDBs (e.g., escape), are introduced. It is important that the patient understand why and how engaging in emotional behav- iors is problematic. The therapist explains that unhelp- ful emotional behaviors actually (1) prevent habituation to a feared stimulus, so that fear levels are maintained at a high or constant level while in contact with the stimu- lus; (2) interfere with the process of extinction, so that the conditioned association between the cue and fearful response is maintained instead of weakened; (3) prevent the patient from developing a sense of control or self-ef- ficacy in managing the fear, because positive outcomes are attributed to the avoidance strategy; and (4) actually signal to the person that the situation, context, or stimu- lus is dangerous and should be avoided. The therapist asks the patient to generate personally relevant examples of emotional behaviors and discusses how those strate- gies have maintained the cycle of emotions.

THERAPIST: We’re going to shift our focus now and look at how behavioral responses to emotions, what we call “emotional behaviors,” contribute to your emotional experiences. First, let’s talk about overt avoidance. Sometimes you might avoid doing things, like activities, because you anticipate the activity will make you feel uncomfortable. For example, you mentioned that sometimes your friends invite you to go out with them—either to dinner or for other so- cial activities—which triggers thoughts that you are not as successful and not as “good” as they are. Is that right?

MARIANNE: Yes, exactly. It’s really hard to spend time with them, because they start talking about all the great stuff they’re doing, like how their jobs and re- lationships are going so well. And then I just think of my own situation, and I feel terrible about myself.

THERAPIST: So then you avoid going out with them so you’re not confronted with these negative feelings about yourself. This is a good example of one of the ways we try to avoid uncomfortable emotions. There are also some behaviors that can be more subtle, things we aren’t even aware we are doing as an avoid- ance strategy, and this is called “subtle behavioral

246 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

avoidance.” For example, someone who has panic at- tacks might avoid caffeine so he/she doesn’t have to feel the physical sensations of increased arousal. Can you think of any examples of more subtle ways you may be avoiding uncomfortable emotions?

MARIANNE: I guess that when I do spend time with them, I usually avoid talking about myself. I try to change the subject, because I don’t want to have to explain how bad things are for me.

THERAPIST: So you’re trying to avoid feeling even worse about yourself by not talking about your situation?

MARIANNE: Yes, exactly. I’m also trying to avoid feel- ing embarrassed in front of my friends.

THERAPIST: So you can see that we have subtle and more overt ways of avoiding uncomfortable emo- tions, but the question is, does it make the problem go away?

MARIANNE: Not really. When I don’t go out with my friends, I feel bad about not being a good friend. Plus I sit at home with nothing to do. If I do go out and I avoid talking about myself, I end up not feeling very close to any of them.

THERAPIST: So you can see that avoidance might make the problem go away in the short term, but in the long term, this strategy is not particularly helpful and may even make the situation worse. In fact, these avoidance behaviors can strengthen the association of fear and anxiety with these situations—the more you avoid seeing or talking with your friends, the harder and harder it gets!

Next, in-session exercises to demonstrate the effects of emotional avoidance are conducted. The first exer- cise involves asking the patient directly to suppress a memory of when he/she felt very embarrassed. Mari- anne, for example, had been actively trying not to think about a recent e-mail she sent to her former boss, asking if he would serve as a reference for a job application. She was worried that he would respond negatively to her e- mail and decline to serve as a reference. Marianne was asked to think about this memory of sending the e-mail for 30 seconds, then to think of anything other than the e-mail for 30 seconds. Predictably, Marianne found it extremely difficult to prevent ruminations about her boss’s potential responses from coming into her mind. Thus, this exercise presents a poignant and personally relevant demonstration of the futility of active attempts to avoid distressing topics or situations.

Of note, emotional behaviors can sometimes be dif- ficult to identify, and specific behaviors (e.g., escape, distraction) are not always considered unhelpful emo- tional behaviors. Rather, it depends on the function of the behavior for each patient. For example, patients may force themselves to stay in a situation when feel- ing angry, so that they do not feel as though they are “giving in.” In this situation, the emotional behavior is staying in the situation—it gives a feeling of control in the short-term but fuels anger in the long-term. So, es- caping may actually be a helpful way of responding. In the case of Marianne, even though distraction is often considered an unhelpful emotional behavior, it can ac- tually be adaptive and helpful if distraction allows her to prevent herself from getting “stuck” and ruminating about her inadequacies.

Alternative Action

The concept of alternative action is introduced next. Alternative action means engaging in any behavior other than the emotional behaviors, so that emotions that are typically avoided are instead experienced to the fullest. Doing alternative action instead of emotional behaviors provides new information about a situation and also strengthen the patient’s ability to cope with distress. Over time, the patient also begins feeling differently about the situation. In the transcript below, Marianne describes some examples of what alternative action could be for her.

THERAPIST: You mentioned that in the evenings, you often avoid activities because you have a headache. Can you tell me what that is like and what you are doing during that time?

MARIANNE: Yeah, often my head starts to hurt around 4:00 to 5:00 P.M. I feel a little tingling and then I just feel this immense pressure all over my head. At that point, I just feel like I need to lie down. So I usually just lie down in my bed for a while.

THERAPIST: And how do you feel, right when you de- cide to not go out and to lie down instead?

MARIANNE: I feel a bit of relief. Like I said, it’s hard for me to go out, and when I have a headache, it’s extra hard.

THERAPIST: So it sounds like you engage in overt avoid- ance when you feel a headache coming on?

MARIANNE: Yeah, I guess. But I’m just worried that if I

Emotional Disorders 247

do go out, my headache will get worse and I won’t be able to get home easily, and then I’ll feel really bad.

THERAPIST: So, do you end up feeling better staying at home and lying down?

MARIANNE: I mean, probably not. I end up just staring at my room, trying to sleep, and thinking about how I’ll never be able to do anything with my life. I guess I do feel pretty bad.

THERAPIST: OK, so let’s try to think of some alterna- tive actions you could do instead of lying down. Re- member, it won’t necessarily feel good right away to change your behavior, but it might help you feel a bit more empowered, even if your headache doesn’t go away. What else could you do?

MARIANNE: I could go out, even if just for a few min- utes.

THERAPIST: Yes, that’s right! Going out of your house doesn’t have to be for hours at a time. Even going out for a few minutes would be an alternative action that would start to break the cycle of emotional behav- iors. What else could you do?

MARIANNE: I could stay at home but not lie down. I could do something quiet, like make a nice dinner, or listen to music in my living room.

THERAPIST: Those are great examples! Alternative ac- tion isn’t just one behavior. It can be many different behaviors that are not the emotional behavior in that situation.

Module 6: Understanding and Confronting Physical Sensations

Module 6 introduces the first opportunity to engage in an exposure that focuses on eliciting physical sen- sations that often trigger strong emotional reactions, and to begin to build the patient’s awareness of the contribution of physical sensations to emotional expe- riences. Following an introduction to the rationale for provoking physical sensations, the therapist and patient work through a list of exercises designed to elicit emo- tion through physical activation, known as a Physical Sensation Test. Some examples include hyperventilat- ing, spinning, and running in place. In addition, any exercises that may be particularly relevant to the patient may be added. For example, in patients with depres- sion, a sense of “heaviness” can be induced by having the patient wear wrist or ankle weights while walking around, wearing a heavy backpack, or lying down with

a weight on his/her chest. Prior to each exercise, the therapist demonstrates the exercise and, following the patient’s completion of the exercise, asks the patient to rate the level of distress and similarity to physical sensa- tions typically experiences during an emotion, each on a scale of 0 (None) to 10 (Extreme).

THERAPIST: So today we’ll do a number of exercises to induce some of these physical sensations that are often present when you experience anxiety or other emotions, and look at the level of your distress, and how similar the sensations are to your typical experi- ence of uncomfortable emotions. The first one I’m going to ask you to do is the hyperventilation exer- cise. ( following the exercise) What sensations do you notice?

MARIANNE: I noticed that my heart started beating faster and I felt a bit dizzy. I found it pretty unpleas- ant.

THERAPIST: So you are having thoughts and judgments about the sensations, which we would expect. In terms of the sensations themselves, how would you rate your level of distress about those sensations?

MARIANNE: Maybe a 3? THERAPIST: And similarity? MARIANNE: Well, I don’t usually get dizzy, so not very

similar. Maybe a 2.

Next, the therapist begins another exercise. The dis- cussion below follows Marianne’s experience of breath- ing through a thin straw.

THERAPIST: How would you rate your distress this time?

MARIANNE: That was really scary and really intense. I would say a 9.

THERAPIST: What did you notice was different with this exercise?

MARIANNE: I don’t know. I just felt really trapped when I was trying to breathe through the thin straw. It might sound weird, but I just felt like I couldn’t get away. And then I started having all these negative thoughts about myself. I felt scared and sad.

THERAPIST: That is very interesting. So the sensations triggered other emotions and negative thoughts?

MARIANNE: Yes, definitely. I didn’t realize I would have that reaction.

248 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: OK, let’s try another exercise. This time, I want you to lie down on the floor here. I have a heavy book that I’m going to give you to place on your chest for as long as you can or until I tell you to stop.

MARIANNE: ( following the exercise) Wow, that was harder than I thought. The feeling I had was really similar to the heaviness I sometimes feel in my chest when I feel really depressed.

THERAPIST: So how would you rate the similarity on the 0–10 scale?

MARIANNE: I would say maybe an 8. THERAPIST: And how about the level of distress you

felt? MARIANNE: It was pretty high. I would rate that at a

9. That sensation just triggered a really strong feeling of hopelessness.

THERAPIST: That’s really interesting, and it’s great that we were able to trigger that emotional response by eliciting that physical sensation of heaviness. Do you notice how this was different from the other exercise?

MARIANNE: Yeah, exactly. They were both really un- comfortable but in completely different ways.

Following the completion of all the chosen exercises, therapist and patient choose the most relevant exercises to engage in regularly over the next week. The patient is asked to complete one exercise several times a day, until the associated distress decreases. This repeated exposure helps facilitate learning of new information about the dangerousness (or lack thereof) of physical sensations and may help diminish future distress when physical symptoms do occur.

Module 7: Emotion Exposures

This treatment module allows application of all the skills learned thus far to actual situations, events, or activities that trigger strong levels of emotions that the patient has previously avoided. The therapist begins with a discussion about the rationale for emotion ex- posures. Although this module in the treatment pro- gram is often the most challenging, it is the best op- portunity to make lasting behavioral and emotional changes. Emotion exposures serve three critical goals: (1) Interpretations and appraisals about the dangerous- ness of situations (internal or external) are modified and

replaced with newer, more adaptive interpretations and appraisals; (2) avoidance and related impairment is re- versed; and (3) emotional behaviors are recognized and modified. These all work toward achieving the primary goal of extinguishing anxious and distressing reactions to the experience of intense emotions.

In addition to engaging in emotion exposures for homework, an important part of this module is practic- ing emotion exposures in session. This is critical, be- cause the therapist can often challenge the patient to engage in more difficult exposures in session and will be able to note any use of emotional behaviors that may be outside the patient’s awareness. The particular in- session exposure tasks vary from patient to patient, and it is important that the therapist be able to generate a number of different possible tasks in which to engage. Once the task has been identified, the therapist can dis- cuss any anxious or negative automatic appraisals oc- curring and help the patient consider other possibilities. The therapist should also remind the patient to use the skills of present-focused awareness and try to prevent any emotional behaviors that would interfere with the exposure. At the end of each session, the therapist helps the patient choose several emotion exposures to engage in outside of session for homework.

For Marianne, several different exposures were de- signed to target her intense self-criticism and depres- sion. Examples included spending 15 minutes looking at job websites, scheduling social activities with friends, taking a walk around the block every day, gardening for at least 15 minutes one time per week, not canceling plans due to headache, and watching a sad movie and then engaging in an activity.

Described in the discussion below, an exposure near the top of Marianne’s hierarchy was to actually apply for a job. This would require her to engage in a num- ber of challenging situations. First, she would have to search for and identify a potential job that fit with her qualifications. However, for the purposes of the expo- sure, if she could not find an advertisement for a job that was directly relevant to her experience, it would still be useful to apply for any job. Second, she would have to write a cover letter detailing her experience and why she is a good fit for the job. Third, she would need to submit the application, which, due to its very nature, would lead to having another person evaluate her. The following is a review of this exposure at the following session.

Emotional Disorders 249

THERAPIST: Wow, this was a really challenging ex- posure. Let’s start from the beginning, when you searched for the job. Do you remember what you were experiencing just before you started that search on the Internet?

MARIANNE: Well, I did the actual search about a week ago. I felt a pit in my stomach and a real sense of dread. I felt tired and heavy.

THERAPIST: So, a lot of physical sensations associated with both depression and anxiety. What about when you actually submitted the application yesterday?

MARIANNE: It was the same feeling but just way worse. I was even shaking a little bit. I put off this exposure until yesterday, but then I knew I had to do it.

THERAPIST: Good! So you noticed some emotional behaviors but were eventually able to engage in al- ternative action by submitting the application. What types of thoughts were you having?

MARIANNE: I just kept thinking “There is no way I can do this.” I’ve thought about applying so many times, but I just have never been able to do it. And I also had the usual thoughts—“I’m useless, they will never hire me”—that kind of stuff.

THERAPIST: So, what happened when you filled out the application?

MARIANNE: I was just really nervous. It was hard to stay focused, and I kept getting up to get water. It helped that we had done some exposures before about what I would say in my application.

THERAPIST: That’s great. What did you take away from this experience?

MARIANNE: Well, it was really, really hard. But one thing I did think of is that I felt pretty much the same way when I first started searching for jobs a week ago, and compared to submitting the applica- tion, that seems so easy now!

THERAPIST: Did your automatic thought of “I can’t do this” come true?

MARIANNE: Well, no, I guess. I mean, I did it. I guess there is something to be said for that. But I still don’t know if they will hire me.

THERAPIST: That’s true. Sometimes our fears about what will happen in the future cannot be fully exam- ined, because it hasn’t happened yet. But what is your fear if you don’t get called for an interview?

MARIANNE: That I will fall back into a deep, deep de- pression.

THERAPIST: And if that did happen, how would you cope with it?

MARIANNE: I guess I would just keep doing what I’m doing. I’ve learned a lot of new skills I didn’t know before, and my friendships are getting a bit better, so I have a little more support. I guess if I was able to survive it once, I can survive it again.

This exposure was an important step for Marianne to start to reverse the cycle of emotional behaviors and introduce some flexibility in her responses to emotional situations. However, Marianne continued to maintain the core belief that she was “useless” and “incompe- tent.” Additional exposures were designed to target these beliefs directly.

THERAPIST: You seem like you have been making some important changes in your behaviors over last few weeks, would you agree?

MARIANNE: Yes, I agree that I have been trying to do that. But I still walk around and think that I’m to- tally worthless and useless.

THERAPIST: Yes, I’ve wondered about that. Can you tell me a little bit more about what your experience has been?

MARIANNE: Well, I’ve been able to force myself to do some of these exposures, but I’m just pushing myself through it. I still feel really badly about myself most of the time.

THERAPIST: I wonder how that affects your behav- ior during the exposures? Do you think getting stuck in that core belief is causing you to make subtle changes in how you are behaving during these ex- posures?

MARIANNE: I’m not sure. I notice I do get distracted when I start thinking about how useless I am.

THERAPIST: OK, that’s a great example. So, the emo- tional behavior would be getting distracted. What would the alternative action be?

MARIANNE: I guess staying involved in whatever ex- posure I’m doing? Using emotional awareness to ground in the present?

THERAPIST: Yes, that’s great. What other emotional be- haviors might you be doing in these situations?

250 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

MARIANNE: I think it’s possible that I hunch over, and I probably look like I’m worried. People have told me that before.

THERAPIST: Yes, body posture and facial expressions are also emotional behaviors. What would alterna- tives to these emotional behaviors be?

MARIANNE: I could try sitting up straight. And maybe trying to smile? But that seems really hard!

THERAPIST: Yes, I do think it will be challenging. These are some very ingrained emotional behaviors associated with anxiety and depression. And, this may be the best way to start to reverse this cycle— let’s give it a shot!

In future sessions, the therapist revisits the patient’s continuing need for emotional exposures. If the thera- pist determines that the patient would benefit from ad- ditional emotion exposures, they can be continued both in session and for homework at this time. Additionally, the therapist can focus on any events or emotional reac- tions over the past week that can be processed in ses- sion. Obstacles to exposure completion and reactions to exposures are discussed in session.

Module 8: Recognizing Accomplishments and Looking to the Future

In the final module of treatment, the therapist reviews both the major concepts presented in treatment and the patient’s progress. The therapist introduces the UP Skills Action Plan, which consists of using the “three- point check” learned earlier, then briefly reviewing all the skills learned in treatment, including cognitive flex- ibility, awareness and tolerance of physical sensations, and modifying emotional behaviors. Progress made over the course of treatment can be reviewed by exam- ining scores on the OASIS and ODSIS forms, as well as having the patient complete the Progress Evaluation. Using these measures, the therapist can highlight both areas of improvement and those in need of continued practice. Reasons for lack of improvement (e.g., initial error in conceptualization, lack of understanding treat- ment principles, unrealistic goals, and lack of motiva- tion) should also be reviewed. The therapist then dis- cusses the inevitability of future stressors and potential reoccurrence of symptoms. The continuation of infor- mal emotion exposures and use of skills learned are en- couraged and detailed in the Practice Plan, which the

patient and therapist can work on together in session to help identify concrete skills that will require ongoing practice. The therapist may further assist the patient in staying committed to treatment by establishing long- term goals for the patient.

CASE OUTCOME AND CONCLUSION

Marianne’s symptoms were assessed at pre- and post- treatment using a battery of self-report questionnaires, as described earlier. During treatment, Marianne’s BDI-II score decreased from 53 at pretreatment to 18 at posttreatment. Her PSWQ score decreased from 65 to 29. Her ODSIS and OASIS scores decreased from 18 and 12 to 9 and 4, respectively. Functionally, Marianne was able to meet many of her treatment goals over the course of treatment. For example, she was able to suc- cessfully apply for a job, a task at the top of her emotion exposure hierarchy that had previously been causing significant anxiety and reinforcing her negative be- liefs about herself. By approaching this task, Marianne gained a greater sense of confidence in her ability to use the skills learned in treatment and to cope through difficult situations. She significantly increased her so- cial interactions with friends, which increased her self- confidence and sense of self-worth, and she challenged her belief that she was “messing up” all of her friend- ships. She gained control of her headache symptoms and no longer engaged in avoidance behaviors related to her symptoms. At the time of termination, Marianne had not yet been hired for a job, but she expressed a sense of hopefulness with regard to several prospective employers. She was in contact with previous cowork- ers, both socially and professionally. Marianne did not participate in an independent posttreatment clinical in- terview; however, her clinician (L. A. P.) estimated that her CSR for MDD was now at a 3, which is considered subclinical. The diagnosis of persistent depressive disor- der remained at a 4, which is considered just above clin- ical severity with moderate symptoms. Additionally, she reported fewer headaches, although she noted that they were still frequent enough to cause some interference in her activities.

Marianne returned to our Center for a follow-up assessment 6 months posttreatment that comprised re- administration of the ADIS-5 and self-report question- naires. At follow-up, Marianne had improved signifi- cantly even from posttreatment. During her interview,

Emotional Disorders 251

Marianne reported that she had recently been hired at a start-up biotech company. She had also started dating, and despite having some anxiety about meeting people, she felt positively about the process. Clinician ratings using the ADIS-5 seemed largely to coincide with Mari- anne’s self-report. Having not experienced clinical lev- els of depression or anxiety for more than 5 months, the diagnosis of persistent depressive disorder was now con- sidered in partial remission with subclinical symptoms (CSR = 3). Symptoms of MDD were no longer evident, and residual depressive symptoms were captured in the persistent depressive disorder diagnosis.

With regard to self-report questionnaires, Mari- anne’s BDI-II score was now 10, and her score on the PSWQ was 20, reflective of a mild amount of anxi- ety and worry. Her ODSIS score was now 9, and her OASIS score remained at a 4. These questionnaires re- flected her report of substantially improved symptoms, both on long- and short-term levels. Although she still experienced residual symptoms of depression, she was able to successfully manage them, so that they no lon- ger caused significant interference in her life.

REFERENCES

Allen, L. B., White, K. S., Barlow, D. H., Shear, M. K., Gor- man, J. M., & Woods, S. W. (2010). Cognitive-behavior therapy (CBT) for panic disorder: Relationship of anxiety and depression comorbidity with treatment outcome. Jour- nal of Psychopathology and Behavioral Assessment, 32(2), 185–192.

American Psychiatric Association. (2000). Diagnostic and sta- tistical manual of mental disorders (4th ed., text rev.). Wash- ington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and sta- tistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Andrews, G. (1990). Classification of neurotic disorders. Journal of the Royal Society of Medicine, 83(10), 606–607.

Andrews, G. (1996). Current controversies in the anxiety disorders. In R. M. Rapee (Ed.), Comorbidity in neurotic disorders: The similarities are more important than the dif- ference (pp. 3–20). New York: Guilford Press.

Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford Press.

Barlow, D. H. (1991). Disorders of emotion. Psychological In- quiry, 2, 58–71.

Barlow, D. H. (2000). Unraveling the mysteries of anxiety and its disorders from the perspective of emotion theory. American Psychologist, 55(11), 1247–1263.

Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford Press.

Barlow, D. H., Bullis, J. R., Comer, J. S., & Ametaj, A. A. (2013). Evidence-based psychological treatments: An up- date and the way forward. Annual Review of Clinical Psy- chology, 9, 1–27.

Barlow, D. H., & Craske, M. G. (2007). Mastery of your anxi- ety and panic: Client workbook for anxiety and panic (4th ed.). New York: Oxford University Press.

Barlow, D. H., Ellard, K. K., Sauer-Zavala, S., Bullis, J. R., & Carl, J. R. (2014). The origins of neuroticism. Perspectives on Psychological Science, 9(5), 481–496.

Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., et al. (2017). The Unified Protocol for Transdiagnostic Treatment of Emo- tional Disorders compared with diagnosis-specific pro- tocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry, 74(9), 875–884.

Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized con- trolled trial. Journal of the American Medical Association, 283, 2529–2536.

Barlow, D. H., Sauer-Zavala, S. E., Carl, J. R., Bullis, J. R., & Ellard, K. K. (2014). The nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical Psychological Science, 2(3), 344–365.

Beck, A. T. (1967). The diagnosis and management of depres- sion. Philadelphia: University of Pennsylvania Press.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depres- sion Inventory manual (2nd ed.). San Antonio, TX: Psycho- logical Corporation.

Bentley, K. H., Gallagher, M. W., Carl, J. R., & Barlow, D. H. (2014). Development and validation of the Overall De- pression Severity and Impairment Scale. Psychological As- sessment, 26, 815–830.

Boelen, P. A., Vrinssen, I., & van Tulder, F. (2010). Intol- erance of uncertainty in adolescents: Correlations with worry, social anxiety, and depression. Journal of Nervous and Mental Disease, 198, 194–200.

Boettcher, H., & Conklin, L. R. (2018). Transdiagnostic assessment and case formulation: Rationale and applica- tion with the Unified Protocol. In D. H. Barlow & T. J. Farchione (Eds.), Applications of the unified protocol for transdiagnostic treatment of emotional disorder (pp. 17–37) (ABCT Clinical Practice Series). New York: Oxford Uni- versity Press.

Borkovec, T. D. (1994). The nature, functions, and origins of worry. In G. C. L. Davey & F. Tallis (Eds.), Worrying: Perspectives on theory, assessment, and treatment (pp. 5–34). New York: Wiley.

252 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Borkovec, T. D., Hazlett-Stevens, H., & Diaz, M. L. (1999). The role of positive beliefs about worry in generalized anxiety disorder and its treatment. Clinical Psychology and Psychotherapy, 6, 126–138.

Boswell, J. F., Thompson-Holland, J., Farchione, T. J., & Barlow, D. H. (2013). The intolerance of uncertainty: A common factor in the treatment of emotional disorders. Journal of Clinical Psychology, 69, 630–645.

Bouton, M. E. (2005). Behavior systems and the contextual control of anxiety, fear, and panic. In L. Feldman Barrett, P. M. Niedenthal, & P. Winkielman (Eds.), Emotion and consciousness (pp. 205–227). New York: Guilford Press.

Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A mod- ern learning theory perspective on the etiology of panic disorder. Psychological Review, 108, 4–32.

Brown, T. A. (2007). Temporal course and structural rela- tionships among dimensions of temperament and DSM- IV anxiety and mood disorder constructs. Journal of Ab- normal Psychology, 116, 313–328.

Brown, T. A., Antony, M. M., & Barlow, D. H. (1995). Diag- nostic comorbidity in panic disorder: Effect on treatment outcome and course of comorbid diagnoses following treatment. Journal of Consulting and Clinical Psychology, 63, 408–418.

Brown, T. A., & Barlow, D. H. (1995). Long-term outcome in cognitive-behavioral treatment of panic disorder: Clinical predictors and alternative strategies for assessment. Journal of Consulting and Clinical Psychology, 63, 754–765.

Brown, T. A., & Barlow, D. H. (2002). Classification of anxiety and mood disorders. In D. H. Barlow (Ed.), Anxi- ety and its disorders: The nature and treatment of anxiety and panic (2nd ed., pp. 292–327). New York: Guilford Press.

Brown, T. A., & Barlow, D. H. (2009). A proposal for a dimensional classification system based on the shared features of the DSM-IV anxiety and mood disorders: Implications for assessment and treatment. Psychological Assessment, 21, 256–271.

Brown, T. A., & Barlow, D. H. (2014). Anxiety and Related Disorders Interview Schedule for DSM-5® (ADIS-5L)—Life- time Version. New York: Oxford University Press.

Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comor- bidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110, 49–58.

Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Struc- tural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology, 107, 179–192.

Brown, T. A., Di Nardo, P. A., & Barlow, D. H. (2014). Anxi- ety Disorders Interview Schedule for DSM-5. New York: Oxford University Press.

Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood

disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110, 49–58.

Bullis, J. R., Sauer-Zavala, S., Bentley, K. H., Thompson- Hollands, J., Carl, J. R., et al. (2015). The Unified Proto- col for transdiagnostic treatment of emotional disorders: Preliminary exploration of effectiveness for group delivery. Behavior Modification, 39, 295–321.

Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hof- mann, S. G. (2006a). Acceptability and suppression of negative emotion in anxiety and mood disorders. Emotion, 6, 587–595.

Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hof- mann, S. G. (2006b). Effects of suppression and accep- tance on emotional responses in individuals with anxiety and mood disorders. Behaviour Research and Therapy, 44, 1251–1263.

Campbell-Sills, L., Liverant, G. I., & Brown, T. A. (2004). Psychometric evaluation of the behavioral inhibition/be- havioral activation scales in a large sample of outpatients with anxiety and mood disorders. Psychological Assessment, 16(3), 244–254.

Campbell-Sills, L., Norman, S. B., Craske, M. G., Sullivan, G., Lang, A. J., & Chavira, D. A. (2009). Validation of a brief measure of anxiety-related severity and impair- ment: The Overall Anxiety Severity and Impairment Scale (OASIS). Journal of Affective Disorders, 112(1–3), 92–101.

Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., & Harrington, H. (2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science, 301, 386–389.

Cassiello-Robbins, C., Southward, M. W., Tirpak, J. W., & Sauer-Zavala, S. (2020). A systematic review of Unified Protocol applications with adult populations: Facilitating widespread dissemination via adaptability. Clinical Psy- chology Review, 78, Article 101852.

Chorpita, B. F., Albano, A. M., & Barlow, D. H. (1998). The structure of negative emotions in a clinical sample of chil- dren and adolescents. Journal of Abnormal Child Psychol- ogy, 107, 74–85.

Chorpita, B. F., & Barlow, D. H. (1998). The development of anxiety: The role of control in the early environment. Psychological Bulletin, 124, 3–21.

Clark, D. M. (2012). The English Improving Access to Psycho- logical Therapies (IAPT) program: History and progress. In R. K. McHugh & D. H. Barlow (Eds.), Dissemination and implementation of evidence-based psychological interven- tions (pp. 61–77). New York: Oxford University Press.

Clark, L. A. (2005). Temperament as a unifying basis for personality and psychopathology. Journal of Abnormal Psy- chology, 114, 505–521.

Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and taxonomic im- plications. Journal of Abnormal Psychology, 103, 103–116.

Craske, M. G., & Barlow, D. H. (2006). Mastery of your

Emotional Disorders 253

anxiety and worry (2nd ed.). New York: Oxford University Press.

Craske, M. G., Rowe, M., Lewin, M., & Noriega-Dimitri, R. (1997). Interoceptive exposure versus breathing retraining within cognitive-behavioural therapy for panic disorder with agoraphobia. British Journal of Clinical Psychology, 36, 85–99.

Davis, L., Barlow, D. H., & Smith, L. (2010). Comorbidity and the treatment of principal anxiety disorders in a natu- ralistic sample. Behavior Therapy, 41(3), 296–305.

de Ornelas Maia, C. A. C., Nardi, A. E., & Cardoso, A. (2015). The utilization of unified protocols in behavioral cognitive therapy in transdiagnostic group subjects: A clinical trial. Journal of Affective Disorders, 172, 179–183.

Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., & Addis, M. E. (2006). Random- ized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658–670.

Drabant, E. M., Ramel, W., Edge, M. D., Hyde, L. W., Kuo, J. R., Goldin, P. R. (2012). Neural mechanisms underlying 5-HTTLPR-related sensitivity to acute stress. American Journal of Psychiatry, 169, 397–405.

Endicott, J., Nee, J., Harrison, W., & Blumenthal, R. (1993). Quality of Life Enjoyment and Satisfaction Question- naire: A new measure. Psychopharmacology Bulletin, 29(2), 321–326.

Eysenck, H. J. (1947). Dimension of personality. London: Routledge & Kegan Paul.

First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2016). Structured Clinical Interview for DSM-5 Disorders, Clinician Version (SCID-5-CV). Arlington, VA: American Psychiatric Association.

Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a brief instrument for assessment post-traumatic stress disorder. Journal of Trau- matic Stress, 6(4), 459–473.

Foa, E. B., & Tolin, D. F. (2000). Comparison of the PTSD Symptom Scale—Interview Version and the Clinician-Ad- ministered PTSD scale. Journal of Traumatic Stress, 13(2), 181–191.

Gallagher, M. W., Long, L. J., Richardson, A., D’Souza, J., Boswell, J. F., Farchione, T. J., et al. (2020). Examining hope as a transdiagnostic mechanism of change across anxiety disorders and CBT treatment protocols. Behavior Therapy, 51(1), 190–202.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., & Hill, C. L. (1989). The Yale– Brown Obsessive Compulsive Scale: I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 1006–1011.

Grisanzio, K. A., Goldstein-Piekarski, A. N., Wang, M. Y., Ahmed, A. P. R., Samara, Z., & Williams, L. M. (2018). Transdiagnostic symptom clusters and associations with

brain, behavior, and daily function in mood, anxiety, and trauma disorders. JAMA Psychiatry, 75(2), 201–209.

Hafner, J., & Marks, I. M. (1976). Exposure in vivo of agora- phobics: Contributions of diazepam, group exposure, and anxiety evocation. Psychological Medicine, 6, 71–88.

Hamilton, M. (1959). The assessment of anxiety states by rat- ing. British Journal of Medical Psychology, 32, 50–55.

Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56–62.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Ac- ceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.

Heimberg, R. G., Horner, K. J., Juster, H. R., Safren, S. A., Brown, E. J., & Schneier, F. R. (1999). Psychometric prop- erties of the Liebowitz Social Anxiety Scale. Psychological Medicine, 29(1), 199–212.

Heimberg, R. G., Liebowitz, M. R., Hope, D. A., Schneier, F. R., Holt, C. S., & Welkowitz, L. A. (1998). Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Archives of General Psychiatry, 55(12), 1133–1141.

Hettema, J. M., Neale, M. C., & Kendler, K. S. (2001). A review and meta-analysis of the genetic epidemiology of anxiety disorders. American Journal of Psychiatry, 158, 1568–1578.

Huppert, J. D., Bufka, L. F., Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2001). Therapists, thera- pist variables and cognitive-behavioral therapy outcome in a multicenter trial for panic disorder. Journal of Consulting and Clinical Psychology, 69, 747–755.

Insel, T. R., Cuthbert, B. N., Garvey, M. B., Heinssen, R., Pine, D. S., Quinn, K., et al. (2010). Research domain cri- teria (RDoC): Toward a new classification framework for research on mental disorders. American Journal of Psychia- try, 167, 748–751.

Izard, C. E. (1971). The face of emotion. New York: Appleton- Century-Crofts.

Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Be- havioral activation treatment for depression: Returning to contextual roots. Clinical Psychology: Science and Practice, 8, 255–270.

Kendler, K. S. (1996). Major depression and generalized anxiety disorder: Same genes, (partly) different environ- ments—revisited. British Journal of Psychiatry, 30(Suppl.), 68–75.

Kendler, K. S., Walters, E. E., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1995). The structure of genetic and environmental risk factors for six major psy- chiatric disorders in women: Phobia, generalized anxiety disorder, panic disorder, bulimia, major depression, and alcoholism. Archives of General Psychiatry, 52, 374–382.

Kessler, R. C., Nelson, C. B., McGonagle, K. A., Lui, J., Swartz, M., & Blazer, D. G. (1996). Comorbidity of DSM- III-R major depressive disorder in the general population:

254 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Results from the National Comorbidity Survey. British Journal of Psychiatry, 168, 17–30.

Keyes, C. L. M. (2005). Mental illness and/or mental health?: Investigating axioms of the complete state model of health. Journal of Consulting and Clinical Psychology, 73, 539–548.

Keyes, C. L. M. (2006). Mental health in adolescence: Is America’s youth flourishing? American Journal of Ortho- psychiatry, 76, 395–402.

Keyes, C. L., Wissing, M., Potgieter, J. P., Temane, M., Kru- ger, A., & van Rooy, S. (2008). Evaluation of the Mental Health Continuum—Short Form (MHC-SF) in Setswa- na-speaking South Africans. Clinical Psychology and Psy- chotherapy, 15(3), 181–192.

Lamers, S. M., Westerhof, G. J., Bohlmeijer, E. T., ten Klooster, P. M., & Keyes, C. L. (2011). Evaluating the psychometric properties of the Mental Health Continu- um-Short Form (MHC-SF). Journal of Clinical Psychology, 67(1), 99–110.

Lee, J. K., Orsillo, S. M., Roemer, L., & Allen, L. B. (2010). Distress and avoidance in generalized anxiety disorder: Exploring the relationships with intolerance of uncertainty and worry. Behavior Therapy, 39, 126–136.

Liebowitz, M. R. (1987). Social phobia. Modern Problems in Pharmacopsychiatry, 22, 141–173.

Liebowitz, M. R., Heimberg, R. G., Schneier, F. R., Hope, D. A., Davies, S., & Holt, C. S. (1999). Cognitive-behavioral group therapy versus phenelzine in social phobia: Long- term outcome. Depression and Anxiety, 10(3), 89–98.

Linehan, M. M. (1993). Cognitive-behavioral treatment of bor- derline personality disorder. New York: Guilford Press.

Liverant, G. I., Brown, T. A., Barlow, D. H., & Roemer, L. (2008). Emotion regulation in unipolar depression: The effects of acceptance and suppression of subjective emo- tional experience on the intensity and duration of sadness and negative affect. Behaviour Research and Therapy, 46, 1201–1209.

Lonsdorf, T. B., Golkar, A., Lindstöm, K. M., Fransson, P., Schalling, M., & Ohman, A. (2011). 5-HTTLPR and COMTval158met genotype gate amygdala reactivity and habituation. Biological Psychology, 87, 106–112.

Lopez, M. E., Stoddard, J. A., Noorollah, A., Zerbi, G., Payne, L. A., Hitchcock, C. A., et al. (2015). Examining the efficacy of the unified protocol for transdiagnostic treatment of emotional disorders in the treatment of indi- viduals with borderline personality disorder. Cognitive and Behavioral Practice, 22(4), 522–533.

Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335–343.

Margraf, J., Taylor, C. B., Ehlers, A., Roth, W. T., & Agras, W. S. (1987). Panic attacks in the natural environment. Journal of Nervous and Mental Disease, 175, 558–565.

McHugh, R. K., & Barlow, D. H. (Eds.). (2012). Dissemina-

tion and implementation of evidence-based psychological in- terventions. New York: Oxford University Press.

McTeague, L. M., Rosenberg, B. M., Lopez, J. W., Carreon, D. M., Huemer, J., Jiang, Y., et al. (2020). Identification of common neural circuit disruptions in emotional pro- cessing across psychiatric disorders. American Journal of Psychiatry, 177(5), 411–421.

Mennin, D. S., Ellard, K. K., Fresco, D. M., & Gross, J. J. (2013). United we stand: Emphasizing commonalities across cognitive-behavioral therapies. Behavior Therapy, 44(2), 234–248.

Mennin, D. S., Heimberg, R. G., Turk, C. L., & Fresco, D. M. (2005). Preliminary evidence for an emotion dysregu- lation model of generalized anxiety disorder. Behaviour Research and Therapy, 43, 1281–1310.

Merikangas, K. R., Zhang, H., & Aveneoli, S. (2003). Longi- tudinal trajectories of depression and anxiety in a prospec- tive community study. Archives of General Psychiatry, 60, 993–1000.

Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487–495.

Miller, W. R., & Rollnick, S. (2013). Motivational interview- ing: Preparing people for change (3rd ed.). New York: Guil- ford Press.

Montag, C., Fiebach, C. J., Kirsch, P., & Reuter, M. (2011). Interaction of 5-HTTLPR and a variation on the oxytocin receptor gene influences negative emotionality. Biological Psychiatry, 69, 601–603.

Munafò, M. R., Brown, S. M., & Hariri, A. R. (2008). Se- rotonin transporter (5-HTTLPR) genotype and amyg- dala activation: A meta-analysis. Biological Psychiatry, 63, 852–857.

Nathan, P. E., & Gorman, J. M. (Eds.). (2007). A guide to treatments that work (3rd ed.). New York: Oxford Univer- sity Press.

Norman, S. B., Cissell, S. H., Means-Christensen, A. J., & Stein, M. B. (2006). Development and validation of an Overall Anxiety Severity and Impairment Scale (OASIS). Depression and Anxiety, 23(4), 245–249.

Pezawas, L., Meyer-Lindenberg, A., Drabant, E. M., Verchin- ski, B. A., Munoz, K. E., & Kolachana, B. S. (2005). 5-HTTLPR polymorphism impacts human cingulate– amygdala interactions: A genetic susceptibility mechanism for depression. Nature Neuroscience, 8(6), 828–834.

Raffa, S. D., Stoddard, J. A., White, K. S., Barlow, D. H., Gorman, J. M., & Shear, M. K. (2008). Relapse follow- ing combined-treatment discontinuation in a placebo- controlled trial for panic disorder. Journal of Nervous and Mental Disease, 196(7), 548–555.

Rapee, R. M., Craske, M. G., & Barlow, D. H. (1990). Sub- ject described features of panic attacks using a new self- monitoring form. Journal of Anxiety Disorders, 4, 171–181.

Reinholt, N., Aharoni, R., Winding, C., Rosenberg, N., Rosenbaum, B., & Arnfred, S. (2017). Transdiagnostic

Emotional Disorders 255

group CBT for anxiety disorders: The unified protocol in mental health services. Cognitive Behaviour Therapy, 46(1), 29–43.

Roy-Byrne, P. P., Craske, M. G., & Stein, M. B. (2006). Panic disorder. Lancet, 368, 1023–1032.

Rutter, M., Moffit, T. E., & Caspi, A. (2006). Gene–environ- ment interplay and psychopathology: Multiple varieties but real effects. Journal of Child Psychology and Psychiatry, 47, 226–261.

Ruzek, J. I., Karlin, B. E., & Zeiss, A. (2012). Implemen- tation of evidence-based psychological treatments in the Veterans Health Administration. In R. K. McHugh & D. H. Barlow (Eds.), Dissemination and implementation of evidence-based psychological interventions (pp. 78–96). New York: Oxford University Press.

Safren, S. A., Heimberg, R. G., Horner, K. J., Juster, H. R., Schneier, F. R., & Liebowitz, M. R. (1999). Factor struc- ture of social fears: The Liebowitz Social Anxiety Scale. Journal of Anxiety Disorders, 13(3), 253–270.

Sakiris, N., & Berle, D. (2019). A systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention. Clinical Psychology Review, 72, Article 101751.

Sauer-Zavala, S. E., & Barlow, D. H. (2014). The case for borderline personality disorder as an emotional disorder: Implications for treatment. Clinical Psychology: Science and Practice, 21(2), 118–138.

Sauer-Zavala, S., & Barlow, D. H. (2021). Neuroticism: A new framework for emotional disorders and their treatment. New York: Guilford Press.

Sauer-Zavala, S., Boswell, J. F., Gallagher, M. W., Bentley, K. H., Ametaj, A., & Barlow, D. H. (2012). The role of negative affectivity and negative reactivity to emotions in predicting outcomes in the Unified Protocol for the trans- diagnostic treatment of emotional disorders. Behaviour Research and Therapy, 50(9), 551–557.

Sharp, P. B., Miller, G. A., & Heller, W. (2015). Transdiag- nostic dimensions of anxiety: Neural mechanisms, execu- tive functions, and new directions. International Journal of Psychophysiology, 98(2), 365–377.

Shear, K., Belnap, B. H., Mazumdar, S., Houck, P., & Roll- man, B. L. (2006). Generalized Anxiety Disorder Severity Scale (GADSS): A preliminary validation study. Depres- sion and Anxiety, 23(2), 77–82.

Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., Sho- lomskas, D. E., & Woods, S. W. (1997). Multicenter col- laborative Panic Disorder Severity Scale. American Journal of Psychiatry, 154, 1571–1575.

Shear, M. K., Vander Bilt, J., & Rucci, P. (2001). Reliabil- ity and validity of a Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH-A). Depression and Anxiety, 13, 166–178.

Sloan, E., Hall, K., Moulding, R., Bryce, S., Mildred, H., & Staiger, P. K. (2017). Emotion regulation as a trans- diagnostic treatment construct across anxiety, depression, substance, eating and borderline personality disorders:

A systematic review. Clinical Psychology Review, 57, 141– 163.

Steele, S. J., Farchione, T. J., Cassiello-Robbins, C., Ametaj, A., Sbi, S., Sauer-Zavala, S., et al. (2018). Efficacy of the Unified Protocol for transdiagnostic treatment of comor- bid psychopathology accompanying emotional disorders compared to treatments targeting single disorders. Journal of Psychiatric Research, 104, 211–216.

Stein, M. B., Campbell-Sills, L., & Gelernter, J. (2009). Ge- netic variation in 5HTTLPR is associated with emotional resilience. American Journal of Genetics B: Neuropsychiatric Genetics, 150, 900–906.

Storch, E. A., Larson, M. J., Price, L. H., Rasmussen, S. A., Murphy, T. K., & Goodman, W. K. (2010). Psychometric analysis of the Yale–Brown Obsessive–Compulsive Scale Second Edition Symptom Checklist. Journal of Anxiety Disorders, 24, 650–656.

Suárez, L., Bennett, S. M., Goldstein, C., & Barlow, D. H. (2009). Understanding anxiety disorders from a “triple vulnerability” framework. In M. M. Antony & M. B. Stein (Eds.), Handbook of anxiety and the anxiety disorders (pp. 153–172). New York: Oxford University Press.

Tabak, B. A., Young, K. S., Torre, J. B., Way, B. M., Burklund, L. J., Eisenberger, N. I., et al. (2020). Preliminary evidence that CD38 moderates the association of neuroticism on amygdala–subgenual cingulate connectivity. Frontiers in Neuroscience, 14, 11.

Tsao, J. C. I., Mystkowski, J. L., Zucker, B. G., & Craske, M. G. (2002). Effects of cognitive-behavior therapy for panic disorder on comorbid conditions: Replication and exten- sion. Behavior Therapy, 33, 493–509.

Tsao, J. C. I., Mystkowski, J. L., Zucker, B. G., & Craske, M. G. (2005). Impact of cognitive-behavioral therapy for panic disorder on comorbidity: A controlled investigation. Behaviour Research and Therapy, 43, 959–970.

Tull, M. T., & Roemer, L. (2007). Emotion regulation dif- ficulties associated with the experience of uncued panic attacks: Evidence of experiential avoidance, emotional nonacceptance, and decreased emotional clarity. Behav- iour Research and Therapy, 38, 378–391.

Tyrer, P. J. (1989). Classification of neurosis. Chichester, UK: Wiley.

Tyrer, P. J., Seivewright, N., Murphys, S., Ferguson, B., King- don, D., & Barczak, B. (1998). The Nottingham study of neurotic disorder: Comparison of drug and psychological treatments. Lancet, 2, 235–240.

Watson, D. (2005). Rethinking the mood and anxiety disor- ders: A quantitative hierarchical model for DSM-V. Jour- nal of Abnormal Psychology, 114, 522–536.

Watson, D., Clark, L. A., & Tellegen, A. (1988). Develop- ment and validation of brief measures of positive and nega- tive affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070.

Weinberg, A., & Hajcak, G. (2010). Electrocortical evidence for vigilance–avoidance in generalized anxiety disorder. Psychophysiology, 48(6), 1–10.

256 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Weiser, M., Pauli, P., Weyers, P., Alpers, G., & Mühlberger, A. (2009). Fear of negative evaluation and the hypervigi- lance–avoidance hypothesis: An eye-tracking study. Jour- nal of Neural Transmission, 116, 717–723.

Westerhof, G. J., & Keyes, C. L. (2009). Mental illness and mental health: The two continua model across the lifes- pan. Journal of Adult Development, 17(2), 110–119.

Westra, H. A., Arkowitz, H., & Dozois, D. J. A. (2009). Add- ing a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A pre- liminary randomized controlled trial. Journal of Anxiety Disorders, 23, 1106–1117.

Westra, H. A., & Dozois, D. J. A. (2006). Preparing clients for cognitive behavioural therapy: A randomized pilot study of motivational interviewing for anxiety. Cognitive Therapy and Research, 30, 481–498.

Williams, J. B. (1988). A Structured Interview Guide for the Hamilton Depression Rating Scale. Archives of General Psychiatry, 45, 742–747.

Wilner Tirpak, J., Cassiello-Robbins, C., Ametaj A., Ole- snycky, O. S., Sauer-Zavala, S., Farchione, T. J., et al. (2019). Changes in positive affect in cognitive-behavioral treatment of anxiety disorders. General Hospital Psychiatry, 61, 111–115.

257

One of the most important developments in psychological approaches to emotional problems has been the success of cognitive therapy for depression. Evidence for the powerful efficacy of this ap- proach has increased steadily over the years, particularly in regard to successful long-term outcome. Employing a variety of well-specified cognitive and behavioral techniques, cognitive therapy is also distinguished by the detailed structure of each session, with its specific agendas, and the very de- liberate and obviously effective therapeutic style of interacting with the patient through a series of questions (Socratic style). Moreover, the authors underscore very clearly the importance of a col- laborative relationship between therapist and patient, and outline specific techniques to achieve this collaborative state, so that patient and therapist become an investigative team. In this chapter, the authors cover not only traditional cognitive therapy but also an expansion of cognitive therapy called “schema-focused” therapy. This approach concentrates on identifying and modifying early maladaptive or “core” schemas thought to develop during childhood in more severely depressed and treatment-resistant patients, often with comorbid personality disorders that may make the patient vul- nerable to relapse. Detailed explication of this expanded treatment will be invaluable to experienced cognitive therapists, as well as to those becoming acquainted with cognitive therapy for depression for the first time. Two compelling cases—“Denise,” treated with traditional cognitive therapy, and “Barbara,” treated with schema-focused therapy—illustrate each approach. —D. H. B.

Depression is one of the most common disorders en- countered by mental health professionals. Research

from the National Epidemiologic Survey on Alcohol and Related Conditions–III (NESARC-III; Hasin et al., 2018), the Centers for Disease Control and Preven- tion (CDC; 2010), the Substance Abuse and Mental Health Services Administration (SAMHSA; 2008; 2019), and the World Health Organization (WHO; 2017, 2020) indicate the following:

• The lifetime prevalence estimate for major de- pressive disorder in adults in the United States is 20.6% (Hasin et al., 2018).

• The 12-month prevalence estimate for major de- pressive disorder in the United States is 10.4% (Hasin et al., 2018).

• Across countries and cultures, the lifetime preva- lence estimates for major depressive disorder are 14.6% in high-income and 11.1% in low- to mid- dle-income countries; the 12-month prevalence estimates are 5.5% in high-income and 5.9% low- to middle-income countries (Kessler & Bromet, 2013). Additionally, the number of people living with depression worldwide increased by 18.4% be- tween 2005 and 2015 (WHO, 2017).

• Among adults ages 18 or older, major depressive

C H A P T E R 7

Cognitive Therapy for Depression

Jeffrey E. Young Erin F. Ward‑Ciesielski Jayne L. Rygh Arthur D. Weinberger Aaron T. Beck

258 CliniCal Handbook of PsyCHologiCal disorders

episodes in the United States are associated with higher rates of substance dependence or abuse (21.5%) compared to those without major depres­ sive episodes (8.2%; SAMHSA, 2008) and youth ages 12–17 exhibit a similar pattern, in which substance use is more common among those with versus those without major depressive episodes (32.7% vs. 14.0%; SAMHSA, 2019).

• Depression increases the risk of heart attacks and is more common in those with chronic conditions such as obesity, diabetes, cardiovascular disease, cancer, asthma, and arthritis (Chapman, Perry, & Strine, 2005; Strine et al., 2008).

• Major depressive disorder in the United States is associated with 27.2 lost workdays and bipolar dis­ order (I or II) with 65.5 lost workdays for each ill worker per year (Kessler et al., 2006).

• Major depressive disorder is the leading cause of disability in the United States for people ages 15–44 (Friedrich, 2017), and is a major contribu­ tor to the global burden of disease (GBD) (WHO, 2020; GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018).

The high risk of relapse (Forte et al., 2015), high resource utilization (e.g., Howland, 1993; Tusa et al., 2019), and loss of human capital (Berndt et al., 2000) associated with depression reveal the seriousness of the problem. The WHO (2004) projects that depression will be among the top three causes of the total number of years of life lost to illness, disability, or premature death by 2030. As these reports indicate, depression is widespread, debilitating, costly, and potentially devas­ tating.

No amount of data can adequately capture or convey the personal pain and suffering experienced in depres­ sion. Many depressed people do not get professional help (e.g., Kohn, Saxena, Levav, & Saraceno, 2004; Wang et al., 2005), and although the number seeking help continues to increase, undertreatment remains a se­ rious problem (Olfson, Blanco, & Marcus, 2016; Wang et al., 2005). The cost and/or lack of sufficient coverage by health insurance companies, concerns about confi­ dentiality, continued social stigma, low perceived need for help or the desire to handle the problem alone, and the lack of information regarding where to go and what type of services to obtain are still obstacles to receiving appropriate and adequate mental health services (Moj­ tabai et al., 2011; SAMHSA, 2008). Obtaining the right type of help can be at once inhibiting and over­

whelming, especially to those already impaired. The following quote remains relevant today:

Americans who do seek treatment for depressive symp­ toms must decide where to seek which treatment and from what type of practitioner. . . . The clinician must select a somatic, psychological, or combination of treatment, at a given dose and/or schedule of appointments.  .  .  . Throughout this procedure, the patient decides to what extent he/she will comply with the recommendations, for how long, against recognized and unrecognized econom­ ic, practical, physical, and emotional costs.  .  .  . Sadly, the lack of information as well as the continued social stigma of psychiatric illness and treatment influence de­ cision­making. Simultaneously, the decisions occur in an environment filled with social, political, and economic debate, and tension among policy makers, third­party payers, and clinicians, as well as among different types of practitioner guilds. (Jarrett, 1995, p. 435)

When care is provided, it is frequently inadequate or minimally adequate (Wang et al., 2005), which can leave depressed individuals feeling frustrated, hopeless, or anxious (Mago, Fagiolini, Weiller, & Weiss, 2018). Evidenced­based treatments have not been widely ad­ opted in clinical practice (Wiltsey Stirman et al., 2012), reflecting a public health crisis (Keller & Boland, 1998). The need for delivery of treatments with proven and rapid efficacy remains paramount.

One of the major developments in the treatment of depression has been the emergence of cognitive therapy, which has expanded exponentially since A. T. Beck’s publication of a detailed treatment manual for depres­ sion in 1979 (Beck, 1967, 1976; Beck, Rush, Shaw, & Emery, 1979). The work of Beck and his colleagues led to a paradigm shift within psychotherapy (Salkov skis, 1996). Due in part to Beck’s development of testable hypotheses and clinical protocols, cognitive therapy has received an enormous amount of professional attention (Hollon, 1998; McGinn & Young, 1996; Rehm, 1990). Of all the cognitive­behavioral treatment approaches to depression, Beck’s paradigm (Beck, 1967; Beck et al., 1979) has received the greatest amount of empiri­ cal study, validation, and clinical application (Barlow & Hofmann, 1997; de Oliveira, 1998; Dobson, 2016; Dobson & Pusch, 1993; Hollon, 1998; Hollon, Thase, & Markowitz, 2002; Jarrett & Thase, 2010; Rehm, 1990; Roberts & Hartlage, 1996; Scott, 1996; Vittengl, Clark, Dunn, & Jarrett, 2007). Cognitive therapy has become the treatment of choice for many disorders (e.g., Clark & Beck, 2010; Newman, Leahy, Beck, Reilly­

Cognitive Therapy for Depression 259

Harrington, & Gyulai, 2002). There are many excel­ lent books for practitioners who teach cognitive therapy procedures (e.g., J. S. Beck, 2021), as well as workbooks and/or guides for clients (e.g., Fox & Sokol, 2011; Gil­ son, Freeman, Yates, & Freeman, 2009; Leahy, 2011; Wright & McCray, 2011).

Along with this attention, however, has come confu­ sion about what is actually meant by the term cogni- tive therapy. The actual cognitive therapeutic strategies employed in “cognitive” treatments may differ in many ways from one another and from those explicitly pre­ scribed by Beck and colleagues (1979) in their manual for cognitive therapy of depression. Thus, the reader should be aware that common use of the term cognitive therapy does not necessarily imply uniformity in proce­ dures. The therapy described by Beck and colleagues involves the use of both cognitive and behavioral tech­ niques, and can therefore be accurately labeled cogni- tive-behavioral; however, in the literature, both terms have been applied in describing Beck and colleagues’ procedures, with some articles utilizing the term cogni- tive therapy (Sacco & Beck, 1995, p. 345).

RESEARCH ON TREATMENT OF THE ACUTE PHASE

Outcome research has found cognitive therapy to be effective with clinical populations in numerous con­ trolled trials (see reviews by Beck & Alford, 2009; Dobson, 2016; Hollon & Shelton, 2001). Although some early studies (Blackburn, Bishop, Glen, Whal­ ley, & Christie, 1981; Rush, Beck, Kovacs, & Hollon, 1977) suggested that cognitive therapy may be superior to drug treatment for depression at termination, Me­ terissian and Bradwejn (1989) noted that psychophar­ macological interventions often were not adequately implemented. In research in which interventions were adequate, cognitive therapy generally was shown to be equivalent in efficacy to antidepressant medica­ tions, including tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) in the treatment of outpatients with nonbipolar depression (DeRubeis et al., 2005; Hollon et al., 1992; Murphy, Simmons, Wetzel, & Lustman, 1984) and a mono­ amine oxidase inhibitor (MAOI) in the treatment of outpatients with atypical depression (Jarrett et al., 1999). Furthermore, Cuijpers and colleagues (2013) found no significant overall differences between cog­ nitive­behavioral therapy (CBT) and pharmacotherapy

across 20 trials. And in a recent meta­analysis of in­ dividual patient­level data from trials comparing CBT to antidepressants (Weitz et al., 2015), although scores on a clinician­ administered depression measure (i.e., Hamilton Rating Scale for Depression) were signifi­ cantly more affected by antidepressants than by CBT, there were no differences in rates of response to treat­ ment or remission between treatments.

Although some reviews have reported that combined psychotherapy and pharmacotherapy is superior to ei­ ther treatment alone for depressed outpatients (e.g., Friedman et al., 2004; Pampallona, Bollini, Tibalbi, Kupelnick, & Munizza, 2004), several researchers have not found this effect in trials comparing combined CBT and medications to their component parts (Biggs & Rush, 1999; Evans et al., 1992; Hollon, Shelton, & Loosen, 1991; Scott, 1996; Shaw & Segal, 1999). No­ tably, in their meta­analysis, Cuijpers and colleagues (2013) found that CBT plus pharmacotherapy signifi­ cantly outperformed pharmacotherapy alone across the 11 relevant trials included. The increment in efficacy appears to be modest in the acute phase of treatment at best, with increases in efficacy from 10 to 20% (Conte, Plutchik, Wild, & Karasu, 1986). Specific studies re­ garding treatment with depressed inpatients also sug­ gest beneficial results when CBT is combined with medication (Cuijpers et al., 2011; Stuart & Bowers, 1995; Wright, 1996). Although cognitive therapy ap­ pears to be a useful adjunct to standard care with in­ patients, it remains unclear whether cognitive therapy alone is sufficient (Boschloo et al., 2019; Cuijpers et al., 2011; Hollon et al., 2002).

Although many studies comparing CBT to pharma­ cotherapy have not included pill­placebo conditions, the studies by Jarrett and colleagues (1999) and De­ Rubeis and colleagues (2005) found the active treat­ ments superior to pill­placebo. Importantly, only two studies that included a pill­placebo found cognitive therapy to be less effective than psychopharmacologi­ cal intervention. The first was the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP) with mod­ erate to severe depression in adults. The second was the multisite Treatment for Adolescents with Depression Study (TADS) for reduction of depressive symptoms in adolescents.

The NIMH TDCRP was the first major study to include a pill­placebo condition. The initial results of the TDCRP (Elkin et al., 1989) suggested lower rates of improvement with CBT than did earlier studies. It

260 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

also appeared that with more severely depressed patient groups, interpersonal psychotherapy and antidepressant drugs might be superior to CBT. The high visibility and prestige of the NIMH TDCRP study generated a great deal of debate (Hollon, DeRubeis, & Evans, 1996; Wolpe, 1993), because it appeared that the benefits of CBT in the acute treatment phase might have been overestimated in previous studies. However, on later ex- amination of the data, Elkin, Gibbons, Shea, and Shaw (1996) acknowledged Jacobson and Hollon’s (1996) ob- servation that the outcome results varied across sites, with cognitive therapy performing as well as medication at one of the three sites with severely depressed clients. Jacobson and Hollon noted that the best results were obtained at the site with the most experienced thera- pists. Hollon and colleagues (2002, p. 62) “suspect that the explanation is not that cognitive therapy cannot be effective with such patients, but that the therapist’s ex- pertise makes a greater difference the more difficult the depression is to treat.” Additionally, a study by Albon and Jones (2003) raised the question of the distinctive- ness of the two types of psychotherapy treatments in the TDCRP. Albon and Jones, expert therapists in CBT and interpersonal psychotherapy, respectively, devel- oped prototypes of ideal regimens of their own respec- tive treatments. Then, actual transcripts of treatment sessions from the TDCRP were compared to these ex- pert prototypes. Albon and Jones found that both CBT and interpersonal psychotherapy sessions conformed most closely to the cognitive-behavioral prototype, and that closer adherence to the cognitive-behavioral pro- totype produced more positive correlations with out- come measures across both types of treatment. Perhaps this is why Quilty, McBride, and Bagby (2008) found equivalent outcomes with interpersonal psychotherapy, CBT, and pharmacotherapy, and Peeters and colleagues (2013) found similar remission rates with CBT, inter- personal psychotherapy, and both treatments combined with medication. Similarly, Luty and colleagues (2007) found interpersonal psychotherapy and CBT equally effective overall but (in contrast to the NIMH TDCRP study) they found CBT to be more effective with se- vere depression. This is further supported by a recent meta-analysis of CBT for unipolar depression, in which Johnsen and Friborg (2015) found that experienced providers achieved better results than less experienced therapists.

In further analysis of the same dataset used in the Luty and colleagues (2007) study, Joyce and colleagues (2007) found that comorbidity of personality and major

depressive disorders adversely affected the treatment re- sponse to interpersonal psychotherapy but not CBT. Bellino, Zizza, Rinaldi, and Bogetto (2007) found in- terpersonal psychotherapy and CBT (each combined with fluoxetine) equally effective in the treatment of depression in patients with borderline personality and major depressive disorders. Fournier and colleagues (2008) found that at 16 weeks of treatment, CBT was more effective in reducing depression than medication (paroxetine) for patients with moderate to severe de- pression and no personality disorder, but less effective for those with a personality disorder. This study did not include patients with borderline, schizotypal, or antiso- cial personality disorders. The efficacy of CBT (alone or as an adjunct to psychopharmacological treatment) with coexisting major depressive and personality disor- ders is still not clear.

The second pill-placebo study, the multisite TADS (2004) for reduction of depressive symptoms in adoles- cents, found that the combination of medication (fluox- etine) and CBT produced the most positive outcome, that medication alone was superior to pill-placebo, but CBT alone did not significantly differ from pill- placebo. These findings were based on 12-week out- come measures. Analyses (TADS, 2007) on data from outcome measures at Weeks 18, 24, and 36, however, indicated that by Week 36 the effectiveness of CBT sig- nificantly increased and was equivalent to medication, and that the combination of medication and CBT was slightly more effective than CBT or medication alone.

Some writers have argued that the major psychother- apies are essentially equivalent in effectiveness, regard- less of the disorder studied. To test this hypothesis, a meta-analysis examined whether CBT was superior to other forms of psychotherapy across a range of disor- ders (Tolin, 2010). The results showed that, across all disorders included in the study, CBT was superior to psy- chodynamic therapy, although not to interpersonal or supportive therapies, at posttreatment and at follow-up. However, the analysis revealed that CBT was signifi- cantly superior to the alternative therapies studied for depressive and anxiety disorders. Tolin (2010) conclud- ed that “these results argue against previous claims of treatment equivalence and suggest that CBT should be considered a first-line psychosocial treatment of choice, at least for patients with anxiety and depressive disor- ders” (p. 710).

CBT for depression has also demonstrated consid- erable effects for children and adolescents, not just for adults. Spirito, Esposito-Smythers, Wolff, and Uhl

Cognitive Therapy for Depression 261

(2011) completed a review of outcome studies regard- ing CBT for adolescent depression and suicidality. They summarized the data regarding depression by concluding that “CBT for adolescent depression has re- ceived considerable support in the research literature. Individual and group CBT, with and without a parent component, appears to be well established and/or ef- ficacious for the majority of participants” (p. 195). This is consistent with a more recent meta-regression analysis of CBT for child and adolescent depression (Oud et al., 2019) that demonstrated reduced depressive symptoms at posttreatment and at follow-up in CBT compared to inactive control conditions. Regarding CBT and sui- cidality in adolescents, Spirito and colleagues (2011) concluded that

the majority of studies of CBT for depressed adolescents have found a reduction in suicidal ideation regardless of CBT format (i.e., individual, group). It should be noted that reductions in suicidality have also been found in response to family therapy, supportive therapy, and pharmacotherapy. Nonetheless, while various forms of therapy resulted in comparable reductions in adolescent suicidality, CBT has shown the most promise in concur- rently reducing MDD diagnoses/symptoms and suicidal ideation. (p. 196)

Notably, a recent meta-analysis of posttreatment follow-up outcomes (Rith-Najarian et al., 2019) found large effect size gains from pre- to posttreatment that were maintained for up to 2 years for adolescents across CBT treatments for depression, anxiety, and traumatic stress.

A recent development in the treatment outcome literature is the availability of large numbers of CBT trials that enable robust meta-analytic procedures. For example, a meta-analysis by Cuijpers and colleagues (2013) included 115 randomized trials comparing CBT to a control group or another active treatment for adult depression. Although they found that CBT outper- formed comparison treatments overall, they cautioned that higher study quality was associated with smaller effect sizes in favor of CBT. This suggests that the mean effects of CBT may be overestimated. With few excep- tions, they found no differences between cognitive therapy and either medication or psychotherapy com- parison conditions, and the differences observed must be interpreted with caution because they involved a small number of studies. Additionally, in a recent meta- analysis (Johnsen & Friborg, 2015) of 70 CBT trials be- tween 1977 and 2014, the authors found that the effects

of CBT as documented in the research literature have decreased over time. These and other large-scale analy- ses provide important information about the areas in which CBT has room to further develop and improve.

In attempts to make traditional cognitive therapy more accessible and/or affordable for the general pub- lic, Internet-based (ICBT) and group (CBGT) CBT have been explored. In reviews of rapidly accumulating data on ICBT (e.g., Baumeister, Reichler, Munzinger, & Lin, 2014; Cowpertwait & Clarke, 2013; Johans- son & Andersson, 2012; Karyotaki et al., 2017; König- bauer, Letsch, Doebler, Ebert, & Baumeister, 2017), researchers have highlighted mounting support for the effectiveness of ICBT; particularly, guided ICBT (structured self-help materials with therapist contact via e-mail) outperforms unguided ICBT (no therapist contact). Research also indicates that guided ICBT is comparable to face-to-face therapy in effectiveness and that tailored treatments (which include additional spe- cific techniques for coexisting diagnoses) are superior to nontailored treatments (same material for all patients) with severe depression (Johansson & Anderson, 2012).

Regarding CBGT, a recent meta-analysis (Moore, Carr, & Hartnett, 2017) found large, significant effect sizes when comparing CBGT to treatment-as-usual and wait-list control conditions, and medium effects for ac- tive control groups. Another meta-analysis (Feng et al., 2012) also examined treatment characteristics associ- ated with outcomes and revealed that CBGT was more effective with mild to moderate depression. The effect decreased as depression severity increased. Additional notable findings from that review include: the optimal length of session was 60–90 minutes, take-home as- signments improved results, and higher turnover rates were related to poorer outcomes.

RESEARCH ON RELAPSE PREVENTION1

Even though the vast majority of patients recover from an episode of depression, they nevertheless remain vul- nerable to future depression.

Recurrence is a major problem for many individuals suffering from depression: At least 50% of individuals who suffer from one depressive episode have another within 10 years. Those experiencing two episodes have a 90% chance of suffering a third, while individuals with three or more lifetime episodes have relapse rates of 40% within 15 weeks of recovery from an episode (Kupfer, Frank, & Wamhoff, 1996, p. 293).

262 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Other investigators have found that 21% of adults with a major depressive episode have a new episode dur- ing a 3-year follow-up period (Hoertel et al., 2017), and 85% of patients with unipolar depression are likely to experience recurrences (Keller & Boland, 1998, p. 350). Wang (2004), through a 6-year follow-up, found that 49.8% of those treated for major depression developed subsequent major depressive episodes. As these num- bers clearly show, there is an urgent need for treatments capable of minimizing and preventing relapse.

What we consider a very exciting finding in the treatment of depression with cognitive therapy is the consistent observation (Paykel, 2007) that patients treated with cognitive therapy alone or with a combina- tion of cognitive therapy and medication fare far better in terms of relapse than do patients treated with medi- cation alone (when both treatments are stopped at ter- mination). Despite differences in sample characteristics and methodologies across studies, cognitive therapy ap- pears to have important prophylactic properties. After a 1-year follow-up, numerous studies have reported lower relapse rates for patients treated with cognitive therapy than for patients treated with antidepressants. Simons, Murphy, Levine, and Wetzel (1986) found relapse rates of 12% with cognitive therapy versus 66% with anti- depressants; Bowers (1990) found relapse rates of 20% with cognitive therapy versus 80% with antidepres- sants; Shea and colleagues (1992) reported 9% relapse with cognitive therapy versus 28% with antidepres- sants; Hollon and colleagues (2005) reported rates of 31% relapse with cognitive therapy versus 76% with an- tidepressants. Results from an extensive meta-analysis revealed that “on average, only 29.5% of the patients treated with cognitive therapy relapsed versus 60% of those treated with antidepressants” (Gloaguen, Cot- traux, Cucherat, & Blackburn, 1998, p. 68). This was also reported in a more recent meta-analysis, in which participants who received psychotherapy (including primarily CBT interventions) alone or in combination with another treatment had a lower likelihood of anoth- er depressive episode over more than 4 years of follow- up (Steinert, Hofmann, Kruse, & Leichsenring, 2014). The prophylactic benefits of cognitive therapy are all the more significant because “there is no evidence that pharmacotherapy confers any protection against the re- turn of symptoms after treatment has been terminated.2 Since the majority of depressed individuals will experi- ence multiple episodes, the capacity of an intervention to prevent the return of symptoms after treatment may

be at least as important as its ability to treat the current episode” (Evans et al., 1992, p. 802).

A related concern—and one of the most salient (but not exclusively associated) with psychotropic agents— is the presence of residual symptoms after treatment: “Treatment of depression by pharmacological means is likely to leave a substantial amount of residual symp- toms in most patients” (Fava, Rafanelli, Grandi, Conti, & Belluardo, 1998b, p. 820). Inevitably, patients who improve on antidepressants continue to manifest some of the symptoms of depression and, as numerous in- vestigators have concluded, unless patients achieve full recovery, residual symptoms increase the risk of relapse (Evans et al., 1992; Fava et al., 1998b; Hardeveld, Spij- ker, de Graaf, Nolen, & Beekman, 2010; Keller & Bo- land, 1998; Rush et al., 2006).

A group of investigators who were concerned about the risk of relapse associated with residual symptoms looked at the lingering symptoms after treatment with fluoxetine (Prozac). Nierenberg et al. (1999) found that

even among subjects who are considered full responders to fluoxetine 20 mg for 5 weeks, more than 80% had 1 or more residual DSM-III-R symptoms of major depressive disorder, more than 30% had 3 or more symptoms, and 10.2% met formal criteria for either minor or subsyndro- mal depression. . . . These findings imply that minimal depressive symptoms are prodromal and increase the risk of developing an initial full-blown episode of major de- pression. (pp. 224–225)

Cognitive therapy has been found to be effective in reducing both residual symptoms and relapse after the termination of medication: “Short-term CBT after suc- cessful antidepressant drug therapy had a substantial effect on relapse rate after discontinuation of antide- pressant drugs. Patients who received CBT reported a substantially lower relapse rate (25%) during the 2-year follow-up than those assigned to [clinical manage- ment] (80%)” (Fava et al., 1998b, p. 818). The protec- tive benefits of cognitive therapy were still noticeable in a 4-year follow-up study, although the benefits faded after a 6-year period (Fava, Rafanelli, Grandi, Canes- trari, & Morphy, 1998a). In another study, Williams (1997) found that only 5% of the “CBT treated and re- covered” group sought additional treatment compared with 39% of the antidepressant group. Paykel and col- leagues (1999) found significantly lower cumulative relapse rates at 68 weeks in patients who received 16 sessions of CBT following a partial response to pharma-

Cognitive Therapy for Depression 263

cotherapy. Bockting and colleagues (2005) compared treatment as usual (TAU) that included continuation of medication with TAU augmented with brief cognitive therapy and found relapse significantly reduced in pa- tients with five or more previous episodes of depression. The relapse rates were 72% for TAU versus 46% for TAU augmented with brief cognitive therapy. Further- more, in a 10-year follow-up of this trial, Bockting and colleagues (2015) reported sustained effects of cogni- tive therapy as evidenced by significantly longer time to first depression relapse compared to TAU.

A preventive strategy used by psychiatrists to deal with high relapse rates associated with antidepressant medication is “continuation medication” or “continu- ation phase treatment,” which is long-term (and in many cases lifelong) maintenance treatment (Evans et al., 1992; Fava et al., 1998b; Rush, Aaronson, & De- myttenaere, 2019)—usually at the same dosage pro- vided during the acute phase of treatment. The research comparing relapse rates in patients continuing medica- tion over the long term versus those treated and then withdrawn from cognitive therapy does not suggest a significant advantage to this practice. For example, De- Rubeis and colleagues (2005) found that both groups had equivalent relapse rates (40%); Hollon and col- leagues (2005) found that 31% relapsed when treated and then withdrawn from cognitive therapy compared to 47% who relapsed when treated with continuation medication. Fournier and colleagues (2008) found that patients with both major depression and a personality disorder who responded positively to 16 weeks of CBT, with three optional booster sessions over a 12-month period, showed superior sustained improvement with CBT compared to pharmacotherapy withdrawal, and equivalent improvement to pharmacotherapy with con- tinuation over those 12 months. Dobson and colleagues (2008) followed patients who responded to a treatment of CBT, behavioral activation, or pharmacotherapy for acute depression. During a 2-year follow-up, psy- chotherapy patients received no further treatment and pharmacotherapy patients received either continuation pharmacotherapy or continuation pill-placebo. They found that CBT provided the strongest protection; both psychotherapies were equivalent to pharmacother- apy with continuation; and both psychotherapies were superior to continuation pill-placebo. In a particularly long-term (up to 12 years) follow-up study of depressed patients, Peselow, Tobia, Karamians, Pizano, and IsHak (2015) found that 76.5% of patients who initially

responded to treatment with an SSRI had a depressive episode recurrence. In those who received concomitant CBT during the maintenance phase, 58.8% had a re- currence, while 81.9% without CBT had a recurrence.

An additional research area focuses on providing treatment after a standard course of CBT or medica- tions to increase treatment gains and/or prevent remis- sion of depression. Recently, Dunlop and colleagues (2019) evaluated the addition of CBT or antidepres- sant combination treatment to patients who had not achieved remission with 12 weeks of the other treat- ment. They found that patients who did not achieve remission with CBT who then received concurrent antidepressant treatment evidenced greater response rates over an additional 12 weeks than did patients who originally did not respond to antidepressants and were given concurrent CBT. By contrast, in their meta-anal- ysis of interventions delivered after remission to prevent relapse, Biescheuvel-Leliefeld and colleagues (2015) found that cognitive therapy interventions significantly outperformed TAU but not antidepressants. Taken to- gether, these results suggest a complex relationship be- tween the order in which treatments are provided and the long-term effects of each one.

Some researchers have pointed out the tautological nature of the relapse solution of continuing medica- tions indefinitely: “Drug treatment results in a higher relapse rate than cognitive-behavioral therapy; there- fore patients should be maintained on drugs to prevent relapse” (Antonuccio, Danton, & DeNelsky, 1995, p.  578). Although drugs are still the initial and most frequently prescribed form of treatment for major de- pression in the United States (Antonuccio et al., 1995; Purgato et al., 2014), and the most commonly used method to maintain treatment gains (Geddes et al., 2003), three important points need to be considered: premature termination, iatrogenic effects of pharmaco- therapy, and cost-effectiveness.

Research has shown that “a sizeable group of patients either chooses not to continue long-term pharmaco- therapy in the absence of any depressive symptoms, cannot take medication due to a medical condition that precludes the use of antidepressants, or suffer from side effects that are intolerable to them” (Spanier, Frank, McEachran, Grochocinski, & Kupfer, 1999, p.  250). Although the newer “first-line” medications are more tolerable than older medications, 70% of patients con- tinue to experience significant depressive symptoms with one of these medications (Kato & Chang, 2013),

264 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

and up to 50% discontinue trials due to unwanted side effects (Connolly & Thase, 2012). Thase (2011) has noted that various combinations of antidepressants are widely prescribed as the result of problems with insuf- ficient or no response, even though properly controlled and adequately powered clinical trials have not yet been conducted on such combinations.

Regarding iatrogenic effects, one group of research- ers concluded that

there is much evidence that antidepressant medications are not benign treatments.  .  .  . Many antidepressants are cardiotoxic, have dangerous side effects, and are often used in suicide attempts. . . . [They also] result in relatively poorer compliance than psychotherapy, have a higher dropout rate, and result in as much as a 60% non- response rate with some patient populations. (Antonuc- cio et al., 1995, p. 581)

We should note that psychotherapy also may have un- intended and undesirable side effects (Mohr, 1995), but very little is known about negative effects associated with cognitive therapy.

The third consideration is the cost-effectiveness of treatment. The research on this topic is relatively lim- ited but has begun to receive more attention in recent years. Antonuccio, Thomas, and Danton (1997) con- ducted a cost-effectiveness analysis on several outcome studies on depression and found that over a 2-year pe- riod, the cost of fluoxetine alone was 33% higher than individual CBT, and that the cost of the combined treatment of fluoxetine with CBT was 23% higher than CBT alone. In an Australian study, Vos, Corry, Haby, Carter, and Andrews (2005) examined the costs and benefits of CBT and drugs in the episodic and main- tenance treatment of depression. They found mainte- nance treatment with SSRIs to be the most expensive option, nearly double that of bibliotherapy, group CBT, individual CBT, and TCAs. Scott, Palmer, Paykel, Teas- dale, and Hayhurst (2003) compared the cost-effective- ness of relapse prevention in depression by comparing CBT as an adjunctive treatment to antidepressants and clinical management, and with antidepressants and clinical management alone, over a 17-month period. They found the addition of CBT was more expensive but also more effective in reducing cumulative relapse rates (relapse rates were 29% with adjunctive CBT vs. 47% without adjunctive CBT). Importantly, they noted that the costs associated with adjunctive CBT in their study were a “worst-case” scenario, because the follow-

up extended only 17 months; other research (as noted in the previous section) has demonstrated maintenance of gains and lowered relapse rates up to 6 years with CBT. Although Dobson and colleagues (2008) did not conduct a formal statistical comparison of costs among treatment conditions, they noted that the “cumula- tive cost of continued medications proved to be more expensive by the end of the first year of follow-up in this study” (p. 471). Scott and colleagues (2003) argued that the incrementally adjusted costs over time to re- lapse should be considered in decision making on the value of various treatments. Koeser, Donisi, Goldberg, and McCrone (2015) conducted an analysis comparing the cost-effectiveness of CBT to pharmacological treat- ment and combined treatment in the United Kingdom across 11 trials. They found that CBT alone was most cost-effective, followed by pharmacotherapy alone. Ad- ditionally, in a systematic review that included seven RCTs of CBT compared to pharmacotherapy, Karyo- taki, Tordrup, Buntrock, Bertollini, and Cuijpers (2017) concluded CBT was more cost-effective than pharmacotherapy. These findings suggest that CBT, either alone or in combination with drugs, can enhance cost-effectiveness, particularly when higher short-term costs of combined treatments are balanced against bet- ter outcomes and lower marginal costs in the long term.

What is the optimum frequency and duration of ses- sions for cognitive therapy to be effective, both at termi- nation and at long-term follow-up? According to Sacco and Beck (1995, p. 332),

General guidelines suggest 15 to 25 (50-minute) sessions at weekly intervals, with more seriously depressed clients usually requiring twice-weekly meetings for the initial 4–5 weeks. To avoid an abrupt termination, a “tapering off” process is recommended, with the last few sessions occurring once every 2 weeks. After termination, some clients may also need a few booster sessions (four or five are common).

Some writers have noted that longer courses of treat- ment may be necessary for full and more lasting recov- ery (Elkin et al., 1996; Thase, 1992). Research by Jar- rett and colleagues (2001) suggests that relapse rates in high-risk patients with an early age of onset or unstable remission might possibly be reduced further with “con- tinuation-phase cognitive therapy” (C-CT), which con- sists of 10 sessions (biweekly during the first 2 months and once a month for the following 6 months) follow- ing the acute phase of treatment. The focus in the con-

Cognitive Therapy for Depression 265

tinuation phase is on relapse prevention and the gen- eralization of skills (across responses, settings, stimuli, and times). This strategy is supported by studies (Jar- rett et al., 2001; Vittengl et al., 2007; Vittengl, Clark, & Jarrett, 2009) aimed at preventing relapse in responders to a variety of treatment modalities (pharmacotherapy, interpersonal psychotherapy, and/or CBT) for the acute phase of depression. In two trials comparing C-CT to fluoxetine and a pill-placebo control (Jarrett, Min- hajuddin, Gershenfeld, Friedman, & Thase, 2013; Vit- tengl, Clark, Thase, & Jarrett, 2014), C-CT and fluox- etine exhibited similar effects on relapse over 8 months and 2 years of follow-up. As a result of these and other studies (Jarrett & Thase, 2010; Jarrett, Vittengl, & Clark, 2008; Vittengl, Clark, Thase, & Jarrett, 2017), researchers have suggested using scores on a variety of measures (Hamilton Rating Scale for Depression, Beck Depression Inventory [BDI], Inventory for Depressive Symptomatology, and the Longitudinal Interval Fol- low-Up Evaluation) to help cognitive therapists decide how many more sessions may be needed to help avoid relapse or recurrence.

Another alternative for relapse prevention is mind- fulness-based cognitive therapy (MBCT), developed by Teasdale, Segal, and Williams (1995). MBCT draws from acceptance and meditation strategies that are also central to dialectical behavior therapy for borderline personality (Linehan, 1993a, 1993b). “MBCT aims at developing participants’ awareness of, and changing their relationship to, unwanted thoughts, feelings, and body sensations, so that participants no longer avoid them or react to them in an automatic way but rather respond to them in an intentional and skillful manner” (Ma & Teasdale, 2004, p. 32). Teasdale and colleagues (Ma & Teasdale, 2004; Teasdale, 1997a, 1997b; Teas- dale et al., 1995, 2002) have argued that the primary mechanism of therapeutic change in cognitive therapy is in distancing or decentering from cognition rather than changing the content of thought. Two studies con- ducted on MBCT found that TAU followed by MBCT, in comparison with TAU alone, significantly reduced relapse in patients with three or more episodes of depres- sion. In the first study, 66% relapsed with TAU alone versus 37% with TAU followed by MBCT (Teasdale et al., 2000); in the second study, 78% relapsed with TAU alone versus 36% with TAU followed by MBCT (Ma & Teasdale, 2004). Encouragingly, Mathew, Whitford, Kenny, and Denson (2010) and Munshi, Eisendrath, and Delucchi (2013) also reported maintained treat- ment gains over 2- and nearly 5-year follow-up peri-

ods, respectively. While Mathew et al. (2010) noted a weakening of effects over time that appeared to be related to the amount of formal MBCT practice, Mun- shi and colleagues (2013) found no association between amount of practice and depression outcomes. Notably, Williams and colleagues (2014) compared 8-week treat- ment of MBCT plus TAU, psychoeducation plus TAU, and TAU alone. They found no differences between conditions on risk of relapse over a 12-month follow-up period. Additionally, Kuyken and colleagues (2016), in an individual patient data meta-analysis that included nine studies, found that patients who received MBCT had a significantly reduced risk of relapse over 5 years of follow-up relative to comparison conditions, and there was some evidence of a larger effect for patients who had greater pretreatment depression severity.

Although prior researchers (Segal, Williams, & Teasdale, 2002) presumed that the difficulty con- centrating and negative thinking during a depressive episode would preclude training in attentional control skills with MBCT, van Aalderen and colleagues (2012) found that MBCT plus TAU, compared to TAU alone, showed equivalent gains in effectiveness for patients in remission as for those currently depressed. Mani- cavasagar, Perich, and Parker (2012) also examined the effectiveness of MBCT in reducing current depres- sion. They compared CBGT and MBCT, and found equivalent improvements in depression. Interestingly, they found no significant differences between the two conditions in mindfulness or rumination scores. The potential for lower costs associated with treatments that can be implemented in a group format suggests that they may be attractive for not only relapse prevention but also recurrent depression.

RESEARCH ON CHRONIC DEPRESSION

As the previous data demonstrate, CBT has been shown to be an effective treatment across a wide range of de- pressed populations. Nevertheless, many depressed patients still do not respond to treatment (Solomonov & Barber, 2016). Depression that is resistant to cur- rent treatments remains a major public health problem. Between 40 and 50% of patients may not complete or respond to CBT treatment for acute depression (De- Rubeis et al., 2005; Jarrett & Thase, 2010), and 50% of patients do not achieve full remission in depressive symptoms after two trials of medication (Mathys & Mitchell, 2011; Rush et al., 2006; Trivedi et al., 2006).

266 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Negt and colleagues (2016) note from current research that around 30% of depressions are chronic and that 47% of outpatient mental health patients suffer from chronic depression.

McCullough (2003) proposed, on the basis of ex- isting research, that there are qualitative differences between chronic and nonchronic forms of depression, and that they require different treatment strategies. According to McCullough, research “shows that the chronic disorders, when compared with acute/episodic major depression (both single and recurrent episodes with interepisode full recovery), differ significantly in terms of age of onset, clinical course patterns, devel- opmental history, modal Axis II comorbidity profiles, characteristic response-to-treatment rates, predictable relapse percentages, and need for long-term treat- ment” (p. 243). He noted that these differences largely have not been addressed in the treatment literature; consequently, therapeutic work by psychologists, psy- chiatrists, and social workers has been conducted as if patients with depression are an undifferentiated popu- lation. Young, Klosko, and Weishaar (2003) noted that although traditional CBT is highly effective for many patients, there remains a significant number who either are not helped or continue to experience emotional dis- tress and impaired functioning, particularly those with significant character pathology. For those with chronic problems, a more extensive treatment approach may be required.

Before discussing specific treatments for chronic de- pression, we describe the general characteristics of this population. An early age of onset (usually in midadoles- cence, before age 20) in the form of dysthymia tends to differentiate between the chronic and nonchronic forms of depression in 70–75% of clinical populations (Keller & Boland, 1998; Keller & Hanks, 1995; McCullough, 2000). Early life trauma or adverse family relations (loss of a parent in childhood; sexual, physical, and/or verbal abuse; neglect; and overprotection) are more evident in those with chronic depression (Chapman et al., 2004; Cong et al., 2012; Dube et al., 2001; Heim & Nem- eroff, 2001; Kendler et al., 1995; Lizardi et al., 1995; Randolph & Dykman, 1998; Sachs-Ericsson, Verona, Joiner, & Preacher, 2006). In patients with early-onset dysthymia who experience chronic stress, those with the addition of an adverse family history evidence an increase in depression severity over time, compared to those without such adverse family histories but with familial loadings for dysthymic disorder (Dougherty, Klein, & Davila, 2004). There is a higher prevalence of

comorbid disorders, particularly personality disorders (Garyfallos et al., 1999; Pepper et al., 1995). Cluster C personality disorders are associated with chronic de- pression (Hayden & Klein, 2001).

Five potentially promising treatments that expand on CBT have been developed that can address chron- ic depression. These treatments are Harley, Sprich, Safren, Jacob, and Fava’s (2008) application of Line- han’s (1993b) dialectical behavior therapy (DBT) skills training, applications (Barnhofer et al., 2009; Eisen- drath, Chartier, & McLane, 2011), Segal and col- leagues’ (2002) MBCT, Wells and colleagues’ (2012) metacognitive therapy (MCT), McCullough’s (2000) cognitive-behavioral analysis system of psychotherapy (CBASP), and Young and colleagues’ (2003) schema therapy (ST).

Harley and colleagues (2008) have provided prelimi- nary evidence that DBT skills training conducted in groups may be an effective alternative for treatment- resistant depression. Patients who had not achieved re- mission with antidepressant medication were assigned to either a 16-session, once-weekly DBT skills training condition (mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance) or a wait-list condition. They found significantly greater improve- ment (with large effect sizes on the Hamilton Rating Scale for Depression and the BDI) in depressive symp- toms in the DBT skills training group. Feldman, Har- ley, Kerrigan, Jacobo, and Fava (2009) hypothesized that DBT skills training helps patients process their emotional experience in a way that reduces rather than exacerbates their depressive symptoms.

Another preliminary study (Barnhofer et al., 2009) and one case study (Eisendrath et al., 2011) successfully used MBCT to treat chronic depression. Barnhofer and colleagues (2009) compared MBCT plus TAU and TAU alone, and found significantly greater improve- ment in the MBCT plus TAU group. Eisendrath and colleagues (2011) successfully treated a patient with a modified version of MCBT. They added exercises and metaphors from acceptance and commitment therapy (ACT; Luoma, Hayes, & Walser, 2007; Zettle, 2007), and focused on current depression in their MCBT treatment. Building on these results, Meadows and col- leagues (2014) conducted a randomized trial of MBCT plus depression relapse active monitoring (DRAM) compared to DRAM alone. They found participants who received MBCT had fewer days with depression and fewer participants relapsed both 1 and 2 years post- treatment. These are intriguing initial results, especial-

Cognitive Therapy for Depression 267

ly since these treatments are of relatively short duration and conducive to a group format.

Wells and colleagues (2012) also conducted a pre- liminary study in which they used MCT to treat pa- tients with treatment-resistant depression. Attentional control, rumination, worry, and metacognitive beliefs were targeted in eight treatment sessions. They found significant improvements both posttreatment and at 12-month follow-up. Dammen, Papageorgiou, and Wells (2015) followed up on these results with a small open trial of MCT delivered in a group format over 10 weeks. All 11 patients were classified as recovered, based on depression symptoms, and improvements were maintained at a 6-month follow-up assessment. Finally, Papageorgiou and Wells (2015) evaluated 12-session group MCT and observed improvements in depres- sion that were maintained at a 6-month follow-up. This treatment will be of further interest if the positive re- sults can be replicated in a randomized controlled trial.

McCullough’s (2000) CBASP is an integrative, time- limited treatment that contains elements of cognitive, behavioral, interpersonal, and psychodynamic psycho- therapies. McCullough (2003) states:

Treatment begins with a cognitive-emotionally retarded adult child who brings a negative “snapshot” view of the world to the session. The chronic patient functions, at least in the social–interpersonal arena, with the struc- tural mindset of a 4–6 year old preoperational (Piaget) child. . . . The patient must be taught to function formal- ly, to perceive that his or her behavior has consequences, be taught to generate authentic empathy, and to learn to assert himself or herself effectively. Psychotherapy begins with an “adult child” who must be assisted to mature de- velopmentally in the cognitive–emotive sphere. (pp. 247, 248)

Change is brought about through a contingency program that relies on negative reinforcement. First, contingencies between behaviors and consequences are exposed. Then, as the result of positive changes in be- havior, discomfort and distress are reduced or eliminat- ed. Three techniques are used to bring about change: situational analysis, interpersonal discrimination exer- cise, and behavioral skill training/rehearsal. Two initial studies used CBASP with chronically depressed out- patients. The first (Keller et al., 2000) compared the effects of CBASP alone, Serzone (nefazodone) alone, and combined treatment after a 12-week acute phase of treatment. The overall response rate was 48% for both monotherapies, compared with 73% for the combined

treatment. Among the 76% (519 out of 681) completers of the study, 52% responded to CBASP, 55% respond- ed to Serzone, and 85% responded to combined treat- ments. The second (Klein et al., 2004), a 1-year follow- up to this initial study, examined relapse and depressive symptoms over time in the CBASP responders by com- paring the effects of continuation CBASP therapy (16 sessions over 52 weeks) with assessment only. There were significantly fewer relapses and depressive symp- toms for those in the continuation CBASP therapy. A recent meta-analysis of CBASP for chronic depression (Negt et al., 2016), including these studies and five oth- ers, found superior outcomes for CBASP, particularly in comparison to TAU and interpersonal psychotherapy control conditions.

ST also is an integrative therapy (Young et al., 2003), with elements of cognitive, behavioral, interpersonal, and emotion-focused therapies. Hawke and Povencher (2011) noted that “Young’s schema theory does not at- tempt to compete with traditional Beckian theory, but rather expands on it for treatment-resistant clientele whose psychological problems are thought to be main- tained by complex characterological underpinnings. It does so by placing greater emphasis on the developmen- tal origins of severe psychopathology” (p. 258).

A study by Giesen-Bloo and colleagues (2006) found surprisingly strong and significant results in favor of ST over transference-focused therapy with the chronic disorder of borderline personality. After 3 years of treat- ment (sessions twice per week), 45% of the patients in ST (vs. 24% in transference-focused therapy) complete- ly recovered. One year later, over half (52%) in ST had fully recovered (vs. 29% in transference-focused thera- py) and two-thirds (70%) in ST showed significant im- provement. In addition, patients in ST were significant- ly less likely to drop out of therapy (27% dropped out of ST vs. 50% out of transference-focused therapy). Even stronger results were reported (Farrell, Shaw, & Web- ber, 2009) for group schema-focused therapy (GST; see Farrell & Shaw, 2012) for people with borderline per- sonality disorder. This study compared individual TAU (CBT or psychodynamic) plus adjunct GST with TAU alone. Ninety-four percent receiving TAU plus GST, compared to 16% receiving TAU alone, no longer met criteria for borderline personality disorder at the end of 20 months of treatment. In addition, there was a 0% dropout rate in the TAU plus GST condition compared to 25% in the TAU condition. Given the high degree of similarities between patients with chronic disorders (adverse childhood histories, early-onset depression,

268 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

and a multitude of schemas), we believe that ST is very likely to be an effective treatment for the chronically depressed population as well.

Evidence from case series studies supports this hy- pothesis. For example, Malogiannis and colleagues (2014) conducted a single case series study with 12 pa- tients with chronic depression. Participants completed baseline, introduction, and ST phases. At posttreat- ment, 60% of participants had remitted or responded. More recently, Renner, Arntz, Peeters, Lobbestael, and Huibers (2016) conducted a multiple-baseline case se- ries study with 25 participants with chronic depression. Participants completed a baseline phase, an exploration phase, then up to 65 sessions of ST. Compared to the no-treatment baseline phase, ST had a large and signifi- cant effect on depression. Additionally, a meta-analysis by Körük and Özabaci (2018) included five additional experimental studies of ST provided to participants with depressive disorders and found support for the efficacy of ST. Given the substantial heterogeneity be- tween studies (duration, delivery format), additional experimental studies are needed to continue to evaluate ST with chronically depressed patients.

CURRENT STATUS AND FUTURE RESEARCH ON TREATING DEPRESSION

There is now a considerable body of research on treat- ments for depression. Certainly, there are enough in- consistencies in the literature to warrant continued debate and research regarding the relative merits of dif- ferent treatments for depression. Nevertheless, the over- all efficacy of cognitive therapy for depression is clearly a replicable and robust finding.

Many important, unanswered questions—along with inconsistent research findings—will probably make it impossible for proponents of any single treat- ment to make firm recommendations favoring one treatment for depression over another across disorders and populations. In the spirit of Beck’s emphasis on testable hypotheses and clinical protocols, we hope that, through more sophisticated research studies, it will eventually be possible to better understand which types of depressed patients benefit most from which type of treatment, or combination of treatments, and in what sequence.

The remainder of this chapter is devoted to describ- ing the cognitive model of depression and schema the-

ory, detailing the basic characteristics of cognitive and schema therapies, and demonstrating applications of cognitive and schema therapies to depression in clinical practice.

COGNITIVE MODEL OF DEPRESSION

The cognitive model assumes that cognition, behav- ior, and biochemistry are all important components of depressive disorders. We view them not as com- peting theories of depression but as different levels of analysis. Each treatment approach has its own “focus of convenience.” The pharmacotherapist intervenes at the biochemical level; the cognitive therapist intervenes at the cognitive, affective, and behavioral levels. Our experience suggests that when we change depressive cognitions, we simultaneously change the characteristic mood, behavior, and, as some evidence suggests (e.g., Free, Oei, & Appleton, 1998; Joffe, Segal, & Singer, 1996; Kéri, Szabó, & Kelemen, 2014; Mondin et al., 2015), the biochemistry of depression. Although the exact mechanism of change remains a target of consid- erable investigation, speculation, and debate (Barber & DeRubeis, 1989; Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; DeRubeis et al., 1990; DeRubeis & Feeley, 1990; Franklin, Carson, & Welch, 2016; Hayes & Strauss, 1998; Oei & Dingle, 2001; Oei & Free, 1995; Shea & Elkin, 1996; Whisman, 1993; Yang et al., 2018), “there are indications that cognitive therapy works by virtue of changing beliefs and information- processing proclivities and that different aspects of cognition play different roles in the process of change” (Hollon et al., 1996, p. 314).

Our focus in this chapter is on the cognitive dis- turbances in depression. Cognitive science research emphasizes the importance of information processing in depressive symptomatology (e.g., Ingram & Holle, 1992; Park et al., 2019). According to these theories, negatively biased cognition is a core process in depres- sion. This process is reflected in the “cognitive triad of depression”: Depressed patients typically have a nega- tive view of themselves, of their environment, and of the future. They view themselves as worthless, inad- equate, unlovable, and deficient. Depressed patients view the environment as overwhelming, as presenting insuperable obstacles that cannot be overcome, and that continually result in failure or loss. Moreover, they view the future as hopeless: Their own efforts will be insuf- ficient to change the unsatisfying course of their lives.

Cognitive Therapy for Depression 269

This negative view of the future often leads to suicidal ideation and actual suicide attempts.

Depressed patients consistently distort their interpre- tations of events, so that they maintain negative views of themselves, their environment, and the future. Beck suggests that much of this distorted cognitive process- ing takes place outside of conscious awareness, in the form of “automatic thoughts,” those thoughts that in- tervene between life events and the patient’s emotional reactions to those events. Automatic thoughts often go unnoticed by the patient because they are out of aware- ness, they are part of a repetitive or habitual way of thinking, and they occur so often. Automatic thoughts are often contrary to what a patient logically and con- sciously knows to be true, and most patients, prior to therapy, cannot stop them through rational thought processes.

This process of cognitive distortion is far more com- mon in depressed patients than in nondepressed indi- viduals. For example, a depressed woman whose hus- band comes home late one night may conclude that he is having an affair with another woman, even though there is no other evidence supporting this conclusion. This example illustrates an “arbitrary inference,” reach- ing a conclusion that is not justified by the available evidence. Other distortions include all-or-nothing thinking, overgeneralization, selective abstraction, and magnification (Beck et al., 1979).

SCHEMA THEORY

According to subsequent developments within the cognitive model, an important predisposing factor for many patients with depression is the presence of sche- mas (Stein & Young, 1992; Young, 1990/1999).3 Beck (1976) emphasized the importance of schemas in de- pression and provided the following definition: “A schema is a cognitive structure for screening, coding, and evaluating the stimuli that impinge on the organ- ism.  .  .  . On the basis of this matrix of schemas, the individual is able to orient himself in relation to time and space and to categorize and interpret experiences in a meaningful way” (p. 233).

Furthermore, Beck, Freeman, and Associates (1990) noted:

In the field of psychopathology, the term “schema” has been applied to structures with a highly personalized idiosyncratic content that are activated during disorders

such as depression, anxiety, panic attacks, and obsessions, and become prepotent. . . . Thus, in clinical depression, for example, the negative schemas are in ascendancy, resulting in a systematic negative bias in the interpreta- tion and recall of experiences as well as in short-term and long-term predictions, whereas the positive schemas be- come less accessible. It is easy for depressed patients to see the negative aspects of an event, but difficult to see the positive. They can recall negative events much more readily than positive ones. They weigh the probabilities of undesirable outcomes more heavily than positive out- comes. (p. 32)

There has also been increasing recognition that “fo- cusing on core schemas is a key to effective short-term therapy” (Freeman & Davison, 1997, p. 8).

Through clinical observation, Young has identi- fied a subset of schemas that he terms early maladap- tive schemas (EMSs): “Early Maladaptive Schemas refer to extremely stable and enduring themes that develop during childhood and are elaborated upon throughout the individual’s lifetime and that are dysfunctional to a significant degree” (Young, 1990/1999, p. 9). The 18 EMSs identified by Young are listed in Figure 7.1.4

According to Young’s (see Young et al., 2003) theory, early schemas5 result from an interaction between the child’s innate temperament and early negative life ex- periences, especially with significant others. Children gradually construct pervasive, maladaptive views of themselves and others that are filtered through, and consistent with, their schemas.

According to Young, EMSs are (1) a priori truths about oneself and/or the environment; (2) self-perpet- uating and resistant to change; (3) dysfunctional; (4) often triggered by some environmental change (e.g., loss of a job or mate); (5) tied to high levels of affect when activated; and (6) as noted earlier, usually result from an interaction of the child’s temperament with dysfunctional developmental experiences with family members, caretakers, and peers (Young, 1990/1999). Young goes on to elaborate that when an EMS is trig- gered, specific early memories, core beliefs, strong emo- tions, and physiological reactions are also activated. (In Young’s model, core beliefs represent the cognitive com- ponent of schemas.6)

EMSs are likely to develop when the environment does not meet the child’s core needs for safety, stability or predictability, love, nurturance and attention, accep- tance and praise, empathy, realistic limits, and valida- tion of feelings and needs. When their core needs are not met, children often internalize attitudes and beliefs

270 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

1. ABANDONMENT/INSTABILITY The perceived instability or unreliability of those available for support and connection. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable (e.g., angry outbursts), or unreliable or erratically present; because they will die imminently; or because they will abandon the patient in favor of someone better.

2. MISTRUST/ABUSE The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the result of unjustified and extreme negligence. May include the sense that one always ends up being cheated relative to others or “getting the short end of the stick.”

3. EMOTIONAL DEPRIVATION Expectation that one’s desire for a normal degree of emotional support will not be adequately met by others. The three major forms of deprivation are as follows:

A. Deprivation of nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of empathy: Absence of understanding, listening, self-disclosure, or mutual sharing of

feelings from others. C. Deprivation of protection: Absence of strength, direction, or guidance from others.

4. DEFECTIVENESS/SHAME The feeling that one is defective, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involve hypersensitivity to criticism, rejection, and blame; self-consciousness, comparisons, and insecurity around others; or a sense of shame regarding one’s perceived flaws. These flaws may be private (e.g., selfishness, angry impulses, unacceptable sexual desires) or public (e.g., undesirable physical appearance, social awkwardness).

5. SOCIAL ISOLATION/ALIENATION The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community.

6. DEPENDENCE/INCOMPETENCE Belief that one is unable to handle one’s everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Often presents as helplessness.

7. VULNERABILITY TO HARM OR ILLNESS Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (A) medical catastrophes (e.g., heart attacks, AIDS); (B) emotional catastrophes (e.g., going crazy); (C) external catastrophes (e.g., elevators collapsing, victimized by criminals, airplane crashes, earthquakes).

8. ENMESHMENT/UNDEVELOPED SELF Excessive emotional involvement and closeness with one or more significant others (often parents), at the expense of full individuation or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. May also include feelings of being smothered by, or fused with, others OR insufficient individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning one’s existence.

(continued)

FIGURE 7.1. Early maladaptive schemas. Copyright © 1999 Jeffrey E. Young. Reprinted by permission.

Cognitive Therapy for Depression 271

9. FAILURE The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to one’s peers, in areas of achievement (school, career, sports, etc.) Often involves beliefs that one is stupid, inept, untalented. ignorant, lower in status, less successful than others, and so forth.

10. ENTITLEMENT/GRANDIOSITY The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interaction. Often involves insistence that one should be able to do or have whatever one wants regardless of what is realistic, what others consider reasonable, or the cost to others; OR an exaggerated focus on superiority (e.g., being among the most successful, famous, and wealthy) in order to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of others: asserting ones power, forcing one’s point of view, or controlling the behavior of others in line with one’s own desires—without empathy or concern for others’ needs or feelings.

11. INSUFFICIENT SELF-CONTROL/SELF-DISCIPLINE Pervasive difficulty or refusal to exercise sufficient self-control and frustration tolerance to achieve one’s personal goals, or to restrain the excessive expression of one’s emotions and impulses. In its milder form, patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion—at the expense of personal fulfillment, commitment, or integrity.

12. SUBJUGATION Excessive surrendering of control to others because one feels coerced—usually to avoid anger, retaliation, or abandonment. There are two major forms of subjugation:

A. Subjugation of needs: Suppression of one’s preferences, decisions, and desires. B. Subjugation of emotion: Suppression of emotional expression, especially anger.

Usually involves the perception that one’s own desires, opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a buildup of anger, manifested in maladaptive symptoms (e.g., passive–aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal of affection, “acting out,” substance abuse).

13. SELF-SACRIFICE Excessive focus on voluntarily meeting the needs of others in daily situations at the expense of one’s own gratification. The most common reasons are to prevent causing pain to others, to avoid guilt from feeling selfish, or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain of others. Sometimes leads to a sense that one’s own needs are not being adequately met and to resentment of those who are taken care of. (Overlaps with concept of codependency.)

14. APPROVAL SEEKING/RECOGNITION SEEKING Excessive emphasis on gaining approval, recognition or attention from other people or fitting in, at the expense of developing a secure and true sense of self. One’s sense of esteem is dependent primarily on the reactions of others rather than on one’s own natural inclinations. Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievements—as a means of gaining approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthentic or unsatisfying, or in hypersensitivity to rejection.

(continued)

FIGURE 7.1. (continued)

272 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

that later prove maladaptive. For example, a child who is criticized repeatedly may develop a Failure schema: a sense that no matter what he/she does, his/her perfor- mance will never be good enough.

A schema usually occurs outside of awareness and may remain dormant until a life event (e.g., being fired from a job) activates it. In this example, once the Fail- ure schema has been activated, the patient categorizes, selects, and encodes information in such a way that the schema is maintained. EMSs therefore predispose many depressed patients to distort events in a characteristic fashion, leading to a negative view of themselves, the environment, and the future.

For patients who have a large number of strong and deeply entrenched EMSs, and for patients who cope

with their schemas by rigidly avoiding life situations or by overcompensating for them, we have found that the concept of “schema modes” (Young et al., 2003) is very often invaluable in understanding and changing patients’ thoughts, feelings, and behaviors. Mode work strengthens and develops healthy modes and weakens dysfunctional modes, thereby increasing control over one’s responding.

Young’s concept of a mode is similar to that of an ego state. A mode is defined as “those schemas or schema operations—adaptive or maladaptive—that are cur- rently active for an individual” (Young et al., 2003, p. 271). Modes include whatever an individual is think- ing, feeling, and doing at a given point in time, and may therefore be thought of as states rather than traits. A

15. NEGATIVITY/PESSIMISM A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc.), while minimizing or neglecting the positive or optimistic aspects. Usually includes an exaggerated expectation—in a wide range of work, financial, or interpersonal situations—that things will eventually go seriously wrong, or that aspects of one’s life that seem to be going well will ultimately fall apart. Usually involves an inordinate fear of making mistakes that might lead to financial collapse, loss, humiliation, or being trapped in a bad situation. Because potential negative outcomes are exaggerated, these patients are frequently characterized by chronic worry, vigilance, complaining, or indecision.

16. EMOTIONAL INHIBITION The excessive inhibition of spontaneous action, feeling, or communication—usually to avoid disapproval by others, feelings of shame, or losing control of one’s impulses. The most common areas of inhibition involve (A) inhibition of anger and aggression; (B) inhibition of positive impulses (e.g., joy, affection, sexual excitement, play); (C) difficulty expressing vulnerability or communicating freely about one’s feelings, needs, etc.; or (D) excessive emphasis on rationality while disregarding emotions.

17. UNRELENTING STANDARDS/HYPERCRITICALNESS The underlying belief that one must strive to meet very high internalized standards of behavior and performance usually to avoid criticism. Typically results in feelings of pressure or difficulty slowing down and in hypercriticalness toward oneself and others. Must involve significant impairment in pleasure, relaxation, health, self-esteem, sense of accomplishment, or satisfying relationships. Unrelenting standards typically present as (A) perfectionism, inordinate attention to detail, or an underestimate of how good one’s own performance is relative to the norm; (B) rigid rules and “shoulds” in many areas of life, including unrealistically high moral, ethical, cultural, or religious precepts; or (C) preoccupation with time and efficiency so that more can be accomplished.

18. PUNITIVENESS The belief that people should be harshly punished for making mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people (including oneself) who do not meet one’s expectations or standards. Usually includes difficulty forgiving mistakes in oneself or others because of a reluctance to consider extenuating circumstances, allow for human imperfection, or empathize with feelings.

FIGURE 7.1. (continued)

Cognitive Therapy for Depression 273

dysfunctional mode is activated when specific maladap- tive schemas have erupted into distressing emotions, avoidance responses, or self-defeating behaviors that take over and control an individual’s functioning at a given point in time. An individual may “flip” from one mode to another; as that shift occurs, an individual’s cognitions, emotions, and coping responses change as well. Young and colleagues have identified four main types of modes: Child modes (Figure 7.2a), Maladap-

tive Coping modes (Figure 7.2b), Dysfunctional Par- ent modes (Figure 7.2c), and the Healthy Adult mode. The Healthy Adult mode is “the healthy, adult part of the self that serves an ‘executive’ function relative to the other modes. The Healthy Adult helps meet the child’s basic emotional needs. Building and strengthening the patient’s Healthy Adult to work with the other modes more effectively is the overarching goal of mode work in ST” (Young et al., 2003, p. 277).

FIGURE 7.2A. Child modes. From Young, Klosko, and Weishaar (2003). Copyright © 2003 The Guilford Press. Reprinted by permission.

Child Mode Description Common associated schemas

Vulnerable Child Experiences dysphoric or anxious affect, especially fear, sadness, and helplessness, when “in touch” with associated schemas.

Abandonment, Mistrust/Abuse, Emotional Deprivation, Defectiveness, Social Isolation, Dependence/Incompetence, Vulnerability to Harm or Illness, Enmeshment/Undeveloped Self, Negativity/Pessimism.

Angry Child Vents anger directly in response to perceived unmet core needs or unfair treatment related to core schemas.

Abandonment, Mistrust/Abuse, Emotional Deprivation, Subjugation (or, at times, any of the schemas associated with the Vulnerable Child).

Impulsive/ Undisciplined Child

Impulsively acts according to immediate desires for pleasure without regard to limits or others’ needs or feelings (not linked to core needs).

Entitlement, Insufficient Self-Control/Self- Discipline.

Happy Child Feels loved, connected, content, satisfied. None. Absence of activated schemas.

FIGURE 7.2B. Maladaptive Coping modes. From Young, Klosko, and Weishaar (2003). Copyright © 2003 The Guilford Press. Reprinted by permission.

Maladaptive Coping Modes

Description

Compliant Surrenderer Adopts a coping style of compliance and dependence.

Detached Protector Adopts a coping style of emotional withdrawal, disconnection, isolation, and behavioral avoidance.

Overcompensator Adopts a coping style of counterattack and control. May overcompensate through semiadaptive means, such as workaholism.

274 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Research Related to Schema Theory

A large number of research studies have examined the 18 EMSs, as measured by the Young Schema Ques- tionnaire (YSQ; Young, 2005). While the results have varied somewhat across different populations, all 18 EMSs have generally been supported (e.g., Calvete, Orue, & González-Diez, 2013; Lee, Taylor, & Dunn, 1999; Schmidt, 1994; Schmidt, Joiner, Young, & Telch, 1995).

Numerous studies have examined EMSs in de- pressed patients. Hawke and Provencher (2011) provide an excellent review of research on EMSs in both mood (Halvorsen et al., 2009; Halvorsen, Wang, Eisemann, & Waterloo, 2010; Özdin et al., 2018; Riso et al., 2003, 2006; Wang, Halvorsen, Eisemann, & Waterloo, 2010) and anxiety disorders. Elevations across most, if not all, schema domains have been evident when comparing depressed patients with never-ill controls. For example, in a study specifically comparing EMSs in patients with chronic depression, nonchronic depression, and healthy controls, Riso and colleagues (2003) found that both depressed groups scored higher on all schema domains compared to healthy controls. However, the scores in the chronic depression group were highest on schemas in the disconnection and rejection, impaired autonomy and performance, and overvigilance domains, even when researchers controlled for depressive and person- ality disorder symptoms. Hawke and Provencher (2011, p.  261) note: “This suggests that chronic depression is associated more strongly with EMSs than the non- chronic form, and that this association is not simply a function of current depressive or Axis II symptoms.”

Renner, Lobbestael, Peeters, Arntz, and Huibers

(2012) also found EMSs, particularly those in the dis- connection and rejection and impaired autonomy and performance domains, to be related to severity of de- pressive symptoms. They note that, consistent with Beck’s theory, “these findings are consistent with the cognitive model of depression, placing schemas or core beliefs in the domains of failure, loss, and worthlessness at the core of depressive symptoms” (p. 587). In their examination of the robustness of EMSs with evidence- based treatments (CBT and interpersonal psychothera- py, with and without medication) for depression, they found that EMSs remained relatively stable over time (pre- and posttreatment). This finding is consistent with Young and colleagues’ (2003) notion of EMSs as stable, trait-like beliefs that remained even after suc- cessful treatment of Axis I symptoms. According to the schema model, these results should not be surprising, since none of the treatments in this study specifically targeted change in EMSs. A study by Calvete, Orue, and Hankin (2015) also revealed that EMSs did not moderate the effect of stressors on symptoms of depres- sion and anxiety in adolescents, further suggesting the independence, and perhaps stability, of EMS domains.

In another study examining the relationship between EMSs and depression, Eberhart, Auerbach, Bigda- Peyton, and Abela (2011) examined how EMSs and stress impact depressive symptoms by comparing two models of stress: diathesis–stress and stress generation. The diathesis–stress model posits that EMSs only create vulnerability to depression when interacting with high levels of stressors. The stress generation model posits that EMSs are instrumental in creating stressful condi- tions which then increase depression. The results sup-

Dysfunctional Parent Mode

Description Common associated schemas

Punitive/Critical Parent Restricts, criticizes, or punishes the self or others.

Subjugation, Punitiveness, Defectiveness, Mistrust/Abuse (as abuser).

Demanding Parent Sets high expectations and high level of responsibility toward others; pressures the self or others to achieve them.

Unrelenting Standards, Self-Sacrifice.

FIGURE 7.2C. Dysfunctional Parent modes. From Young, Klosko, and Weishaar (2003). Copyright © 2003 The Guilford Press. Reprinted by permission.

Cognitive Therapy for Depression 275

ported the stress generation hypothesis. The researchers noted that

a number of maladaptive schemas in the domains of disconnection and rejection, impaired autonomy and performance, and other-directedness predicted the gen- eration of dependent, interpersonal stressors. These dependent interpersonal stressors, in turn, predicted increases in depressive symptoms. Moreover, there was evidence that these stressors mediated the relationships between maladaptive schemas and depressive symptoms. In particular, mediation effects were observed for subju- gation schemas, failure schemas, and a number of sche- mas related to disconnection and rejection. (p. 96)

This research highlights the importance of targeting EMSs in the treatment of chronic depression.

In the following sections we present information about the general characteristics and nature of cognitive therapy, a discussion of the process of cognitive therapy, then two case examples that illustrate cognitive therapy in action. The patient in the first case has a nonchronic form of depression and is treated with “standard” cog- nitive therapy (as originally outlined in Beck et al.’s [1979] book). The focus of standard cognitive therapy is on changing depressive thinking in the present. The patient in the second case has chronic depression and is treated with both cognitive therapy and ST. The focus of ST, in this case, is on identifying and modifying the patient’s underlying schemas through mode work.

CHARACTERISTICS OF COGNITIVE THERAPY

Cognitive therapy with adult depressed outpatients is usually undertaken in the therapist’s office. It has most frequently been applied in a one-to-one setting. How- ever, group cognitive therapy has also been shown to be successful with many depressed outpatients (Oei, 2008), although it may not be as effective as individ- ual treatment, at least in the short-term (Cuijpers, van Straten, & Warmerdam, 2008; Huntley & Salisbury, 2012). Additionally, computer-assisted cognitive ther- apy for depression appears to show promise (Cowper- twait & Clark, 2013; Eells, Barrett, Wright, & Thase, 2014), although findings across trials have been mixed (So et al., 2013). It is not unusual to involve spouses, partners, parents, and other family members during treatment. For example, they may provide information

that helps patients test the validity of their thinking with respect to how other family members view them. Moreover, couple therapy based on the cognitive model is often very effective in relieving depression related to chronic interpersonal problems (e.g., Beck, 1988; Cohen, O’Leary, & Foran, 2010).

In our clinical experience, a number of therapist characteristics contribute to effective cognitive therapy. First, cognitive therapists ideally should demonstrate the “nonspecific” therapy skills identified by other writ- ers (see, e.g., Truax & Mitchell, 1971): They should be able to communicate warmth, genuineness, sincer- ity, and openness. Second, the most effective cognitive therapists seem to be especially skilled at seeing events from their patients’ perspectives (accurate empathy). They are able to suspend their own personal assump- tions and biases while listening to depressed patients de- scribe their reactions and interpretations. Third, skilled cognitive therapists can reason logically and plan strate- gies; they are not “fuzzy” thinkers. In this respect, they resemble good trial lawyers, who can spot the some- times subtle flaws in another individual’s reasoning and skillfully elicit a more convincing interpretation of the same events. Skilled cognitive therapists plan strategies several steps ahead, anticipating the desired outcome. Fourth, the best practitioners of this approach are ac- tive. They have to be comfortable taking the lead, pro- viding structure and direction to the therapy process.

Although patient characteristics have received some empirical attention (Eifert, Beach, & Wilson, 1998; Padesky, with Greenberger, 2021; Persons, Burns, & Perloff, 1988; Schindler, Hiller, & Witthöft, 2013), we do not yet have adequate knowledge as to which patient characteristics are related to success in cognitive ther- apy. Our experience suggests that patients with major depressive disorder (or milder forms of depression) re- spond well to the cognitive therapy approach described in this chapter. To the extent that the patient was diag- nosed with Axis II personality disorders and/or his/her depression was chronic, the combination of cognitive therapy and ST may be significantly longer in duration and more crucial in obtaining a more complete and last- ing positive response to treatment.

Cognitive therapy can serve an important adjunctive role to pharmacotherapy for bipolar disorders (Ball et al., 2006; Basco & Rush, 1996; Chiang et al., 2017; Craighead, Miklowitz, Vajk, & Frank, 1998; Lam, Hayward, Watkins, Wright, & Sham, 2005), and is ef- fective in treating patients with severe endogenous de-

276 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

pression (Thase, Bowler, & Harden, 1991; Whisman, 1993). Preliminary evidence also suggests that cogni- tive therapy is effective in the treatment of women with postpartum depression (Huang, Zhao, Qiang, & Fan, 2018).

It is advisable to assess patients’ suitability for cogni- tive therapy (Padesky, with Greenberger, 2021; Safran & Segal, 1990; Safran, Segal, Vallis, Shaw, & Samstag, 1993). In our experience, certain patient characteristics are predictive of a more rapid response. “Ideal” cogni- tive therapy patients are appropriately introspective and can reason abstractly; are well organized, good plan- ners, and conscientious about carrying out responsi- bilities; are employed or have a history of employment; are not excessively angry at either themselves or other people; are less dogmatic and rigid in their thinking; can identify a clear precipitating event for the depressive episode; and have close relationships with others. Most patients deviate in some ways from this prototype, and these characteristics are not essential to successful treat- ment. However, patients with more of these attributes often show faster improvement in depressive symptoms through cognitive therapy.

Age is not an obstacle. Many studies have indicated that children and adolescents show significant clini- cal improvement following CBT (Oud et al., 2019; Reinecke, Ryan, & DuBois, 1998). Studies of older pa- tients also show that “various forms of cognitive and behavioral psychotherapy can be as effective in treating geriatric depression as depressions occurring earlier in life” (Futterman, Thompson, Gallagher-Thompson, & Ferris, 1995, p. 511; Francis & Kumar, 2013; Thomas et al., 2018).

COLLABORATION

Basic to cognitive therapy is a collaborative relationship between patient and therapist. When therapist and pa- tient work together, the learning experience is enhanced for both, and the cooperative spirit that is developed contributes greatly to the therapeutic process. Equally important, the collaborative approach helps to ensure compatible goals for treatment, and to prevent misun- derstandings and misinterpretations between patient and therapist. Because of the importance of the col- laborative relationship, we place great emphasis on the interpersonal skills of the therapist, the process of joint selection of problems on which to work, regular feed-

back, and the investigative process we call “collabora- tive empiricism.”

Interpersonal Qualities

Because collaboration requires that the patient trust the therapist, we emphasize those interpersonal qualities that contribute to trust. As noted earlier, warmth, ac- curate empathy, and genuineness are desirable personal qualities for the cognitive therapist, as well as for all psy- chotherapists. It is important that the cognitive thera- pist not seem to be playing the role of therapist. The therapist should be able to communicate both verbally and nonverbally that he/she is sincere, open, concerned, and direct. It is also important that the therapist not seem to be withholding impressions or information, or evading questions. The therapist should be careful not to seem critical or disapproving of the patient’s perspec- tive.

Rapport between patient and therapist is crucial in the treatment of depressed patients. When rapport is optimal, patients perceive the therapist as someone who is tuned in to their feelings and attitudes, who is sym- pathetic and understanding, and with whom they can communicate without having to articulate feelings in detail or qualify statements. When the rapport is good, both patient and therapist feel comfortable and secure.

A confident, professional manner is also important in cognitive therapy. A therapist should convey relaxed confidence in his/her ability to help a depressed patient. Such confidence can help to counteract the patient’s initial hopelessness about the future. Because the cogni- tive therapist must sometimes be directive and impose structure, especially in the early stages of treatment, it is helpful to maintain a clear sense of professionalism.

Joint Determination of Goals for Therapy

The patient and therapist collaboratively work together to set therapeutic goals, determine priorities among them, and create an agenda for each session. Problems to be addressed over the course of therapy include spe- cific depressive symptoms (e.g., hopelessness, crying, and difficulty concentrating) and external problems (e.g., couple difficulties, career issues, child-rearing concerns). Priorities are then jointly determined in accordance with how much distress is generated by a particular problem and how amenable that particular problem is to change. During the agenda-setting por-

Cognitive Therapy for Depression 277

tion of each therapy session (discussed in detail in the next section), therapist and patient together determine the items to be covered in that session. Through this collaborative process, target problems are selected on a weekly basis.

The process of problem selection often presents dif- ficulties for the novice cognitive therapist, including failure to reach agreement on specific problems on which to focus, selection of peripheral concerns, and the tendency to move from problem to problem instead of persistently seeking a satisfactory solution to only one problem at a time. Because the problem selection process entails both structuring and collaboration on the part of the therapist, considerable skill is necessary.

Regular Feedback

Feedback is especially important in therapy with de- pressed patients; it is a crucial ingredient in develop- ing and maintaining the collaborative therapeutic rela- tionship. The cognitive therapist initiates the feedback component early in therapy by eliciting the patient’s thoughts and feelings about many aspects of the ther- apy, such as the handling of a particular problem, the therapist’s manner, and homework assignments. Since many patients misconstrue therapists’ statements and questions, it is only through regular feedback that the therapist can ascertain whether he/she and the patient are on the same “wavelength.” The therapist must also be alert for verbal and nonverbal clues to covert negative reactions.

As part of the regular feedback process, the cognitive therapist shares the rationale for each intervention. This helps to demystify the therapy process and facilitates the patient’s questioning of the validity of a particular approach. In addition, when a patient understands how a particular technique or assignment may help solve a particular problem in the patient’s life, he/she is more likely to participate conscientiously.

Another key element of the feedback process is for the therapist to check regularly to determine whether the patient understands his/her formulations. Patients sometimes agree with a formulation simply out of com- pliance, and depressed patients frequently exhibit both compliance and reluctance to “talk straight” with their therapists for fear of being rejected or criticized, or of making a mistake. Therefore, the therapist must make an extra effort to elicit the patient’s feelings or wishes relevant to compliance (e.g., anxiety about rejection,

wish to please) and be alert for verbal and nonverbal clues that the patient may indeed not understand the explanations.

At the close of each session the cognitive therapist provides a concise summary of what has taken place and asks the patient to abstract and write down the main points from the session. The patient keeps this summary for review during the week. In practice, the therapist uses capsule summaries frequently during a standard therapeutic interview: in preparing the agen- da, in a midpoint recapitulation of the material covered up to that point, and in the final summary of the main points of the interview. Patients generally respond favorably to the elicitation of feedback and presenta- tion of capsule summaries. We have observed that the development of empathy and rapport is facilitated by these techniques.

Collaborative Empiricism

When the collaborative therapeutic relationship has been successfully formed, patient and therapist act as an investigative team. Though we elaborate on the in- vestigative process later, it is appropriate to introduce it in the context of the collaborative relationship. As a team, patient and therapist approach the patient’s auto- matic thoughts and schemas in the same manner that scientists approach questions: Each thought or schema becomes a hypothesis to be tested, and evidence is gath- ered that supports or refutes the hypothesis. Events in the past, circumstances in the present, and possibilities in the future are the data that constitute evidence, and the conclusion to accept or reject the hypothesis is joint- ly reached as patient and therapist subject the evidence to logical analysis. Experiments may also be devised to test the validity of particular cognitions. Cognitive therapists need not persuade patients of illogicality or inconsistency with reality, because patients “discover” their own inconsistencies. This guided discovery pro- cess, a widely accepted educational method, is one of the vital components of cognitive therapy.

THE PROCESS OF COGNITIVE THERAPY

Here we attempt to convey a sense of how cognitive therapy sessions are structured and of the course of treatment. Detailed discussion of particular techniques follows this section.

278 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

The Initial Sessions

A main therapeutic goal of the first few sessions is to produce some symptom relief. Reducing the patient’s suffering helps to increase rapport, collaboration, and confidence in the therapeutic process. Symptom relief, however, should be based on more than rapport, sym- pathy, and implied promise of “cure.” In the first few sessions, the cognitive therapist starts the process of de- fining the patient’s problems and demonstrating some of the strategies that will be used in the therapy to deal with those problems.

Problem definition is a primary goal in the early stag- es of therapy. The therapist collaboratively works with the patient to define the specific problems on which they will focus during therapy sessions. The cognitive therapist does this by obtaining as complete a picture as possible of the patient’s psychological and life situation difficulties. The therapist also seeks details concerning the depth of depression and particular symptomatol- ogy. Cognitive therapists are especially concerned with how patients see their problems.

Once the specific problems have been defined, pa- tient and therapist establish priorities among them. Decisions are made on the basis of amenability to therapeutic change and centrality of the life problem or cognition to the patient’s emotional distress. To help establish priorities effectively, the therapist must see the relationships among particular thoughts, particular life situations, and particular distressing emotions.

Another goal of the initial session is to illustrate the close relationship between cognition and emotion. When the therapist is able to observe the patient’s mood change (e.g., crying), he/she points out the alteration in affect and asks for the patient’s thoughts just before the mood shift. The therapist then labels the negative thought and points out its relationship to the change in mood. He/she initially gears homework assignments toward helping the patient see the close connection be- tween cognition and emotion.

A frequent requirement in the early stage of therapy is to socialize the patient to cognitive therapy. A patient who has previously undertaken analytically oriented or Rogerian therapies may begin cognitive therapy expect- ing a more insight-oriented, nondirective therapeutic approach. The cognitive therapist can facilitate the transition to a more active and structured approach by maintaining a problem-oriented stance, which often entails gently interrupting a patient who tends to specu-

late about the sources of the problems and to seek inter- pretations from the therapist.

Finally, the therapist must communicate the impor- tance of self-help homework assignments during the initial session by stressing that the homework is actu- ally more important than the therapy session itself. The therapist also can enhance motivation by explaining that patients who complete assignments generally im- prove more quickly. The nature and implementation of self-help homework assignments are considered in fur- ther detail in a later section of this chapter.

The Progress of a Typical Therapy Session

Each session begins with the establishment of an agen- da for that session. This ensures optimal use of time in a relatively short-term, problem-solving therapeutic approach. The agenda generally begins with a short synopsis of the patient’s experiences since the last ses- sion, including discussion of the homework assignment. The therapist then asks the patient what he/she wants to work on during the session, and often offers topics to be included.

When a short list of problems and topics has been completed, patient and therapist determine the order in which to cover them and, if necessary, the time to be al- lotted to each topic. There are several issues to consider in establishing priorities, including stage of therapy, severity of depression, likelihood of making progress in solving the problem, and potential pervasiveness of the effect of a particular theme or topic. The cognitive therapist is sensitive to a patient’s occasional desire to talk about something that seems important to him/her at the moment, even if such discussion seems not to be productive in terms of other goals. This kind of flex- ibility characterizes the collaborative therapeutic rela- tionship.

After these preliminary matters have been covered, patient and therapist move on to the one or two prob- lems to be considered during the session. The therapist begins the discussion of a problem by asking the patient a series of questions designed to clarify the nature of the patient’s difficulty. In doing so, the therapist seeks to determine whether early maladaptive schemas, mis- interpretations of events, or unrealistic expectations are involved. The therapist also seeks to discover whether the patient had unrealistic expectations, whether the patient’s behavior was appropriate, and whether all possible solutions to the problem were considered. The

Cognitive Therapy for Depression 279

patient’s responses suggest to the therapist a cognitive- behavioral conceptualization of why the patient is hav- ing difficulty in the area of concern. The therapist by now has discerned the one or two significant thoughts, schemas, images, or behaviors on which to work. When this target problem has been selected, the therapist chooses the cognitive or behavioral techniques to apply and shares their rationale with the patient. The specific techniques used in cognitive therapy are explained in the following sections of this chapter.

At the close of the session, the therapist asks the patient for a summary, often in writing, of the major conclusions drawn during the session. The therapist asks for the patient’s reactions to the session to ascertain whether anything disturbing was said and to forestall any delayed negative reactions following the interview. Finally, the therapist gives a homework assignment de- signed to assist the patient in applying the particular skills and concepts from the session to the problem dur- ing the following week.

Progression of Session Content over Time

Although the structure of cognitive therapy sessions does not change during the course of treatment, the content often changes significantly. The first phase of treatment, symptom reduction, focuses on overcoming hopelessness, identifying problems, setting priorities, socializing the patient to cognitive therapy, establishing a collaborative relationship, demonstrating the relation- ship between cognition and emotion, labeling errors in thinking, and making progress on a target problem. Therapy is initially centered on the patient’s symptoms, with attention given to behavioral and motivational dif- ficulties.

In the second phase, which focuses on chang- ing schemas for relapse prevention and chronic cases, therapist and patient turn from specific thoughts about particular problems to core schemas about the self and others, and to the modes associated with those sche- mas. Therapist and patient explore how the schemas and modes initiate, exacerbate, and maintain many of the patient’s problems. Therapist and patient then work collaboratively to restructure and modify the schemas and modes through a variety of techniques, which even- tually brings about a broader and more pervasive im- provement in life functioning and mood.

Over the course of therapy, the patient assumes in- creased responsibility for identifying problems, com-

ing up with solutions, and implementing the solutions through homework assignments. The therapist increas- ingly assumes the role of advisor or consultant as the patient learns to implement therapeutic techniques without constant support. As the patient becomes a more effective problem solver, the frequency of sessions is reduced, and therapy is eventually discontinued.

The remainder of this chapter is devoted to a detailed description of cognitive- and schema-based treatment strategies.

SYMPTOM REDUCTION

Behavioral Techniques

Behavioral techniques are used throughout the course of cognitive therapy, but they are generally concentrat- ed in the earlier stages of treatment. Behavioral tech- niques are especially necessary for those more severely depressed patients who are passive, anhedonic, socially withdrawn, and unable to concentrate for extended periods of time. By engaging such a patient’s attention and interest, the cognitive therapist tries to induce the patient to counteract withdrawal and become more in- volved in constructive activity. From a variety of be- havioral techniques, the therapist selects those that will help the patient cope more effectively with situational and interpersonal problems. Through homework as- signments, the patient implements specific procedures for dealing with concrete situations or for using time more adaptively.

The cognitive therapist uses behavioral techniques, with the goal of modifying automatic thoughts. For ex- ample, a patient who believes “I can’t get anything done any more” can modify this thought after completing a series of graded tasks designed to increase mastery. The severely depressed patient is caught in a vicious cycle, in which a reduced activity level leads to a negative self-label, which in turn results in even further discour- agement and consequent inactivity. Intervention with behavioral techniques can change this self-destructive pattern.

The most commonly used behavioral techniques in- clude scheduling activities that include both mastery and pleasure exercises, cognitive rehearsal, self-reliance training, role playing, and diversion techniques. The scheduling of activities is frequently used in the early stages of cognitive therapy to counteract loss of moti-

280 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

vation, hopelessness, and excessive rumination. The therapist uses the Weekly Activity Schedule for plan- ning activities hour by hour, day by day (see Figure 7.3). Patients maintain an hourly record of the activities in which they engaged. Activity scheduling also helps patients obtain more pleasure and a greater sense of accomplishment from activities on a daily basis. The patients rate each completed activity (using a 0- to 10- point scale) for both mastery and pleasure. The ratings usually contradict patients’ beliefs that they can no lon- ger accomplish or enjoy anything. To assist some pa- tients in initiating mastery and pleasure activities, the therapist may sometimes find it necessary to subdivide an activity into segments, ranging from the simplest to the most difficult and complex aspects of the activity. We call this the “graded task” approach. The subdivi- sion enables depressed patients to undertake tasks that

were initially impossible, thus providing proof of suc- cess.

Cognitive rehearsal entails asking a patient to picture or imagine each step involved in the accomplishment of a particular task. This technique can be especially help- ful with those patients who have difficulty carrying out a task that requires successive steps for its completion. Sometimes impairment in the ability to concentrate creates difficulties for the patient in focusing attention on the specific task. The imagery evoked by the cogni- tive rehearsal technique helps the patient to focus and the therapist to identify obstacles that make the assign- ment difficult for the particular patient.

Some depressed patients rely on others to take care of most of their daily needs. With self-reliance train- ing, patients learn to assume increased responsibility for routine activities such as showering, making their beds,

FIGURE 7.3. Weekly Activity Schedule.

Note: Grade activities M for mastery and P for pleasure 0–10.

Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

M or

ni ng

6–7

7–8

8–9

9–10

10–11

11–12

A fte

rn oo

n

12–1

1–2

2–3

3–4

4–5

5–6

E ve

ni ng

6–7

7–8

8–9

9–10

10–11

11–12

12–6

Cognitive Therapy for Depression 281

cleaning the house, cooking their own meals, and shop- ping. Self-reliance involves gaining increased control over emotional reactions.

Role playing has many uses in cognitive therapy. First, it may be used to bring out automatic thoughts through the enactment of particular interpersonal situ- ations, such as an encounter with a supervisor at work. Second, through homework assignments, it may also guide the patient in practicing and attending to new cognitive responses in problematic social encounters. A third use of role playing is to rehearse new behaviors. Thus, role playing may be used as part of assertiveness training and is often accompanied by modeling and coaching.

Role reversal, a variation of role playing, can be very effective in helping patients test how other people might view their behavior. This is well illustrated by a patient who had a “humiliating experience” while buying some clothes in a store. After playing the role of the clerk, the patient had to conclude that she had insufficient data for her previous conclusion that she appeared clumsy and inept. Through role reversal, patients begin to view themselves less harshly as “self-sympathy” responses are elicited.

Finally, the therapist may introduce various distrac- tion techniques to assist the patient in learning to re- duce the intensity of painful affects. The patient learns to divert negative thinking through physical activity, social contact, work, play, and visual imagery. Practice with diversion techniques also helps the patient gain further control over emotional reactivity.

Cognitive Techniques

The specific cognitive techniques provide points of entry into the patient’s cognitive organization. The cognitive therapist uses techniques for eliciting and testing automatic thoughts, and identifying schemas to help both therapist and patient understand the patient’s construction of reality. In applying specific cognitive techniques in therapy, it is important that the therapist work within the framework of the cognitive model of depression. Each set of techniques is discussed in turn.

Eliciting Automatic Thoughts

Automatic thoughts are those thoughts that intervene between outside events and the individual’s emotional reactions to them. They often go unnoticed, because they are part of a repetitive pattern of thinking, and because

they occur so often and so quickly. People rarely stop to assess their validity, because they are so believable, famil- iar, and habitual. The patient in cognitive therapy must learn to recognize these automatic thoughts for therapy to proceed effectively. The cognitive therapist and the patient make a joint effort to discover the particular thoughts that precede emotions such as anger, sadness, and anxiety. The therapist uses questioning, imagery, and role playing to elicit automatic thoughts.

The simplest method to uncover automatic thoughts is for therapists to ask patients what thoughts went through their minds in response to particular events. This questioning provides a model for introspective exploration that patients can use on their own, when the therapist is not present, and after the completion of treatment.

Alternatively, when a patient is able to identify those external events and situations that evoke a particular emotional response, the therapist may use imagery by asking the patient to picture the situation in detail. The patient is often able to identify the automatic thoughts connected with actual situations when the image evoked is clear. In this technique, therapists ask patients to relax, close their eyes, and imagine themselves in the distressing situation. Patients describe in detail what is happening as they relive the event.

If a distressing event is an interpersonal one, cogni- tive therapists also can utilize role playing. The therapist plays the role of the other person in the encounter, while the patient plays him/herself. The automatic thoughts can usually be elicited when the patient becomes suf- ficiently engaged in the role play.

In attempting to elicit automatic thoughts, the thera- pist is careful to notice and point out any mood changes that occur during the session, and to ask the patient his/her thoughts just before the shift in mood. Mood changes include any emotional reaction, such as tears or anger. This technique can be especially useful when the patient is first learning to identify automatic thoughts.

Once patients become familiar with the techniques for identifying automatic thoughts, they are asked to keep a Daily Record of Dysfunctional Thoughts (Beck et al., 1979; see Figure 7.4), in which they record the emotions and automatic thoughts that occur in upset- ting situations between therapy sessions. In later ses- sions, patients are taught to develop rational responses to their dysfunctional automatic thoughts and to record them in the appropriate column. Therapist and patient generally review the daily record from the preceding week, near the beginning of the next therapy session.

282 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

In sessions, the therapist also teaches chronic patients to recognize modes. Various affective exercises are then used to bring about change in the underlying schemas associated with those modes.

Eliciting automatic thoughts should be distinguished from the interpretation process of other psychothera- pies. In general, cognitive therapists work only with those automatic thoughts mentioned by patients. Sug- gesting thoughts to patients may undermine collabora- tion and inhibit patients from learning to continue the process on their own. As a last resort, however, when nondirective strategies fail, a cognitive therapist may offer several possible automatic thoughts, then ask the patient whether any of these choices fit.

Even when many efforts to elicit automatic thoughts have been made by the therapist, sometimes the thought remains inaccessible. When this is the case, the cogni- tive therapist tries to ascertain the particular meaning of the event that evoked the emotional reaction. For ex- ample, one patient began to cry whenever she had an argument with her roommate, who was a good friend. Efforts to elicit automatic thoughts proved unsuccess-

ful. Only after the therapist asked a series of questions to determine the meaning of the event did it become clear that the patient associated having an argument or fight with ending the relationship. Through this pro- cess, therapist and patient were able to see the meaning that triggered the crying.

Testing Automatic Thoughts with Nonchronic Patients

When therapist and patient have managed to isolate a key automatic thought, they approach the thought as a testable hypothesis. In this “scientific” approach, which is fundamental to cognitive therapy, the patient learns to think in a way that resembles the investigative pro- cess. Through the procedures of gathering data, evalu- ating evidence, and drawing conclusions, patients learn firsthand that their view of reality can be quite differ- ent from what actually takes place. By designing experi- ments that subject their automatic thoughts to objective analysis, patients learn how to modify their thinking, because they learn the process of empirical thinking. Pa- tients who learn to think this way during treatment are

FIGURE 7.4. Daily Record of Dysfunctional Thoughts.

DATE

SITUATION EMOTION(S) AUTOMATIC THOUGHT(S) RATIONAL RESPONSE OUTCOME Describe:

1. Actual event leading to unpleasant emotion, or

2. Stream of thoughts, daydream, or recollection, leading to unpleasant emotion.

1. Specify sad/ anxious/ angry, etc.

2. Rate degree of emotion, 1–100.

1. Write automatic thought(s) that preceded emotion(s).

2. Rate belief in automatic thought(s), 0–100%.

1. Write rational response to automatic thought(s).

2. Rate belief in rational response, 0–100%.

1. Rerate belief in automatic thought(s), 0–100%.

2. Specify and rate subsequent emotions, 0–100%.

Explanation: When you experience an unpleasant emotion, note the situation that seemed to stimulate the emotion. (If the emotion occurred while you were thinking, daydreaming, etc., please note this.) Then note the automatic thought associated with the emotion. Record the degree to which you believe this thought: 0% = not at all; 100% = completely. In rating degrees of emotion: 1 = a trace; 100 = the most intense possible.

Cognitive Therapy for Depression 283

better able to continue the empirical approach after the end of formal therapy.

The cognitive therapist approaches the testing of au- tomatic thoughts by asking the patient to list evidence from his/her experience for and against the hypothesis. Sometimes, after considering the evidence, the patient immediately rejects the automatic thought, recognizing that it is either distorted or actually false.

When previous experience is not sufficient or appro- priate to test a hypothesis, the therapist asks the patient to design an experiment for that purpose. The patient then makes a prediction and proceeds to gather data. If the data contradict the prediction, the patient can reject the automatic thought. The outcome of the experiment may, of course, confirm the patient’s prediction. It is therefore very important for the therapist not to assume that the patient’s automatic thought is distorted.

Some automatic thoughts do not lend themselves to hypothesis testing through the examination of evidence. In these cases, two options are available: The therapist may either produce evidence from his/her own experi- ence and offer it in the form of a question that reveals the contradiction or ask a question designed to uncover a logical error inherent in the patient’s beliefs. The ther- apist might say, for example, to a male patient who is sure he cannot survive without a close personal relation- ship, “You were alone last year, and you got along fine; what makes you think you can’t make it now?”

In testing automatic thoughts, it is sometimes neces- sary to refine the patient’s use of a word. This is particu- larly true for global labels such as bad, stupid, or selfish. What is needed in this case is an operational definition of the word. To illustrate, a patient at our clinic had the recurring automatic thought, “I’m a failure in math.” Therapist and patient had to narrow down the meaning of the word failure before they could test the thought. They operationalized “failure” in math as “being un- able to achieve a grade of C after investing as much time studying as the average class member.” Now they could examine past evidence and test the validity of the hypothesis. This process can help patients to see the overinclusiveness of their negative self-assessments and the idiosyncratic nature of many automatic thoughts.

Reattribution is another useful technique for help- ing the patient to reject an inappropriate, self-blaming thought. It is a common cognitive pattern in depression to ascribe blame or responsibility for adverse events to oneself. Reattribution can be used when the patient un- realistically attributes adverse occurrences to a personal deficiency, such as lack of ability or effort. Therapist

and patient review the relevant events and apply logic to the available information to make a more realistic assignment of responsibility. The aim of reattribution is not to absolve the patient of all responsibility but to examine the many factors that contribute to adverse events. Through this process, patients gain objectivity, relieve themselves of the burden of self-reproach, and can then search for ways to solve realistic problems or prevent their recurrence.

Another strategy involving reattribution is for thera- pists to demonstrate that patients’ criteria for assigning responsibility to their own unsatisfactory behavior are stricter than criteria they use in evaluating the behavior of others. Cognitive therapists also use reattribution to show patients that some of their thinking or behavior problems can be symptoms of depression (e.g., loss of concentration) and not signs of physical decay.

When a patient is accurate in identifying a realistic life problem or skills deficit, the cognitive therapist can use the technique of generating alternatives, in which therapist and patient actively search for alternative solu- tions. Because a depressed person’s reasoning often be- comes restricted, an effort to reconceptualize the prob- lem can result in the patient seeing a viable solution that he/she may previously have rejected.

It should be noted that all the cognitive techniques outlined here entail the use of questions by the thera- pist. A common error we observe in novice cognitive therapists is an exhortative style. We have found that therapists help patients to change their thinking more effectively by using carefully formed questions. If pa- tients are prompted to work their own way through problems and reach their own conclusions, they learn an effective problem-solving process. We next elaborate on the use of questioning in cognitive therapy.

Questioning

As we have stressed throughout this chapter, question- ing is a major therapeutic device in cognitive therapy. A majority of the therapist’s comments during the therapy session are questions. Single questions can serve several purposes at one time, whereas a carefully designed se- ries of questions can help patients consider a particular issue, decision, or opinion. The cognitive therapist seeks through questioning to elicit what patients are think- ing, instead of telling patients what he/she believes they are thinking.

In the beginning of therapy, questions are employed to obtain a full and detailed picture of a patient’s partic-

284 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

ular difficulties; to obtain background and diagnostic data; to evaluate the patient’s stress tolerance, capacity for introspection, coping methods, and so on; to obtain information about the patient’s external situation and interpersonal context; and to modify vague complaints by working with the patient to arrive at specific target problems on which to work.

As therapy progresses, the therapist uses questioning to explore approaches to problems, to help the patient to weigh advantages and disadvantages of possible so- lutions, to examine the consequences of staying with particular maladaptive behaviors, to elicit automatic thoughts, and to demonstrate EMSs and their con- sequences. In short, the therapist uses questioning in most cognitive therapeutic techniques.

Although questioning is itself a powerful means of identifying and changing automatic thoughts and sche- mas, it is important that the questions be carefully and skillfully posed. If questions are used to “trap” patients into contradicting themselves, patients may come to feel that they are being attacked or manipulated by the therapist. Too many open-ended questions can leave patients wondering what the therapist expects of them. Therapists must carefully time and phrase questions to help patients recognize their thoughts and schemas, and to weigh issues objectively.

Self‑Help Homework Assignments

Rationale

Regular homework assignments are very important in cognitive therapy. When patients systematically apply what they have learned during therapy sessions to their outside lives, they are more likely to make sig- nificant progress in therapy and to be able to maintain their gains after termination of treatment. Burns and Spangler (2000) found that patients who did the most homework showed larger and more significant decreas- es in depression than those who were less compliant. Homework assignments are often the means through which patients gather data, test hypotheses, and begin to modify their thoughts and schemas. In addition, the data provided through homework assignments help to shift the focus of therapy from the subjective and ab- stract to more concrete and objective concerns. When patient and therapist review the previous week’s activi- ties during the agenda-setting portion of the interview, they may do so quickly, and the therapist can draw relationships between what takes place in the session

and specific tasks, thereby avoiding tangents and side issues. Homework assignments further patients’ self- reliance and provide them with methods to continue working on problems after the end of treatment. Cogni- tive therapists emphasize the importance of homework by sharing with patients their rationale for assigning homework in therapy. They are also careful to explain the particular benefits to be derived from each individ- ual assignment.

Assigning and Reviewing Homework

The cognitive therapist designs each assignment for the particular patient. The assignment should be directly related to the content of the therapy session, so that the patient understands its purpose and importance. Each task should be clearly articulated and very specific in nature. Near the end of each session, the assignment is written in duplicate, with one copy going to the thera- pist and the other to the patient.

Some typical homework assignments include reading a book or article about a specific problem, practicing distraction or relaxation techniques, counting auto- matic thoughts on a wrist counter, rating activities for pleasure and mastery on the Weekly Activity Sched- ule, maintaining a Daily Record of Dysfunctional Thoughts, and listening to a tape of the therapy session.

During the therapy session, the therapist asks for the patient’s reactions to homework assignments. For example, the therapist might ask whether the assign- ment is clear and manageable. To determine potential impediments, the therapist may ask the patient to imag- ine taking the steps involved in the assignment. This technique can be especially helpful during the earlier stages of therapy. The patient assumes greater responsi- bility for developing homework assignments as therapy progresses through the middle and later stages.

It is essential that patient and therapist review the previous week’s homework during the therapy session itself. If they do not, the patient may conclude that the homework assignments are not important. During the first part of the therapy sessions, therapist and patient discuss the previous week’s assignment, and the thera- pist summarizes the results.

Difficulties in Completing Homework

When a patient does not complete homework assign- ments, or does them without conviction, the cognitive therapist elicits automatic thoughts, schemas, or behav-

Cognitive Therapy for Depression 285

ioral problems that may help them both understand where the difficulty resides. The therapist does not pre- suppose that the patient is being “resistant” or “passive– aggressive.” When the difficulties have been successful- ly identified, therapist and patient work collaboratively to surmount them. It is, of course, common for patients to have difficulties in completing homework, and here we consider some of the typical problems and ways to counteract them.

When patients do not understand the assignment completely, the therapist should explain it more fully, specifying his/her expectations in detail. Sometimes using the behavioral technique of cognitive rehearsal (described earlier) can be helpful in such situations.

Some patients believe that they are naturally disorga- nized and cannot maintain records and follow through on detailed assignments. Therapists can usually help to invalidate such general beliefs by asking patients about other circumstances in which they make lists—for example, when planning a vacation or shopping trip. Therapists can also ask these patients whether they could complete the assignment if there were a substan- tial reward entailed. This kind of question helps such patients recognize that self-control is not the problem; rather, they do not believe that the reward is great enough. When patients realize that the problem is an attitudinal one, therapist and patient can proceed to enumerate the advantages of completing the assign- ment.

More severely depressed patients may need assistance to structure their time, so that homework becomes a regular activity. This can generally be accomplished by setting a specific time each day for the homework as- signment. If necessary, patient and therapist can set up a reward system to increase motivation to complete the homework. For example, patients can reward themselves for doing the assignment by making a special purchase.

Some patients are afraid of failing the assignments or of doing them inadequately. In these cases, the thera- pist can explain that self-help assignments cannot be “failed”: Doing an assignment partially is more helpful than not doing it at all, and mistakes provide valuable information about problems that still need work. In ad- dition, because performance is not evaluated, patients cannot lose if they view the activity from a more adap- tive perspective.

Sometimes patients believe their problems are too deeply embedded and complex to be resolved through homework assignments. The therapist can explain to these patients that even the most complex undertakings

begin with and comprise small, concrete steps. A writer, for example, may resolve “writer’s blocks” by taking the attitude, “If I can’t write a book, I can at least write a paragraph.” When enough paragraphs have been writ- ten, the result is a book. Therapist and patient can con- sider the advantages and disadvantages of the patient’s belief that problems cannot be solved by doing home- work. Or the therapist can ask the patient to experi- ment before reaching such a conclusion. In instances in which a patient believes that he/she has not made enough progress and that the homework is therefore not helpful, the therapist can detail progress the patient has made or help the patient see that it may take more time before substantial change can be perceived.

When patients seem to resent being given assign- ments, the therapist can encourage them to develop their own assignments. He/she might also offer patients alternative assignments from which to choose, making one of the alternatives noncompliance with homework assignments. If patients choose noncompliance, the therapist can help to examine the consequences of that choice. Still another strategy is to present patients with a consumer model of therapy: Patients have a certain goal (overcoming depression), and the therapist offers a means to achieve that goal; patients are free to use or reject the tools, just as they are free to buy or not to buy in the marketplace.

Some patients believe that they can improve just as readily without homework. In this case, therapists have two options. First, they can offer their own clini- cal experience (which is supported by existing empirical evidence) that most patients who do not actively en- gage with and complete therapeutic homework progress more slowly in therapy. The other option is to set up an experiment for a given period of time, during which pa- tients do not have to complete assignments. At the end of the predetermined period, therapists and patients can evaluate patients’ progress during that time inter- val. Once again, it is important for cognitive therapists to keep an open mind: Some patients do indeed effect significant change without formally completing home- work assignments.

Special Problems

The novice cognitive therapist often errs by staying with the standard method we have outlined here, even if it is not working very well. The cognitive therapist should be flexible enough to adapt to the needs of patients and to the several special problems that commonly arise in

286 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

therapy. We have grouped these special problems into two categories: difficulties in the therapist–patient re- lationship, and problems in which the therapy itself seems not to be working.

Therapist–Patient Relationship Difficulties

The first set of problems concerns the therapist–patient relationship itself. When the therapist first perceives a patient to be dissatisfied, oppositional, angry, or hostile, it is imperative that he/she present these observations to the patient in an empathic manner. It is important that the therapist refrain from responding to the patient simply with an increased and rigid adherence to pre- scribed techniques or the therapeutic rationale. It also is important that the therapist refrain from self-criti- cal statements. Research indicates that such responses have detrimental effects on the therapeutic relationship (Castonguay et al., 1996; Henry et al., 1993; Piper et al., 1999). Instead, research (Castonguay et al., 2004; Hatcher, 2015; Safran, Muran, Samstag, & Stevens, 2002; Safran et al., 2014) indicates that the therapist’s use of metacommunication skills (open discussion about the patient’s negative reaction, exploration of the patient’s experience, recognition and acknowledg- ment of the therapist’s contribution to those negative reactions) is significantly more likely to repair and re- store—and even improve—the therapeutic bond.

It is essential for therapists to be aware that many interventions can be misinterpreted in a negative way by depressed patients. Therapists approach problems of misinterpretation in the same way that they approach other thoughts: They work with patients to gather data and search for alternative accounts of the evidence. Dif- ficulties in the therapist–patient relationship can gener- ally be resolved through dialogue. There are times when a therapist may need to tailor behavior to the particular needs of an individual patient. For instance, a therapist may become freer with appropriate self-disclosure and personal reactions to meet the needs of a patient who persists in seeing the therapist as impersonal. Similarly, the therapist can make a point of checking formula- tions of the patient’s thoughts more frequently to meet the needs of a patient who continues to believe that the therapist does not understand him/her.

It is imperative in situations like these for the thera- pist not to assume that the patient is being stubbornly resistant or irrational. Therapeutic reactance (“a motiva- tional state characterized by the tendency to restore or re-assert one’s ability to engage in freedoms perceived

as lost or threatened”; Arnow et al., 2003, p. 1026) was found to be a positive predictor of treatment outcome in directive therapy with chronically depressed patients. Arnow and colleagues found that treatment was en- hanced when therapists responded in a flexible man- ner to such patient behaviors. Cognitive therapists col- laborate with patients to achieve a better understanding of patients’ responses. The reactions themselves often provide data regarding the kinds of distortions patients make in their other social and personal relationships. Therefore, patients’ responses give therapists the oppor- tunity to work with them on their maladaptive inter- pretations in relationships.

Unsatisfactory Progress

A second set of problems occurs when the therapy ap- pears not to be working, even when the patient con- scientiously completes homework assignments and the collaborative relationship seems successful. Sometimes problems stem from inappropriate expectations on the part of the patient—or unrealistic expectations on the part of the therapist—regarding the rapidity and consistency of change. When therapy seems not to be progressing as quickly as it “should,” both patient and therapist must remember that ups and downs are to be anticipated in the course of treatment. It is important for therapists to keep in mind that some patients sim- ply progress more slowly than others. The therapist or patient, or both, may be minimizing small changes that have indeed been taking place. In this case, the thera- pist can emphasize small gains that have been made and remind the patient that large goals are attained through small steps toward them.

At times, hopelessness can lead patients to invalidate their gains. Therapists should seek to uncover the mal- adaptive automatic thoughts, cognitive distortions, and early schemas that contribute to the pervasive hopeless- ness. In these cases, therapists must work to correct mistaken notions about the process of change and the nature of depression before further progress in therapy can occur.

In some cases in which therapy seems not to be work- ing successfully, it may be that some of the therapeu- tic techniques have not been correctly used. Problems often arise when patients do not really believe the ratio- nal responses or are not able to remember them in times of emotional distress. It is important for a therapist to determine the amount of a patient’s belief in the ratio- nal responses and help him/her use the new responses

Cognitive Therapy for Depression 287

as closely as possible to the moment when the automatic thoughts occur. To the patient who does not fully be- lieve a rational response, the therapist can suggest an experimental stance—taking the new belief and “trying it on for size.” The patient who cannot think of answers because of emotional upset should be told that states of emotional distress make reasoning more difficult, and that thoughts such as “If this doesn’t work, nothing will” can only aggravate the problem. Patients should be assured that they will be able to think of rational responses more readily with practice.

Another problem that derives from the misapplica- tion of cognitive therapy techniques occurs when the therapist uses a particular technique inflexibly. It is often necessary for the therapist to try out several be- havioral or cognitive techniques before finding an ap- proach to which a patient responds well. The cognitive therapist must stay with a particular technique for a while to see whether it works, but he/she must also be willing to try an alternative technique when it becomes apparent that the patient is not improving. To give a specific example, behavioral homework assignments are sometimes more helpful with particular patients, even though the therapist has every reason to predict in ad- vance that cognitive assignments will be more effective.

In some instances in which it appears that little prog- ress is being made in therapy, it turns out that the ther- apist has selected a tangential problem. The cognitive therapist should be alert to this possibility, especially during the early stages of therapy. When there appears to be little or no significant change in depression level, even when the patient seems to have made considerable progress in a problem area, the therapist should con- sider the possibility that the most distressing problem has not yet been uncovered. A typical example of this kind of difficulty is the patient who presents difficulty at work as the major problem, when it turns out that relationship problems are contributing significantly to the work difficulties. The patient my avoid the real issue because it seems too threatening.

Finally, cognitive therapy is not for everyone. If the therapist has tried all available approaches to the prob- lem and has consulted with other cognitive therapists, it may be best to refer the patient to another therapist with either the same or a different orientation.

Regardless of why therapy is not progressing satisfac- torily, cognitive therapists should attend to their own af- fect and cognitions. They must maintain a disciplined, problem-solving stance. If the cognitive therapist finds him/herself unduly influenced by a patient’s despair or

begins to notice that his/her own schemas are triggered by therapeutic interactions, then he/she should seek su- pervision. Hopelessness in patients or therapists is an obstacle to problem solving. If therapists can effectively counteract their own negative self-assessments and other dysfunctional thoughts, then they will be better able to concentrate on helping patients find solutions to their problems.

Case Study: Nonchronic Depression

In the case study that follows, we describe the course of treatment for a nonchronically depressed woman, “De- nise,” seen at our Center. Through the case study, we illustrate many of the concepts described earlier in this chapter, including elicitation of automatic thoughts, the cognitive triad of depression, collaborative empiricism, structuring a session, and feedback.

Assessment and Presenting Problems

At the initial evaluation, Denise, a 59-year-old widow, reported that she had lived alone for the last year. De- nise’s husband had been diagnosed with brain cancer 3 years earlier and had died approximately 1 year earlier. She had two grown, unmarried children (ages 27 and 25 years) who were pursuing careers in other parts of the country. Denise had an undergraduate degree and had worked until age 30 but stopped after marrying. She described her major problems as depression (over the last year and a half), difficulty coping with daily life, and loneliness. She reported one prior episode of major depression around age 25, following the death of her father.

Denise said she had become increasingly socially isolated with the onset of her husband’s illness (brain cancer). She reported having had normal friendships as a child, teenager, and young adult. She and her husband had led a relatively quiet life together, with a focus on raising their children and their respective work. When they had free time, they had enjoyed intellectual and cultural activities together (museums, lectures, con- certs, and fine restaurants). The few close friends with whom they socialized had retired to Florida and Ari- zona during the time of the husband’s illness.

Denise was diagnosed with a major depressive disor- der, recurrent. Her test scores verified the diagnosis of depression. Denise’s BDI-II score was 28, placing her in the moderate to severe range of depression. Her most prominent depressive symptoms included loss of plea-

288 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

sure, irritability, social withdrawal, inability to make decisions, fatigue, guilt, difficulty motivating herself to perform daily functions, and loneliness.

Session I

The session began with Denise describing the “sad feel- ings” she was having. The therapist almost immediately started to elicit Denise’s automatic thoughts during these periods.

THERAPIST: What kind of thoughts went through your mind when you had these sad feelings this past week?

DENISE: Well, I guess I’m thinking what’s the point of all this. My life is over. It’s just not the same. I have thoughts like “What am I going to do?” Some- times I feel mad at him, you know, my husband. How could he leave me? . . . Isn’t that terrible of me? What’s wrong with me? How can I be mad at him? He didn’t want to die a horrible death. I should have done more. I should have made him go to the doc- tor when he first started getting headaches. . . . Oh, what’s the use?

THERAPIST: It sounds like you are feeling quite bad right now. Is that right?

DENISE: Yes. THERAPIST: Keep telling me what’s going through your

mind right now. DENISE: I can’t change anything. It’s over. I don’t

know. . . . It all seems so bleak and hopeless. What do I have to look forward to . . . sickness and then death?

THERAPIST: So one of the thoughts is that you can’t change things, and that it’s not going to get any bet- ter?

DENISE: Yes. THERAPIST: And sometimes you believe that complete-

ly? DENISE: Yeah, I believe it, sometimes. THERAPIST: Right now, do you believe it? DENISE: I believe it—yes. THERAPIST: Right now you believe that you can’t

change things and it’s not going to get better? DENISE: Well, there is a glimmer of hope, but it’s most-

ly . . . THERAPIST: Is there anything that you kind of look

forward to in terms of your own life from here on?

DENISE: Well, what I look forward to . . . I enjoy seeing my kids, but they are so busy right now. My son is a lawyer and my daughter is in medical school. So, they are very busy. They don’t have time to spend with me.

By inquiring about Denise’s automatic thoughts, the therapist began to understand her perspective—that she would go on forever, mostly alone. This illustrates the hopelessness about the future that is characteristic of most depressed patients. A second advantage to this line of inquiry is that the therapist introduced Denise to the idea of looking at her own thoughts, which is central to cognitive therapy.

As the session continued, the therapist probed De- nise’s perspective regarding her daily life. The therapist chose to focus on her inactivity and withdrawal. This is frequently the first therapeutic goal in working with a severely depressed patient.

In the sequence that follows, the therapist guided Denise to examine the advantages and disadvantages of staying in her house all day.

DENISE: Usually, I don’t want to leave my house. I want to stay there and just keep the shades closed; you know, I don’t want to do anything. I just want to keep everything out, keep everything away from me.

THERAPIST: Now, do you feel better when you stay in the house all day trying to shut everything out?

DENISE: Sort of . . . THERAPIST: What do you mean? DENISE: Well, I can watch TV all day and just lose my-

self in these silly shows. I feel better when I see other people and their problems on these shows. It makes me feel less lonely and like my problems aren’t so bad.

THERAPIST: And so how much time do you spend doing that?

DENISE: Now, lately?  .  .  . Most of the time. Staying inside and watching TV feels safe, sort of secure, ev- erything . . . like my loneliness, feels more distant.

THERAPIST: Now, after you have spent some time like this, how do you feel about yourself?

DENISE: Afterwards? I usually try not to pay much at- tention to how I’m feeling.

THERAPIST: But when you do, how do you feel? DENISE: I feel bad. I feel bad for wasting the day. I don’t

get to things that I need to take care of . . . like my

Cognitive Therapy for Depression 289

bills, like cleaning, like taking a shower. I usually end up feeling kind of pathetic . . . and guilty.

THERAPIST: On the one hand, you seem to feel soothed and on the other hand, afterwards, you’re a bit criti- cal of yourself?

Note that the therapist did not try to debate or exhort Denise to get out of the house or become involved with necessary daily tasks. Rather, through questioning, the therapist encouraged her to examine more closely her assumption that she was really better off watching TV all day in her house. This is the process we call “col- laborative empiricism.” By the second session, Denise had reexamined her hypothesis about watching TV and remaining in the house all day.

DENISE: About watching TV in the house versus get- ting out, I thought about that the other day. I re- member telling you that it made me feel better to stay there. When I paid attention to what I really felt, it didn’t make me feel better. It just kind of blocked out feeling bad, but I didn’t feel better.

THERAPIST: It is funny then that when you talked about it, your recollection of the experience was more positive than it actually was, but that sometimes hap- pens with people. It happens to me, too. I think that something is good that’s not so hot when I actually check it out.

We now return to the first session. After some prob- ing by the therapist, Denise mentions that it sometimes feels like cognitive therapy “is my last hope.” The thera- pist uses this as an opportunity to explore her hopeless- ness and suicidal thinking.

THERAPIST: What was going through your mind when you said, “This is my last hope”? Did you have some kind of vision in your mind?

DENISE: Yeah, that if this doesn’t work, I feel like I couldn’t take living like this the rest of my life.

THERAPIST: If it doesn’t work out, then what? DENISE: Well, I don’t really care what happens to

me . . . THERAPIST: Did you have something more concrete in

mind? DENISE: Well, right this minute, I don’t think I could

commit suicide, but if I keep feeling this way for a long time, maybe I could. I don’t know, though—

I’ve thought about suicide before, but I have never really thought about how I would do it. I know cer- tain things stop me, like my kids. I think it would really hurt them and some other people, too, like my mother. My mom is in good health now, but she may need me someday. . . . Yeah, those are the two things that stop me, my children, and my mother.

THERAPIST: Now those are the reasons for not commit- ting suicide. Now what are some of the reasons why you might want to, do you think?

DENISE: Because sometimes it just feels so empty and hopeless. There’s nothing to look forward to—every day is the same. My life is such a waste, so why not just end it?

The therapist wanted Denise to feel as free as possible to discuss suicidal thoughts; thus, he tried hard to un- derstand both the reasons for her hopelessness and the deterrents to suicide. After determining that she had no imminent plans to make an attempt, the therapist said that he would work with her to make some changes. He then asked her to select a small problem that they could work on together.

THERAPIST: Now are there any small things that you could do that would affect your life right away?

DENISE: I don’t know. Well, I guess just calling my friend Diane in Florida. She called about a month ago and then again last week. Both times I told her I was busy and would call her back, but I haven’t. I’ve felt so down. I have nothing to say to her.

THERAPIST: Well, when she lived in the area, what kinds of things did you talk about?

DENISE: We have kids about the same age, so we would talk about our kids. We both like to read and we used to go to a book club together—so we would talk about the books we were reading. Both of us liked art. We used to attend lectures at the museum during the week, so we would talk about art and the lectures. We would spend time making plans to do things together in our free time. It always was very interesting when I spent time and with her. We had so much in common. I do miss her.

THERAPIST: It sounds like you used to be involved in a number of interesting activities. What about now?

DENISE: After my husband got sick and then my friends moved, I just stopped. I haven’t done any of those things in quite a while.

290 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: What do you think about attending a lec- ture series now?

DENISE: I don’t know. THERAPIST: Well, what do you think about that idea? DENISE: It’s an OK idea, but it just seems like too

much. I don’t think I’ll enjoy it . . . the way I feel . . . I don’t know.

THERAPIST: Would you be willing to test out that thought that you won’t be able to enjoy it now?

DENISE: I don’t know . . . I guess so. THERAPIST: Is that a “yes”? DENISE: Yes, but I don’t see how I’m going to get myself

to do it. THERAPIST: Well, how would you go about finding out

about a lecture series? DENISE: You look online at the museum’s website to see

what’s available. THERAPIST: OK. Do you have a computer? DENISE: Yes. THERAPIST: Is it working? DENISE: Yes. THERAPIST: How do you feel about doing that? DENISE: I guess I could do that. . . . I’m so pathetic, I

know what to do. I don’t need you to spell it out for me. Why didn’t I just do this before?

THERAPIST: Well, you probably had good reasons for not doing it before. Probably you were just so caught up in the hopelessness.

DENISE: I guess so. THERAPIST: When you are hopeless you tend to deny,

as it were, or cut off possible options or solutions. DENISE: Right. THERAPIST: When you get caught up in hopelessness

then, there is nothing you can do. Is that what you think?

DENISE: Yeah. THERAPIST: So, then, rather than be down on your-

self because you haven’t looked this up online before, why don’t we carry you right through?

This excerpt illustrates the process of graded tasks that is so important in the early stages of therapy with a depressed patient. The therapist asked the patient a se- ries of questions to break down the process of attending

a lecture series into smaller steps. Denise realized that she had known all along what to do, but, as the thera- pist pointed out, her hopelessness prevented her from seeing the options.

DENISE: Taking this step is going to be hard for me. THERAPIST: First steps are harder for everybody, but

that’s why there is an old expression: “A journey of a thousand miles starts with the first step.”

DENISE: That’s very true. THERAPIST: It’s the first step that is so very important,

and then you can ready yourself for the second step, and then the third step, and so on. Eventually, you build up some momentum, and each step begins to follow more naturally. But first, all you have to do is take one small step. You don’t have to take giant steps.

DENISE: Well, yeah, I can see that. I guess I was think- ing every step was just as hard as the first. Maybe it will get easier.

In the second session, Denise reported success.

DENISE: I checked online about the lecture series and I surprised myself. One actually sounded interesting, and I’m thinking that I might just register for it on- line. I really didn’t think any of those feelings were still there. I’m kind of looking forward to that next step.

At the end of the first session, the therapist helped Denise fill out the Weekly Activity Schedule for the coming week. The activities were quite simple, such as getting up and taking a shower, fixing meals, going out shopping, and checking out the lecture series online. Finally, the therapist asked Denise for feedback about the session and about her hopelessness.

THERAPIST: Do you have any reactions? DENISE: I’m still feeling down, but I’m also feeling a

little better. It’s interesting that just the idea of look- ing at what lectures might be available is making me feel a little lighter. I even had the thought of calling Diane to talk over the options. . . . Is this a sign of better things to come?

THERAPIST: What do you think? DENISE: Maybe.

Cognitive Therapy for Depression 291

Session 2

In the second session, the therapist began by collabo- rating with Denise to set an agenda. Denise wanted to discuss the fact that she had not been attending to her bills or to her housework and was still spending a good part of the day alone in front of the TV; the therapist utilized this as an opportunity to discuss the issue of activity versus inactivity on the agenda. They then re- viewed the previous homework. Denise had carried out all the scheduled activities and had also listed some of her negative thoughts in between sessions. Her BDI- II score had dropped somewhat. (Patients routinely fill out the BDI-II before each session, so that both patient and therapist can monitor the progress of treatment.)

Denise then shared her list of negative thoughts with the therapist. One concern was that she had expressed angry feelings about her husband during the first ses- sion.

DENISE: I don’t like revealing things about myself, but you told me to write down my thoughts. So here it is. When I went to bed the night after of our first ses- sion, I thought about what I said to you, you know, about being angry at my husband. I was thinking that you probably think I am this really harsh and cold person. I mean, here my husband died this hor- rible death and I have this hard, insensitive reaction. I started thinking that now you probably feel really negatively toward me because of that statement and that you don’t want to work with me.

THERAPIST: I’m really glad you’re telling me these thoughts. Let me start by asking you who is having these negative thoughts?

DENISE: You? Well, no. Actually, it’s me. THERAPIST: Right. Do you think that someone like me

might have another reaction to what you said? DENISE: I don’t know. I mean it is pretty harsh being

angry at someone who had no control over what was happening.

The therapist then offered Denise an alternative per- spective:

THERAPIST: Do you think that someone might react to your statements with empathy?

DENISE: How could they? THERAPIST: I imagine it would be very upsetting and

annoying to have lost both your husband and your friends—all around the same time. Even though you love and care about all of them, feeling angry is un- derstandable. It sounds like a basic human reaction to some very difficult life events.

DENISE: Yeah, I guess that does make sense. Thanks.

This illustrates how a cognitive therapist can utilize events during the session to teach a patient to identify automatic thoughts and to consider alternative interpre- tations. In addition, the therapist provides a summary of a key theme he identified from listening to Denise’s automatic thoughts about her husband and about ther- apy. The theme was her fear of being harshly judged and potentially punished for her statement (Punitive- ness schema). Cognitive therapists often identify and begin to correct EMSs during the first phase of treat- ment. More intensive work on changing schemas in a later phase of treatment may be required to inoculate against relapse. We elaborate on this process in the next section of this chapter.

In the segment that follows, the therapist explained how he arrived at the conclusion that punitiveness was an important schema for Denise.

THERAPIST: When you said that you thought I would have a negative opinion about you and not want to work with you because you said you felt angry at your husband, it sounded as though you were really concerned that you would be harshly judged and punished for your statements.

DENISE: Yes, that’s right. THERAPIST: I don’t want to make too much out of

this at the moment, but you also said that after your friends had moved, you felt angry at them and judg- mental of their decision. Even though you knew that each set of friends had to move for specific finan- cial or health reasons and had been in the process of completing their moves over several years, part of you still felt very angry with them. You mentioned that you strongly believe that friends should be there for each other, especially in times of great need, and if a friend lets another friend down, that relationship should end. Is that right?

DENISE: Right. THERAPIST: So, here, you largely have withdrawn from

these important relationships and now you’re feeling quite lonely. The thought of talking to these friends

292 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

again brings fears that they will now be angry and punitive with you for your reaction to them. You’re caught in a no-win situation. Is that right?

DENISE: Yes, that sounds right. THERAPIST: So one of the things that can really grab

hold of you—and make you feel terrible—is this no- tion that people, including yourself, should behave in specific ways, and if they or you don’t behave the “right” way, then harsh punishment should result. Is that correct?

DENISE: Yes, that sounds right. But hearing you say it makes me realize that it doesn’t really sound right.

THERAPIST: What do you mean? DENISE: It’s too extreme. It’s too harsh. People are

human and they have limitations, and they make mistakes sometimes.

THERAPIST: It’s good that you are starting to notice and evaluate these thoughts rather than just responding to them automatically. What this tells us is that you have to be alert for whenever you have the sense that either you or others should be strongly punished for not behaving in a specified way. The idea that people should not be cut a break, even under very difficult circumstances, may not work very well in real life with real people. You mentioned that both friends told you they felt terrible about leaving you at this time, and both have called you regularly since leav- ing the area. Do you think that if you begin to re- spond to and return their calls, they might react dif- ferently—in the same way that I reacted differently from what you expected?

DENISE: Yes, that is very likely.

About halfway through the session, the therapist asked the patient for feedback thus far.

THERAPIST: Now, at this point, is there anything that we have discussed today that bothered you?

DENISE: That bothered me? THERAPIST: Yeah. DENISE: I feel like I’m a bit of a freak. THERAPIST: That is important. Can you . . . DENISE: Well, I’m trying not to feel that way, but I do. THERAPIST: Well, if you are, you are. Why don’t you

just let yourself feel like a freak and tell me about it? DENISE: Well, I’m feeling like I’m just so different from

everyone else. Other people don’t seem to have my problems. They’re still happily married and carrying on with life. I just feel so different from everyone.

This comment led to identification of a third theme, the Social Isolation/Alienation schema. Denise had been viewing herself as increasingly different for the past couple of years. By this point, however, she was beginning to catch on to the idea of answering her thoughts more rationally. After the therapist pointed out the negative thought in the preceding excerpt, the patient volunteered:

DENISE: I know what to do with the thought “I’m a freak.”

THERAPIST: What are you going to do with it right this minute?

DENISE: I am going to say to myself, “I’m not so differ- ent from other people. Other people have lost their mates. I’m not the only one. I’m just the first one in my group of friends. Eventually, they will all have the same situation as me. It’s just a part of life.” Seeing you for help doesn’t mean I’m a freak. You probably see lots of people and help them with problems like mine.

THERAPIST: Right.

The same automatic thoughts arose later in the ses- sion, when Denise noticed the therapist’s wedding ring. In the following extended excerpt, the therapist helped her set up an experiment to test the thought “I’m so dif- ferent from him.”

THERAPIST: OK, now let’s just do an experiment and see if you yourself can respond to the automatic thought, and let’s see what happens to your feeling. See if responding rationally makes you feel worse or better.

DENISE: OK. THERAPIST: OK. “I’m so different from him.” What is

the rational answer to that? A realistic answer? DENISE: You are wearing a wedding ring and that is dif-

ferent from me, because I’m alone, without a mate. THERAPIST: Yes. And? DENISE: And? . . . I don’t really know much about you,

other than you’re married. I guess from what I do know, that information could also be viewed as a

Cognitive Therapy for Depression 293

similarity. We both have gotten married and know what it’s like to be married. I assume that you’ve never lost a mate, but maybe that is not true. You may have lost a mate as well.

THERAPIST: So, is it that you’re different or that I’m different? Or is it that we just have different situa- tions with respect to our mates at this point in time?

DENISE: We just have different situations right now.

The preceding exchange demonstrates the use of re- attribution. At first, Denise interpreted the therapist’s ring as evidence that they were very different. As a re- sult of the guided discovery approach, she reattributed the difference to one of two factors: that either she or the therapist was different or that the situation with re- spect to mates was different for each. At the end of the experiment, Denise expressed satisfaction that she was finally recognizing this tendency to distort her apprais- als.

DENISE: Right now, I feel glad. I’m feeling a little better that at least somebody is pointing these things out to me. I never realized I was so judgmental of myself and other people, and that I’m assuming I’m so dif- ferent from everyone.

THERAPIST: So you feel good that you have made this observation about yourself?

DENISE: Yes.

After summarizing the main points of the second session, the therapist assigned homework for the com- ing week: to fill out the Daily Record of Dysfunctional Thoughts (see Figure 7.4) and the Weekly Activity Schedule (with mastery and pleasure ratings; see Figure 7.3).

Session 3

By the beginning of the third session, Denise’s mood had visibly improved. She had registered for a lecture series at the museum and was looking forward to at- tending the first lecture. She also had called her friend Diane, with very positive results. She was catching neg- ative and punitive thoughts toward others and herself and challenging these thoughts. The primary agenda item Denise chose to work on was “how I back away from other people,” an aspect of her Unrelenting Stan- dards, Punitiveness, and Social Isolation/Alienation schemas.

DENISE: I want to stop withdrawing from people. I want to be more accepting and engaged with others.

THERAPIST: What holds you back? DENISE: I guess I believe that I have to be a bit removed

and strict in relation to others or they’ll just behave in whatever way they want. People have to know my rules and abide by them if they want to have a rela- tionship with me.

The therapist continued probing to understand why Denise believed she had to have others adhere to such a strict set of rules to have a relationship. As the discus- sion progressed, it became obvious that, in the abstract, she could see that such hard-and-fast rules were not necessarily conducive to having a good relationship— in fact, such rules sometimes put others off. But in real- life situations, Denise never felt she was wrong.

The therapist’s next task was to help Denise bring her rational thinking to bear on her distorted think- ing in the context of a concrete event. At the therapist’s request, Denise then described a conversation with her friend Diane, and how her intolerance for Diane’s deviation from her rules created distance. Denise had wanted Diane and her husband to come for a visit the following summer. Diane, however, told her that their dog had been quite sick, and that if the dog was still alive, she could not leave it. Denise thought this was ridiculous. She believed a relationship with a pet should never take precedence over a human relationship. This occurred when Denise actually had wanted and hoped to get closer to Diane again. The therapist helped her use logic to evaluate her maladaptive schema.

THERAPIST: You had the thought “I’m right to set the record straight with her. She can’t put me in second place to her dog. She can’t do that without consequence.” It seems likely that you believed that thought, and that you believed the thought was right. And since you believed that thought was right, you then felt you had to withdraw your affection from her if she didn’t abide by your wishes.

DENISE: Right. THERAPIST: Now, let’s look at it. Do you think that

thought is correct? DENISE: Well, yes, it’s insulting. THERAPIST: What’s insulting? DENISE: She’s putting her dog in a higher priority posi-

tion.

294 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: Have you ever had a pet? DENISE: No. THERAPIST: Do you think that maybe Diane feels like

her dog is a part of her family? DENISE: I never thought of it that way. THERAPIST: If you look at the situation from that per-

spective, how do you feel? DENISE: I feel like I’m being a little insensitive.  .  .  .

That’s not right. I’m not allowing for any other per- spective. I’ve never had a pet, so I don’t really know what it’s like to have a pet. It’s not right for me to be so judgmental of Diane. I need to be more under- standing. I wasn’t very caring. I am actually behav- ing in a way that goes directly against my deepest values.

THERAPIST: So, according to your own values, was this right?

DENISE: No, it’s not right. I wasn’t respecting her feel- ings. I was just demanding that she respect mine. That wasn’t right.

THERAPIST: OK, now this is one of the problems. If you want to get over this sense that you should never give in or bend your rules for others, one of the things you can do is look for this thought, “I’m right and you should have a negative consequence for your ‘wrong’ decision”—and refer back to this conversation we are having now and decide for your- self whether, indeed, you were right. Now, if every time you approach a conflict in a relationship and allow for the possibility that you might not fully un- derstand, but really think underneath, “But I know I’m right,” you are going to feel put out, and then you are not going to want to engage with that per- son. Is that right?

DENISE: Yeah, that sounds right. THERAPIST: So we have to decide here and now. Do

you indeed think that you are right to suspend your initial negative judgment to leave open the possibility of reevaluating your reaction to her behavior?

DENISE: Yes. THERAPIST: Now, the next time you get the thought

“I’m right and I’m going to make sure this other person knows it,” how are you going to answer that thought?

DENISE: If I’m right? But I’m not necessarily right. I need to consider the other person’s perspective. I

need to try to understand them and then see if what I’m thinking fits.

THERAPIST: Now are you saying that because that is the correct answer, or because you really believe it?

DENISE: No, I really believe it.

The therapist followed this discussion with a tech- nique called “point–counterpoint” to help Denise prac- tice rational responses to her automatic thoughts even more intensively. In this excerpt, the therapist expressed Denise’s own negative thinking as Denise tried to de- fend herself more rationally.

THERAPIST: Now I am going to be like the prosecut- ing attorney, and I’ll say, “Now I understand you let your friend violate one of your rules of friendship. Is that true?”

DENISE: Yes. THERAPIST: “Now it seems to me that that was a very

bad thing for you to do.” DENISE: No, it wasn’t. THERAPIST: “You don’t think it was?” DENISE: No, I should try to understand her perspec-

tive. THERAPIST: “Well, you can sit there and say you should

be more understanding, but I thought you said be- fore that you wanted people to respect you.”

DENISE: I do, but I also need to respect others. THERAPIST: “I know, but now you are saying that you

are going to let her get away with this. What’s next?” DENISE: What’s next can only be a better understand-

ing of one another. We’ll feel closer. THERAPIST: “But how can you feel closer if she’s not

respecting your rules of friendship?” DENISE: Maybe my rules are not appropriate in this

situation. I need to learn to be more understanding, flexible, and tolerant of some deviations from my rules.

THERAPIST: “But then you’ll lose control of the situa- tion.”

DENISE: No, that’s an exaggeration. I don’t need to con- trol the whole situation. I can still decide what makes sense. I am still in control of what’s important.

THERAPIST: “How can that be?” DENISE: Because I can respect myself and respect my

Cognitive Therapy for Depression 295

friend as well. I don’t have to turn everything into an either–or situation to try to make her see and do it my way. That just makes it difficult for her to get along with me, and I’ll lose out on the relationship in the long run if I keep on insisting that she either do it my way or we do nothing.

Finally, the therapist returned to the schema and asked the patient how much she believed the new per- spective.

THERAPIST: If you’re flexible, you’ll lose control. Now do you believe that?

DENISE: No. THERAPIST: Do you believe it partially? DENISE: No. In fact, I’m more likely to lose control of

any possibility of getting what I want if I’m so in- flexible. It’s like I lose sight of the importance of the relationship when I get so stuck on thinking that I have to be in control and that the other person has to do it my way.

THERAPIST: OK, so right now, how much do you be- lieve that?

DENISE: Completely. THERAPIST: 100%? DENISE: Yes. THERAPIST: You are sure 100%, not 90 or 80%? DENISE: No, 100%.

For the remainder of Session 3, Denise and the therapist reviewed other instances in which she noticed that her standards were not flexible and felt the urge to be punitive when her rules were not met. The session ended with a summary of the main issues raised in the first three sessions.

Summary of Initial Sessions

In the first three sessions, the therapist laid the ground- work for the remainder of treatment. He began im- mediately by teaching Denise to identify her negative automatic thoughts. By doing this, the therapist began to understand her feelings of hopelessness and to ex- plore her isolation. By identifying her thoughts in a variety of specific situations, he was able to deduce sev- eral key schemas that later proved central to Denise’s thinking: (1) Unrelenting Standards, (2) Punitiveness,

and (3) Social Isolation/Alienation. All appeared to be contributing to Denise’s social isolation and depression. The therapist made especially skillful use of Denise’s thoughts during the second therapy session to help her see that she was distorting evidence about the therapeu- tic interaction and coming to the inaccurate conclusion that the therapist would be judgmental and punitive with her, and withdraw positive feelings for her, in the same way that Denise tends to respond to others.

Beyond identifying thoughts and distortions, the therapist guided Denise to take concrete steps to over- come her inactivity and withdrawal. He asked her to weigh the advantages and disadvantages of staying in the house all day watching TV; he broke down the task of attending a lecture series at the museum into small, manageable steps; and he worked with her to develop an activity schedule to follow during the week.

Finally, the therapist employed a variety of strategies to demonstrate to Denise that she could test the valid- ity of her thoughts, develop rational responses, and feel better. For example, during the course of the three ses- sions, the therapist set up an experiment, used reattri- bution, offered alternative perspectives, and practiced the point–counterpoint technique.

One final point we want to emphasize is that the pri- mary therapeutic mode was questioning. Most of the therapist’s comments were in the form of questions. This helped Denise to evaluate her own thoughts out- side of the session and prevented her from feeling at- tacked by the therapist.

By the end of these initial sessions, Denise reported being more optimistic that her life could change.

Later Sessions

Denise continued to fill out the Daily Record of Dys- functional Thoughts and gathered evidence that she could relax her standards and be more tolerant of oth- ers’ viewpoints and foibles. She discovered that she felt happier, both with herself and with others, as a result.

The therapist set up several experiments with Denise to test a series of beliefs: that her friends would become punitive with her when she did not behave perfectly, and that her relationships would become unpleasant and undesirable if she relaxed any of her rigid standards regarding how others should behave in relationships.

Through graded tasks, Denise counteracted her ten- dency to withdraw by gradually approaching new and sometimes unfamiliar situations. When she noticed herself imposing her standards of behavior on others,

296 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

or noticed in herself the urge to become punitive, De- nise practiced more open and accepting behaviors (by asking open-ended questions that reflected back her understanding of others’ responses, and by inhibiting harsh and judgmental statements). She practiced tol- erating the discomfort associated with these new be- haviors until they began to feel more comfortable and natural.

When Denise terminated therapy, her BDI-II score was in the normal range. The symptom reduction phase of treatment was successfully completed in 20 sessions.

The next section describes and includes a case ex- ample of ST for chronic depression.

ST FOR CHRONIC DEPRESSION

ST, developed by Young (1990/1999; Young et al., 2003), can be used with patients who present with re- current depressive episodes, dysthymic disorder, early onset of depression, early life trauma or adverse family relations (e.g., the loss of a parent in childhood; sexual, physical or verbal abuse, neglect, and overprotection), comorbid personality disorders, or a large number of EMSs (identified with the YSQ [Young, 2005]). Young and Klosko (1994) have published a self-help book to help patients better understand their schemas.

Beck and colleagues (1990) have noted that

schemas are difficult to alter. They are held firmly in place by behavioral, cognitive, and affective elements. The therapeutic approach must take a tripartite ap- proach. To take a strictly cognitive approach and try to argue patients out of their distortions will not work. Having the patients abreact within the session to fan- tasies or recollections will not be successful by itself. A therapeutic program that addresses all three areas is es- sential. A patient’s cognitive distortions serve as signposts that point to the schema. (p. 10)

As a result, ST represents a significant expansion of traditional CBT. It places more emphasis on early de- velopmental patterns and origins, long-term interper- sonal difficulties, the patient–therapist relationship, and emotion-focused or experiential exercises.

Case Study: Chronic Depression

The second case study demonstrates the use of ST with a chronically depressed patient, “Barbara.”

History and Presenting Problems

Barbara was an extremely attractive 46-year-old woman who had been married for the past 20 years to George, a functional alcoholic working on Wall Street in invest- ment banking. It was the first marriage for both, but it had been extremely rocky throughout. Barbara had wanted children in the marriage but had been unable to conceive naturally. Although fertility treatments and adoption had been discussed, Barbara reported that George resisted following through on these options, because he questioned her ability to be an adequate par- ent.

At the beginning of George and Barbara’s relation- ship, Barbara reported extremely strong sexual chem- istry. However, she stated that the chemistry had been erratic and often disappeared for long periods over the course of their relationship. She said that she had only felt real happiness with George in the first few months of the relationship, when he was extremely generous and attentive. Her decision to marry George was based on a feeling that they were meant for each other. They initially met at a high-end bar, where Barbara had worked as a cocktail waitress. Once their relationship was established, however, George continued to spend most of his free time in cocktail lounges without her, as she did not like to drink.

At the time she came in for her first interview, Bar- bara was spending most of her time in bed or watch- ing TV. She rarely left the house except to go shopping. Outings with her mom or friends “to lift her spirits” often culminated in shopping sprees, followed by ex- tended verbal berating by George, drunk upon his re- turn home from the bar, because of what he perceived as her lack of taste, judgment, and intelligence regard- ing purchases. Barbara entered treatment because her husband told her that she “was driving him crazy with all her ridiculous behavior” and that she should “go get fixed.” Barbara acknowledged feeling very depressed. She stated that this latest episode of depression started after a particularly upsetting fight with her husband over adopting a child.

Barbara reported having mild to moderate depres- sion most of her life, interspersed with multiple episodes of major depression. She first became aware of feeling moderately depressed around age 11. An only child, she initially described her childhood family as “fine.” Bar- bara described her mother as extremely attentive and devoted, a “very good mother who did everything for me.” Barbara stated that her mother lived for her, but

Cognitive Therapy for Depression 297

she also remembered her mother occasionally falling into depressions. As early as age 6, she recalled that her mother was emotionally unavailable when depressed.

Barbara described her father as a workaholic who was almost never home. When he did come home, he was remote, preferring the solitude of his study over in- teracting with Barbara and her mother. If, as a child, Barbara tried to engage him, he would upbraid her by calling her “an annoying simpleton” and demand that she leave him alone.

Barbara described her first major depressive episode, which occurred around age 16, after a breakup with her first serious boyfriend. Later episodes were triggered by other breakups and the fertility problems.

Barbara scored 29 on the BDI-II, placing her in the severe range of depression. She also completed the third edition of the YSQ (Long Form; Young, 2005), and received very high scores on the Emotional De- privation, Defectiveness, Abandonment, Dependence/ Incompetence, Entitlement, Failure, Subjugation, Ap- proval Seeking, and Negativity/Pessimism schemas. Her Schema Mode Questionnaire (Young et al., 2008) indicated that she primarily functioned in the follow- ing modes: Detached Protector, Compliant Surrender, Punitive Parent, and Vulnerable Child.

At Barbara’s initial consultation, the therapist con- ducted additional assessment work through imagery (a standard assessment procedure for ST). During this assessment, Barbara was instructed: “Close your eyes and let your mind float to your earliest memories of your mother.” Barbara reported painful recollections of being 6 years old with her mother in bed, depressed and emotionally unavailable. She reported feeling very scared and lost at these times. The same imagery ex- ercise was utilized in a subsequent session in which Barbara was asked to retrieve an early memory of her father. In this image, Barbara’s father displayed intoler- ant, demeaning, and rejecting behavior toward her as a child. During the exercise, she reported feeling unac- ceptable, ashamed of herself, and unwanted by him.

On the Multimodal Life History Inventory (Lazarus & Lazarus, 1991), a 15-page assessment tool covering a wide range of issues dealing with feelings, thoughts, behaviors, and a variety of other psychotherapeutic is- sues, Barbara reported her main problems as depression, being unhappy with herself, feeling empty and unloved, and feeling unappreciated. She also listed the follow- ing behaviors as applicable: procrastination, with- drawal, concentration difficulties, sleep disturbance, crying, and occasional outbursts of temper. She further

indicated that she often felt sad, depressed, unhappy, hopeless, useless, and lonely. She endorsed the follow- ing statements: “I don’t know what to do with my life,” “Life is empty, a waste,” and “There is nothing to look forward to.”

Based on the initial interview, Barbara was diag- nosed with major depressive disorder, recurrent episode on Axis I, and dependent personality disorder on Axis II, based on DSM-IV-TR (American Psychiatric Asso- ciation, 2000).

Schema Mode Work

This section demonstrates the use of schema mode work—an important component of the ST approach— with Barbara.

The therapist shifted to ST because Barbara’s depres- sion was not lifting with standard cognitive therapy. Although Barbara had learned how to challenge her automatic thoughts, identified and challenged her core beliefs with rational responses, and followed through on graded behavioral assignments to test her thoughts and beliefs, she never emotionally accepted the rational viewpoint, despite much concrete evidence. Barbara remained convinced that she was worthless, useless, and hopeless. Her EMSs continued to be stubbornly entrenched. The therapist decided that the next step would be to introduce emotion-focused exercises to access Barbara’s schemas on a deeper emotional level, utilizing the schema mode approach.

There are seven general steps in schema mode work: (1) Increase awareness of modes by identifying and la- beling modes with the patient; (2) explore the origins of modes in childhood and adolescence, and discuss their adaptive value; (3) link current problems and symptoms to the patient’s maladaptive modes; (4) uncover the ad- vantages and disadvantages of each mode; (5) use im- agery to access the Vulnerable Child mode; (6) conduct dialogues between modes; and (7) generalize the results from mode work in session to the patient’s life outside of sessions. The following sections illustrate each step of mode work in helping Barbara.

Step 1: Increase Awareness of Modes by Identifying and Labeling Modes with the Patient

This first step helps both therapist and patient concep- tualize the problems in terms of different parts of the self or modes. From the Schema Mode Questionnaire, the therapist already was aware that Barbara primarily

298 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

functioned in the Detached Protector, Compliant Sur- renderer, Punitive Parent, and Vulnerable Child modes. The session reveals how the therapist queries the pa- tient, so that she can begin to recognize and differenti- ate these parts within herself.

Throughout this section, the patient is encouraged to label modes with terms that feel right—rather than simply applying generic terms from the Schema Mode Questionnaire. Patients are encouraged to find terms that best capture the thoughts, emotions, and/or be- haviors associated with each mode. A primary goal with this first step is to help the patient observe these parts, and decenter him/herself from them. This step begins the process of interrupting the automaticity of the modes.

THERAPIST: I’m noticing in our sessions that some- times you seem very sad and upset and critical of yourself, and other times you seem a bit distracted from what you’re feeling, like when you were telling me about the great pair of shoes that you found on your shopping trip.

BARBARA: Yeah, I guess that’s true. Talking about my purchases makes me feel better.

THERAPIST: When you say “better,” what do you mean? BARBARA: I feel good. THERAPIST: Like happy, peaceful, and content? BARBARA: I feel pleasure. THERAPIST: In what way is it pleasurable? BARBARA: I feel pleasure when I look at pretty things

with my mom or my friends, and I like buying those things. It takes my mind off of everything else.

THERAPIST: Like you’re temporarily distracted from other feelings?

BARBARA: Yeah, that’s right. THERAPIST: What are those other feelings? BARBARA: Just feeling real bad. I can’t stand those feel-

ings. THERAPIST: So, sometimes there is this one part of you

that just wants distance from this other part of you that feels bad?

BARBARA: Yes. THERAPIST: Are there other things you do besides

shopping that help you distance from bad feelings? BARBARA: Well, yeah, I sleep a lot.

THERAPIST: Anything else? BARBARA: I watch TV, but TV doesn’t always work. THERAPIST: This part of you that wants distance from

feeling bad—what could we call that part of you? BARBARA: That part of me? I don’t know. I don’t know

what to call it. THERAPIST: What does it feel like? BARBARA: It feels like I’m escaping. THERAPIST: OK. So should we call that part “the Es-

capist”? BARBARA: I guess so. . . . That sounds right. THERAPIST: And the part of you that you’ve escaped

from—can you tell me more about that part of you? BARBARA: That part feels bad . .  . really bad and ter-

rible. THERAPIST: Let me hear that part speak about those

feelings. BARBARA: I’m just a bad person. (Starts to cry.) . . . I’m

a useless good for nothing. I feel so hopeless. I don’t know what to do. I can’t figure anything out. I’m such a zero, such a failure. . . . Do we really have to talk about this?

THERAPIST: Barbara, I know that it feels bad to be in touch with this part of yourself, but if you can hang in there for just a bit, it will help me to understand why you’re feeling so bad. Do you know what this part of you wants?

BARBARA: I want to feel good. THERAPIST: What do you think would help you feel

better? BARBARA: I don’t know. I really don’t know. I just want

you to fix me. My husband is right. I am a ridiculous person.

THERAPIST: It sounds like there is one part of you that feels really awful. It sounds like this part is listening and taking in what your husband says about you— that “you’re ridiculous.” I want you to hold back on agreeing with your husband, and I want to hear more about this part of you that feels awful—the part of you who wants everything fixed. That part  .  .  . do you feel it?

BARBARA: Yes, I feel it. THERAPIST: Tell me more. What are the things you

want to fix?

Cognitive Therapy for Depression 299

BARBARA: I don’t know. I just want to feel good about myself, proud of myself, but I just don’t. I want to have a child, but my husband doesn’t think I can handle it. He’s probably right. I need so much help with just everyday living. I don’t know how to handle anything.

THERAPIST: So this part of you, this part that feels awful and helpless but also wants to feel better, what could we call this part?

BARBARA: I don’t know. What do you think? THERAPIST: Well, what does it feel like? BARBARA: It feels helpless—ashamed and helpless. THERAPIST: How old do you feel when you’re in touch

with this part of yourself? BARBARA: I feel young, very young. Therapist: Do you want to call that part “Ashamed Lit-

tle Barbara” [Vulnerable Child mode with associated EMSs of Defectiveness, Dependence/Incompetence, and Enmeshment/Undeveloped Self]?

BARBARA: Sure. THERAPIST: OK. And now this other part—the one

that is agreeing with your husband and calling your- self ridiculous . . .

BARBARA: Well, I am ridiculous and silly. I can’t cope with anything.

THERAPIST: Before you agree with that part, I want you to just notice how that part sounds. How does that part sound to you? Does it sound critical?

BARBARA: Yes, but I deserve it. I’m so useless. THERAPIST: It sounds like you are having a hard time

just listening to that part without automatically agreeing with it?

BARBARA: Yeah, I guess that’s true. THERAPIST: So, what do you want to call that part? BARBARA: I don’t know. . . . But . . . you’re not going to

tell me what to call it, are you? THERAPIST: Right. BARBARA: OK. I guess “the Critic” [Punitive Parent

mode with associated EMSs of Defectiveness and Subjugation].

In this part of the session, the therapist has helped Barbara begin to recognize and label the modes: the De- tached Protector as “the Escapist,” the Punitive Parent

as “the Critic,” and the Vulnerable Child as “Ashamed Little Barbara.” Although not fully illustrated here, the therapist also used a similar sequence of questions to help Barbara identify other modes. From this portion of the session, it is clear that “the Critic” (Punitive Parent mode) is generating a tremendous amount of negative affect in Barbara. Barbara’s only apparent way to cope with the onslaught of punitive statements from this mode is “the Escapist” (Detached Protector mode), in which she sleeps away much of her life. Otherwise, Bar- bara’s primary experience of herself rests with “Ashamed Little Barbara” (the Vulnerable Child mode), where she feels defective, useless, hopeless, and helpless.

Step 2: Explore Origins of Modes in Childhood and/or Adolescence

This section illustrates how the therapist helps Barbara recognize the origins of these modes. In addition, the therapist assesses the strength of her Healthy Parent mode.

THERAPIST: Does “the Critic” sound like anyone else you know or have known in your life?

BARBARA: Yes, it sounds like George. THERAPIST: Anyone else? BARBARA: Yeah, it also sounds like my dad . . . just like

my dad. THERAPIST: In what way? BARBARA: My dad used to talk like that to me  .  .  .

whenever I tried to get his attention. THERAPIST: How old were you? BARBARA: Young, very young . . . 3 or 4 . . . as far back

as I remember. THERAPIST: Can you close your eyes and try to let

yourself feel like that young child again with your dad?

BARBARA: (Closes her eyes.) THERAPIST: Tell me what’s happening. BARBARA: He’s yelling at me because I pulled on his

coat jacket. THERAPIST: Let me hear what he’s saying to you. BARBARA: “Stop it, you little pest. You’re such a simple-

ton. Can’t you find anything better to do than pull on my coat? Get out of here!”

300 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

THERAPIST: And how are you feeling as he is yelling these things at you?

BARBARA: I feel stupid, like I’m a jerk. I’m nothing—a useless pest, an annoyance.

THERAPIST: Does it feel like he’s right, or are you angry at him?

BARBARA: No. I don’t feel angry. I just feel bad (starts to cry)—I’m just bad.

THERAPIST: So there is part of you agreeing with him, punishing yourself—like your dad—thinking you’re bad.

BARBARA: Yeah. THERAPIST: And where is your mom? BARBARA: She’s telling me to shush and leave him

alone. She says he’s tired from working so hard all day.

THERAPIST: And what are you thinking and feeling when she says this?

BARBARA: I’m thinking that I’m a terrible person. THERAPIST: So, you’re getting the message that you are

the problem from both of your parents. It feels like both parents are saying you deserve this harsh treat- ment, and there is a part of you that believes them— you deserve to be punished because you’ve bothered your father. Is that right?

BARBARA: Yes, that’s right. THERAPIST: So there is also this punishing part of you,

this part that accepts that message from your par- ents—this punitive message that you’re bad and a problem, a pest.

BARBARA: Yes. THERAPIST: What is your mom doing? BARBARA: After a while, she takes me out. She sees I’m

sad and wants me to feel better. She tries to make me feel better by giving me something, like a toy, or something to eat. A lot of times she takes me out shopping and buys me something special.

THERAPIST: And how do you feel when she does this? BARBARA: I feel a little better while we are out . . . but

later, I feel bad. I still feel shame because I’m so bad and useless.

THERAPIST: So there is still the “Ashamed Little Bar- bara” underneath?

BARBARA: Yes. That is it.

THERAPIST: If you could have rewritten the script for your family, a family with ideal parents, what would you have happen?

BARBARA: I have no idea. They weren’t bad. They were doing their best.

THERAPIST: Yes, but what if you had had a daddy who was excited to see you at the end of his work day . . . a daddy who enjoyed coming home to his family . . . who found pleasure in talking with you and getting to know you, and played with you?

BARBARA: You mean . . . a daddy who loved me? THERAPIST: Yes. I mean a daddy who was able to show

you his love through all sorts of actions. BARBARA: Wow . . . that would have been so different. THERAPIST: Do you feel any angry feelings at him now

as you think about how he spoke to you—this very young child simply trying to get his attention?

BARBARA: No, I was in his way. He worked hard. I had to leave him alone.

THERAPIST: What you just said—does that sound like anyone you know?

BARBARA: Yes. It sounds like my mother. THERAPIST: And what do you think of that now? BARBARA: Well. She was just trying to keep the peace

and fill in for him. THERAPIST: But what about you, this sweet innocent

little child simply wanting what all children want— love and attention from her father?

BARBARA: It’s sad. I feel sad for me. THERAPIST: Right. It is sad for you. You are a child

doing what all children do—children try to get their parents’ attention; children want to know they are loved, valued, appreciated. You were no different from any other child, but what is happening here?

BARBARA: (Cries.) THERAPIST: No one’s calling your dad on his horrible

behavior toward you. Everyone’s accommodating him and speaking to you as if you are the problem, when all that you are doing is what every young child does. And yet your father and your mother are re- sponding as if you are the problem.

BARBARA: Yeah. You’re right. Why did they do that? THERAPIST: Do you think there was something wrong

Cognitive Therapy for Depression 301

with you, or do you think there was something wrong with the way they were behaving with you?

BARBARA: The way they were behaving with me. .  .  . It’s a problem with the way they treated me.

THERAPIST: Right. They are the ones who should feel shame about their behavior. There was nothing shameful about you or your behavior.

In the preceding section, the therapist helps Barbara to realize the origin of “the Critic,” the part of herself that has accepted her “Punitive Parent” message that she was the problem. The therapist’s questions and comments also help Barbara realize that the problem was actually her parents’ behavior toward her rather than an inherent defect in herself.

The therapist now turns Barbara’s attention to the origin of “the Escapist” mode—the part that was seek- ing relief from these terrible feelings about herself as a child. The therapist also helps Barbara become more aware that “the Escapist” was only able to provide short- term relief.

THERAPIST: Now when you had this bad feeling about yourself as a child, the “Ashamed Little Barbara” feeling, how did you cope with that feeling? What did you do?

BARBARA: A lot of the time, I did nothing. I just sat on my bed in my room daydreaming, wishing ev- erything could be different. I would fantasize being a star, a beautiful person that everyone adored. Peo- ple would dote on me and give me expensive gifts and clothes that made me look even more beautiful. Sometimes when my mom would take me out and buy me things, it kind of felt like she was making this dream come true.

THERAPIST: Is that “the Escapist” part of you trying to help you feel better?

BARBARA: Yes, it definitely is. THERAPIST: And then what would happen? BARBARA: I would feel better, especially as I got older

and I got a lot of attention from the way I looked, but eventually my dad always would start yelling again. I remember him yelling at my mom for “spending too much money” simply to turn me into “a pretty Bimbo.”

THERAPIST: So the efforts to feel better eventually backfired.

BARBARA: Right. I never felt very good for long. I never felt good inside.

Step 3: Link Current Problems and Symptoms to Maladaptive Modes

In this section, the therapist asks Barbara questions that help her to recognize how these modes that developed in childhood are still operating in the present. Barbara begins to connect these modes with why she is feeling so depressed, and she begins to see the repetitive pat- terns in her life.

THERAPIST: Let’s look at what is happening now in your life. Do you recognize any relationship between what we have been talking about—these different parts of you—and how you are thinking and feeling about yourself and coping with your life now?

BARBARA: Yeah, I’m still trying to feel good—or just not feel—by being “the Escapist.” When I go on these shopping sprees and let my mom and my friends dress me up, it still doesn’t work any better than it ever did. And sleeping all the time doesn’t work either.

THERAPIST: What do you mean? BARBARA: Well, I only feel good for a short while.

Then, instead of my dad coming home, now I’m coming home to George or he’s coming home to me. George is just as mean and unavailable as my dad.

THERAPIST: And then what happens? BARBARA: I start to feel really bad again, really de-

pressed. I feel like I’m not worth spending time with, like I’m boring and useless. I’m saying all sorts of bad things about myself, and I agree with every- thing George says about me. I’m my worst “Critic.” In the end, I still feel like the same old “Ashamed Little Barbara” inside who never ever really feels bet- ter. Then, I just want to go to sleep to get away from it all. I’m finally starting to see it more clearly, going around and around the same old circle—nothing has changed and nothing changes. I’ve been miserable my whole life.

THERAPIST: But there is one very important change. BARBARA: What is that? THERAPIST: You’re starting to see and understand

what’s been happening for a long time instead of just being on the treadmill without any awareness.

302 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Step 4: Uncover Advantages and Disadvantages of Each Mode

The therapist now begins to ask Barbara questions re- garding the advantages and disadvantages of listening and acting on these different parts of herself. This helps Barbara to gain more distance from the modes and in- creases her awareness of a choice in how she responds.

THERAPIST: When these different parts of yourself or modes developed, they served a purpose. Why don’t we talk about each of them and explore their advan- tages and disadvantages, both in the past and pres- ent? Let’s start with “the Escapist.”

BARBARA: Well, that part lets me feel good—or at least not feel bad.

THERAPIST: For how long? BARBARA: For a while. THERAPIST: And in the long run? Does that part help

you feel better? BARBARA: No, not really. I can’t really escape feeling

bad. I can’t say I feel any better in the long run. THERAPIST: So, is there any advantage to this part of

you—“the Escapist”? BARBARA: I’m mixed about it. THERAPIST: Sure. I can understand that. If you don’t

know of any other way to feel better, any relief is bet- ter than no relief at all.

BARBARA: Yeah. THERAPIST: But sometimes it’s good to let yourself feel

bad, because when you let yourself stay in touch with your feelings, you often can begin to recognize what feels better in the long run . . . like finding activities that are truly interesting to you, or that give you a sense of accomplishment and purpose, or that bring out a feeling of deep enjoyment.

BARBARA: That makes sense, but I have no idea how to find those things.

THERAPIST: Well, that is something we can work on together.

BARBARA: That sounds good. THERAPIST: And what about “the Critic”? Is there any

advantage to listening to “the Critic”? BARBARA: That part tells me what’s wrong with me. THERAPIST: And what does “the Critic” say is wrong

with you?

BARBARA: That I’m stupid and silly, useless and an- noying.

THERAPIST: Do you think “the Critic” is right? BARBARA: Of course. THERAPIST: But if you put the words of “the Critic”

back in your dad’s mouth and listen to him speak to little 3-year-old Barbara as she excitedly greets him coming home from work, what do you think?

BARBARA: When you put it that way, I think he’s a jerk. I mean, what does he think he is doing to this poor little girl? What’s wrong with him?

THERAPIST: Right. So is there any advantage to listen- ing to these critical words?

BARBARA: No . . . no, definitely not. THERAPIST: Are there any disadvantages of listening to

“the Critic”? BARBARA: Yes. It’s getting clearer now why that part is

making me feel so bad. I have to stop listening to that part. When I accept what my dad said as the truth, I feel bad, really bad, about myself.

THERAPIST: You mean it brings up that “Ashamed Lit- tle Barbara” feeling?

BARBARA: Yes. THERAPIST: And what about her? What does she need? BARBARA: She needs to feel good about herself. She

needs to hear good things about herself. She needs someone to listen to her and pay attention to her—to love her.

THERAPIST: I agree.

Step 5: Use Imagery to Access the Vulnerable Child Mode

The therapist now begins to engage Barbara in the Vul- nerable Child mode. By accessing this mode, therapist and patient can begin to work on the core schemas that are part of “Ashamed Little Barbara.”

THERAPIST: I know it’s sometimes unpleasant to let yourself be in touch with “Ashamed Little Barbara,” but would you be willing to go there, so that we can get to know that part of you to find out what you need to truly feel better and to find out what is get- ting in the way?

BARBARA: I guess . . . (Closes her eyes.)

Cognitive Therapy for Depression 303

THERAPIST: Tell me what you are feeling and thinking right now.

BARBARA: It’s the same old feelings—I feel bad  .  .  . and useless. (Visibly begins to look upset, then opens her eyes.)

THERAPIST: Can you go back there to “Ashamed Little Barbara,” can you let yourself feel her?

BARBARA: OK. (Closes her eyes again.) THERAPIST: Where are you? What are you doing? BARBARA: I’m sitting on my bed in my room. My

daddy just told me to go away. THERAPIST: And how are you feeling? BARBARA: Awful. THERAPIST: And what do you want? BARBARA: I want my mommy to come in and make

me feel better. THERAPIST: Where is she? BARBARA: She’s in her room, lying on her bed. She

doesn’t feel good either. THERAPIST: If you could bring in a healthy mommy to

be with you right now, what would she say to you? Let me hear her speak to Little Barbara.

BARBARA: “You know he’s just tired from work. If you just leave him alone, everything will be all right.”

THERAPIST: Let me hear what Little Barbara thinks about this?

BARBARA: That doesn’t help much. I still feel upset and bad.

THERAPIST: How about if I come in to help? BARBARA: OK. THERAPIST: You are such a loving little girl. So many

fathers would relish coming home to such a greeting from their little girl. Something is wrong with your daddy. Why doesn’t he recognize that you’re offering him something that is precious—so special? . . . How does little Barbara feel as she hears this?

BARBARA: Better. THERAPIST: Let me talk to your father now. BARBARA: OK. THERAPIST: “How can you speak to your daughter that

way? She’s done nothing but welcome you home with joy and love. And look at how you are responding. Your response to her is completely inappropriate. You are so closed off and removed from everything.

What is going on with you? Why can’t you see that you have a beautiful, creative, and loving daughter? Barbara does not deserve this type of treatment. I’m not going to stand for this and let you hurt her any- more.” . . . How does little Barbara feel as she hears this?

BARBARA: A lot better. I wish my mom had spoken to my dad that way. But you know, if you really tried to say anything like that to him, he wouldn’t listen. He never listened to my mom. He’d probably just say something mean to you and then shut the door.

THERAPIST: OK. Well if that happened, what would you want to happen next?

BARBARA: I don’t know. THERAPIST: Let me step in again and say this to him

through the door. “Whether or not you choose to listen, there is a limit, a limit as to how long we will stay here for you. If you choose not to be here for us, we will not stay here for you.”

BARBARA: I don’t think he’ll change. THERAPIST: Then you and I, together, will leave him

and create a better life. BARBARA: Is that really possible? THERAPIST: Do you want to make it happen? BARBARA: Yes, but what about him? He’ll be so lonely. THERAPIST: Who will be lonely? BARBARA: He will, unless we stay. THERAPIST: But if you stay, who will be lonely then? BARBARA: Me. THERAPIST: Do you want to continue to be there for

someone who chooses not to be there for you? BARBARA: Well, no—no, that isn’t right. THERAPIST: So what do you want to do? BARBARA: I want to leave.

In this part of the session, the therapist has taken on the “Healthy Parent” mode for Barbara, because she does not have a strong template for this mode. This is one example of what is meant by “limited reparenting.” In this role, the therapist temporarily steps in to support the client in relation to unmet basic needs for safety; stability or predictability; love, nurturance, and atten- tion; acceptance and praise; empathy; realistic limits; and validation of feelings and needs. The therapist also counters and challenges any unreasonable messages

304 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

or beliefs that such needs should remain unfulfilled. As she begins to feel safer and more protected by the “Healthy Parent” through this work, “Little Barbara” no longer feels so ashamed of herself.

Step 6: Conduct Dialogues between Modes

Once patients begin to internalize the Healthy Parent mode demonstrated by the therapist, their own Healthy Adult mode becomes stronger. The patient’s Healthy Adult mode can now actively challenge and combat the Punitive Parent mode, thereby supporting, protecting, and healing the Vulnerable Child, with the help of the therapist.

The therapist now addresses the Escapist, or De- tached Protector, mode. In the segment that follows, the therapist sets up a dialogue between the Vulnerable Child and Escapist modes.

THERAPIST: How about having “Little Barbara” talk with “the Escapist” about things that she really en- joys?

BARBARA: OK . . . but how do we do that? THERAPIST: First, I want you to sit on this side of the

couch. When you’re on this side of the couch, I want you to let yourself get in touch with and speak for “Little Barbara.” Have “Little Barbara” talk about all those things that interest her—those things that interest and excite her and help her feel alive. And then, I want you to get up and sit on the other side of the couch. When you’re on this side of the couch, I want you to let yourself get in touch with and speak for “the Escapist.” We’ll go back and forth between those two parts of yourself to see what comes out. I’ll help out “Little Barbara” if she needs me.

BARBARA: [as “Little Barbara”] You know, I once made a dress at school, and I noticed that I really liked sew- ing. It was a really simple pattern, nothing special, but I had so much fun making it. I think I might want to take a class to try sewing again.

[as “the Escapist”] Why do you want to do that? If it doesn’t turn out, you’ll just feel bad about yourself. People might think you’re ridiculous at this age, try- ing to learn to sew. Why take the chance that you’ll feel bad or stupid? Why don’t you just lie down and forget about it?

[as “Little Barbara”] But I might like it. If I don’t start trying the things that I think I might enjoy, I’ll never

know what I like or what makes me happy. . . . If I keep listening to you, I’ll do nothing but sleep away the rest of my life. I want to have a life.

[as “the Escapist”] I don’t know if it’s worth the risk of feeling bad.

[as “Little Barbara”] Even if I feel bad at first, it will only be temporary. Either I’ll get good at sewing or I can find something else that I’m good at. I’ll eventu- ally find something if I just keep at it.

[as “the Escapist”] Well OK, suit yourself. [as “Little Barbara”] I will.

At this point, the therapist is focused on helping Bar- bara discover what gives her an inner sense of joy and accomplishment. This task is difficult for Barbara, be- cause she spent so many of her early years dependent on her mother, not developing any special skills or talents, and surrendering to what others wanted her to be. Nev- ertheless, as the previous segment illustrates, Barbara has begun to recognize the importance of trying out new activities that interest her, in spite of the temporary discomfort she may feel about the possibility of failing and feeling stupid again. The final step in therapy is to take these lessons she has learned in the sessions and integrate them into her everyday life experiences.

Step 7: Generalize Results from Mode Work to Real Life

Barbara decided to enroll in one sewing class and sur- prised herself by doing quite well. She then decided to take two more classes—a more advanced sewing class and a course in costume design. Following these classes, she started to volunteer for a local theater group, work- ing on costumes. Barbara received much attention, praise, and appreciation from her teachers and theater friends. At this point in treatment, Barbara commented to her therapist, “You know, I think this is the first time I have ever really felt good and proud of myself.”

As Barbara’s confidence and her network of friends grew, she became less accepting and less tolerant of George’s neglectful and demeaning behaviors toward her. She also became increasingly annoyed with her mother’s pattern of excusing George’s behavior for the sake of “being financially comfortable.” This was in stark contrast to Barbara’s unquestioning acceptance of her relationship with George at the beginning of treat- ment.

As she began to see parallels between how she felt with George and how she felt as a child with her parents,

Cognitive Therapy for Depression 305

Barbara began to question whether this was a healthy marriage for her. She recognized that many of George’s behaviors were damaging to her, just as her parents’ behaviors had been. Although Barbara still wanted to adopt a child, she began questioning George’s ability to be a good parent.

The following vignette from a later session in Bar- bara’s treatment illustrates how much healthier and as- sertive she has become in relation to George:

BARBARA: I’m noticing that when George speaks to me in such a condescending tone, I feel like a little girl with my father again. I don’t want this. I want to be treated with love and respect, and as an equal. It isn’t right for me to accept his behavior—being ignored and demeaned by someone who is supposed to love me.

THERAPIST: So what do you want to do? BARBARA: I think I’m ready to confront George about

his drinking and abusive behavior. I can’t even imag- ine adopting a child and bringing that child into our home if he continues to behave this way.

THERAPIST: What do you want to happen? BARBARA: I want him to stop drinking and start treat-

ing me with love and respect. THERAPIST: And if he doesn’t? Then what? BARBARA: I guess I’ll leave him and seek a divorce. THERAPIST: And how will that be for you—in the

worst case scenario you might imagine? BARBARA: In the worst case  .  .  . you know, I think

I’ll be OK. I mean, I have my own life now. I have my own friends. And I have you, if things really get rough.

THERAPIST: I’ll be here for you whenever you need my support.

BARBARA: Yeah, I think I’ll be OK.

At this point in treatment, Barbara has fully incorpo- rated the Healthy Adult mode and has healed the most damaging schemas that had been part of her Vulner- able Child mode. Along with these changes, Barbara’s depression went into full remission. Soon after this ses- sion, Barbara confronted her husband. Despite couple therapy, George refused to make any changes, and Bar- bara filed for divorce.

Barbara did experience one relapse of major depres- sion as her divorce was finalized. “Ashamed Little Bar-

bara” and “the Escapist” temporarily returned during this period. Barbara, however, was able to recognize the reappearance of the Punitive Parent mode and suc- cessfully overcame it with her now stronger Healthy Adult mode. She was able to empathize with and for- give herself, and to mourn the lost opportunity to have her own family. She decided to go back to school and succeeded in becoming a certified teacher at the high school level, teaching costume design and drama in the theater department. She also developed a lasting relationship with a caring, emotionally available man who shared her passion for theater. Barbara’s chronic depression lifted, and she has, for the most part, been symptom free since.

CONCLUSION

Evidence demonstrating the efficacy of cognitive ther- apy in the treatment of unipolar and bipolar depression continues to mount. Adolescents, adults, and geriatric patients have all been shown to benefit from cognitive therapy.

Cognitive therapy helps patients understand the relationships among their thoughts, behaviors, and feelings. Cognitions are “put to the test” by examin- ing evidence, setting up in vivo experiments, weighing advantages and disadvantages, trying graded tasks, and employing other intervention strategies. Through this process, patients begin to view themselves and their problems more realistically, to feel better, to change their maladaptive behavior patterns, and to take steps to solve real-life difficulties. These changes take place as a direct result of carefully planned, self-help homework assignments—one of the hallmarks of cognitive treat- ment. Cognitive therapy reduces symptoms by helping patients to identify and modify automatic thoughts, and the behaviors associated with them.

An expansion of cognitive therapy called schema therapy (ST) has been developed to deal with the deep- er psychological structures that predispose patients to chronic depression. After utilizing interventions aimed at initial symptom reduction, a great deal of subsequent attention and effort are directed toward identifying and modifying the underlying schemas and modes that often predispose individuals to chronic depression.

Following a thorough assessment, an extensive change component is implemented. During this phase of treatment, patients come to understand their own schemas and modes, their developmental origins, and

306 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

how these dysfunctional schema patterns are triggered, reinforced, and maintained.

Throughout the treatment, cognitive therapists maintain a collaborative alliance with their patients. They are very active in structuring sessions, yet go to considerable lengths to help patients reach conclusions on their own. Cognitive therapists serve as guides, help- ing patients maneuver through a labyrinth of dysfunc- tional cognitions and life patterns. As a result, patients develop the psychological tools they need to become more proactive in making the cognitive, affective, in- terpersonal, and behavioral changes that serve to mini- mize future episodes of depression.

NOTES

1. Some researchers have found it useful to differentiate be- tween relapse (the return of symptoms within 6 months after termination of treatment) and recurrence (a whole new epi- sode of depression, occurring at least 12 months after treat- ment has ended; Gelder, 1994; see also Overholser, 1998). However, this distinction has not been uniformly incorpo- rated into the literature.

2. Reported relapse rates for patients treated with medication have varied depending on the definition of relapse, the dura- tion of the follow-up period, and the severity of depression within the patient population (Williams, 1997). Because of these differences, some of the estimates have ranged from 34 to 92% (Frank, 1996; Overholser, 1998; Versiani, 1998; Williams, 1997), though lower rates have also been reported (Keller & Boland, 1998).

3. The book by Young (1990/1999) cited here and throughout the chapter, Cognitive Therapy for Personality Disorders: A Schema-Focused Approach, refers to the third edition. How- ever, the ideas expressed were developed in 1990, for the original edition. Similarly, the Young Schema Question- naire was developed in 1990, then reprinted in the third edi- tion.

4. Currently, the concept of a schema domain is not a com- ponent of schema theory. Although early factor-analytic re- search supported the grouping of 18 EMSs into five broader domains, later studies have been inconsistent regarding how schemas cluster together, and some domains have not been supported at all. Nevertheless, we have included research studies that focus on these five domains, because the find- ings do shed light on the relationship between schemas and other constructs. We are in the process of reviewing all of the research available so that we can reexamine the question of how schemas cluster together.

5. For the remainder of the chapter, we use the term schemas to refer specifically to Young’s “early maladaptive schemas.”

6. Many cognitive therapists also focus on “underlying as- sumptions,” which represent cognitions that are “deeper” than automatic thoughts but less central than schemas or core beliefs. Underlying assumptions are considered condi- tional beliefs, whereas most schemas are unconditional. In our own work, we have not found this distinction to be nec- essary in working with most patients. Thus, conditional and unconditional beliefs that are enduring and pervasive can be merged into the broader construct of a schema.

REFERENCES

Albon, J. S., & Jones, E. E. (2003). Validity of controlled clinical trials of psychotherapy: Findings from the NIMH Treatment of Depression Collaborative Research Program. American Journal of Psychiatry, 159(5), 775–783.

American Psychiatric Association. (2000). Diagnostic and sta- tistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

Antonuccio, D. O., Danton, W. G., & DeNelsky, G. Y. (1995). Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Profes- sional Psychology: Research and Practice, 26(6), 574–585.

Antonuccio, D. O., Thomas, M., & Danton, W. G. (1997). A cost-effectiveness analysis of cognitive behavior therapy and fluoxetine (Prozac) in the treatment of depression. Be- havior Therapy, 28, 187–210.

Arnow, B. A., Manber, R., Blasey, C., Klein, D. N., Blalock, J. A., Markowitz, J. C., et al. (2003). Therapeutic reac- tance as a predictor of outcome in the treatment of chronic depression. Journal of Consulting and Clinical Psychology, 71(6), 1025–1035.

Ball, J. R., Mitchell, P. B., Corry, J. C., Skillecorn, A., Smith, M., & Malhi, G. S. (2006). A randomized controlled trial  of cognitive therapy for bipolar disorder: Focus on long-term change. Journal of Clinical Psychiatry, 67, 277– 286.

Barber, J. P., & DeRubeis, R. J. (1989). On second thought: Where the action is in cognitive therapy for depression. Cognitive Therapy and Research, 13(5), 441–457.

Barlow, D. H., & Hofmann, S. G. (1997). Efficacy and dis- semination of psychological treatments. In D. M. Clark & C. G. Fairburn (Eds.), Science and practice of cognitive behaviour therapy (pp. 95–117). Oxford, UK: Oxford Uni- versity Press.

Barnhofer, T., Crane, C., Hargus, E., Amarasinghe, M., Winer, R., & Williams, J. M. (2009). Mindfulness-based cognitive therapy as a treatment for chronic depression: A preliminary study, Behaviour Research and Therapy, 47(5), 366–373.

Basco, M. R., & Rush, A. J. (1996). Cognitive-behavioral ther- apy for bipolar disorder. New York: Guilford Press.

Baumeister, H., Reichler, L., Munzinger, M., & Lin, J. (2014). The impact of guidance on Internet-based mental

Cognitive Therapy for Depression 307

health interventions—A systematic review. Internet Inter- ventions, 1(4), 205–215.

Beck, A. T. (1967). Depression: Causes and treatment. Phila- delphia: University of Pennsylvania Press.

Beck, A. T. (1976). Cognitive therapy and the emotional disor- ders. New York: International Universities Press.

Beck, A. T. (1988). Love is never enough. New York: Harper & Row.

Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press.

Beck, A. T., Freeman, A., & Associates. (1990). Cognitive therapy of personality disorders. New York: Guilford Press.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.

Beck, J. S. (2021). Cognitive behavior therapy: Basics and be- yond (3rd ed.). New York: Guilford Press.

Bellino, S., Zizza, M., Rinaldi, C., & Bogetto, F. (2007). Combined therapy of major depression with concomitant borderline personality disorder: Comparison of interper- sonal and cognitive psychotherapy. Canadian Journal of Psychiatry, 52(11), 718–725.

Berndt, E. R., Koran, L. M., Finkelstein, S. N., Gelenberg, A. J., Kornstein, S. G., Miller, I. M., et al. (2000). Lost human capital from early-onset chronic depression. Ameri- can Journal of Psychiatry, 157, 940–947.

Biesheuvel-Leliefeld, K. E. M., Kok, G. D., Bockting, C. L. H., Cuijpers, P., Hollon, S. D., van Marwijk, H. W. J., et al. (2015). Effectiveness of psychological interventions in preventing recurrence of depressive disorder: Meta-analy- sis and meta-regression. Journal of Affective Disorders, 174, 400–410.

Biggs, M. M., & Rush, A. J. (1999). Cognitive and behavioral therapies alone or combined with antidepressant medi- cation in the treatment of depression. In D. S. Janowsky (Ed.), Psychotherapy indications and outcomes (pp.  121– 172). Washington, DC: American Psychiatric Press.

Blackburn, I. M., Bishop, S., Glen, A. I. M., Whalley, L. J., & Christie, J. E. (1981). The efficacy of cognitive therapy in depression: A treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. British Journal of Psychiatry, 139, 181–189.

Bockting, C. L. H., Schene, A. H., Spinhoven, P., Koeter, M. W. J., Wouters, L. F., Huyser, J., et al. (2005). Preventing relapse/recurrence in recurrent depression with cognitive therapy: A randomized controlled trial. Journal of Consult- ing and Clinical Psychology, 73, 647–657.

Bockting, C. L. H., Smid, N. H., Koeter, M. W. J., Spin- hoven, P., Beck, A. T., & Schene, A. H. (2015). Enduring effects of preventive cognitive therapy in adults remitted from recurrent depression: A 10 year follow-up of a ran- domized controlled trial. Journal of Affective Disorders, 185, 188–194.

Boschloo, L., Bekhuis, E., Weitz, E. S., Reijnders, M., De- Rubeis, R. J., Dimidjian, S., et al. (2019). The symptom- specific efficacy of antidepressant medication vs. cognitive

behavioral therapy in the treatment of depression: Results from an individual patient meta-analysis. World Psychia- try, 18(2), 183–191.

Bowers, W. A. (1990). Treatment of depressed in-patients: Cognitive therapy plus medication, and medication alone. British Journal of Psychiatry, 156, 73–58.

Burns, D. D., & Spangler, D. L. (2000). Does psychotherapy homework lead to improvements in depression in cogni- tive-behavioral therapy or does improvement lead to in- creased homework compliance? Journal of Consulting and Clinical Psychology, 68(1), 46–56.

Calvete, E., Orue, I., & González-Diez, Z. (2013). An exami- nation of the structure and stability of early maladaptive schemas by means of the Young Schema Questionnaire–3. European Journal of Psychological Assessment, 29(4), 283– 290.

Calvete, E., Orue, I., & Hankin, B. L. (2015). A longitudinal test of the vulnerability–stress model with early maladap- tive schemas for depressive and social anxiety symptoms in adolescents. Journal of Psychopathology and Behavioral Assessment, 37(1), 85–99.

Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes, A. M. (1996). Predicting the effect of cogni- tive therapy for depression: A study of unique and com- mon factors. Journal of Consulting and Clinical Psychology, 64(3), 497–504.

Castonguay, L. G., Schut, A. J., Aikens, D., Constantino, M. J., Laurenceau, J. P., Bolough, L., et al. (2004). Integrative cognitive therapy: A preliminary investigation. Journal of Psychotherapy Integration, 14(1), 4–20.

Centers for Disease Control and Prevention. (2010). Cur- rent depression among adults—United States, 2006 and 2008. Morbidity and Mortality Weekly Report, 59(38), 1229–1235.

Chapman, D. P., Perry, G. S., & Strine, T. W. (2005). The vital link between chronic disease and depressive disor- ders. Preventing Chronic Disease, 2(1), Article A14.

Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J., & Anda, R. F. (2004). Adverse childhood experiences and the risk of depressive disorders in adult- hood. Journal of Affective Disorders, 82(2), 217–225.

Chiang, K.-J., Tsai, J.-C., Liu, D., Lin, C.-H., Chiu, H.-L., & Chou, K.-R. (2017). Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-anala- ysis of randomized controlled trials. PLoS ONE, 12(5), e0176849.

Clark, D. A., & Beck, A. T. (2010). Cognitive therapy of anxiety disorders: Science and practice. New York: Guilford Press.

Cohen, S., O’Leary, K. D., & Foran, H. (2010). A random- ized clinical trial of a brief, problem-focused couple thera- py for depression. Behavior Therapy, 41(4), 433–446.

Cong, E., Li, Y., Shao, C., Chen, J., Wu, W., Shang, X., et al. (2012). Childhood sexual abuse and the risk of recurrent major depression in Chinese women. Psychological Medi- cine, 42, 409–417.

308 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

Connolly, K. R., & Thase, M. E. (2012). Emerging drugs for major depressive disorder. Expert Opinion on Emerging Drugs, 17(1), 105–126.

Conte, H. R., Plutchik, R., Wild, K. V., & Karasu, T. B. (1986). Combined psychotherapy and pharmacotherapy for depression. Archives of General Psychiatry, 43, 471–479.

Cowpertwait, L., & Clarke, D. (2013). Effectiveness of web- based psychological interventions for depression: A meta- analysis. International Journal of Mental Health and Addic- tion, 11, 247–268.

Craighead, W. E., Miklowitz, D. J., Vajk, F. C., & Frank, E. (1998). Psychological treatments for bipolar disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (pp.  240–248). New York: Oxford University Press.

Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Klei- boer, A., & Dobson, K. S. (2013). A meta-analysis of cog- nitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian Journal of Psychiatry, 58(7), 376–385.

Cuijpers, P., Clignet, F., van Meijel., B., van Straten, A., Li, J., & Andersson, G. (2011). Psychological treatment of depression in inpatients: A systematic review and meta- analysis. Clinical Psychology Review, 31, 535–360.

Cuijpers, P., van Straten, A., & Warmerdam, L. (2008). Are individual and group treatments equally effective in the treatment of depression in adults?: A meta-analysis. Euro- pean Journal of Psychiatry, 22(1), 38–51.

Dammen, T., Papageorgiou, C., & Wells, A. (2015). An open trial of group metacognitive therapy for depression in Nor- way. Nordic Journal of Psychiatry, 69(2), 126–131.

de Oliveira, I. R. (1998). The treatment of unipolar major depression: Pharmacotherapy, cognitive behaviour therapy or both? Journal of Clinical Pharmacy and Therapeutics, 23, 467–475.

DeRubeis, R. J., & Feeley, M. (1990). Determinants of change in cognitive therapy for depression. Cognitive Therapy and Research, 14(5), 469–482.

DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., et al. (2005). Cogni- tive therapy vs. medications in the treatment of moder- ate to severe depression. Archives of General Psychiatry, 62, 409–416.

DeRubeis, R. J., Hollon, S. D., Grove, W. M., Evans, M. D., Garvey, M. J., & Tuason, V. B. (1990). How does cognitive therapy work?: Cognitive change and symptom change in cognitive therapy and pharmacotherapy for depression. Journal of Consulting and Clinical Psychology, 58(6), 862– 869.

Dobson, K. S. (2016). New frontiers in cognitive-behavioral therapy for depression. International Journal of Cognitive Therapy, 9(2), 107–123.

Dobson, K. S., Hollon, S. D., Dimidjian, S., Schmaling, K. B., Kohlenberg, R. J., Gallon, R., et al. (2008). Random-

ized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of Consulting and Clinical Psychology, 76(3), 468–477.

Dobson, K. S., & Pusch, D. (1993). Towards a definition of the conceptual and empirical boundaries of cognitive therapy. Australian Psychologist, 28(3), 137–144.

Dougherty, L. R., Klein, D. N., & Davila, J. (2004). A growth curve analysis of the course of dysthymic disorder: The effects of chronic stress and moderation by adverse parent–child relationships and family history. Journal of Consulting and Clinical Psychology, 72(6), 1012–1021.

Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Wil- liamson, D. F., & Giles, W. H. (2001). Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: Findings from the adverse child- hood experiences study. Journal of the American Medical Association, 286, 3089–3096.

Dunlop, B. W., LoParo, D., Kinkead, B., Mletzko-Crowe, T., Cole, S., Nemeroff, C. B., et al. (2019). Benefits of sequen- tially adding cognitive-behavioral therapy or antidepres- sant medication for adults with nonremitting depression. American Journal of Psychiatry, 176(4), 275–286.

Eberhart, N. K., Auerbach, R. P., Bigda-Peyton, J., & Abela, J. R. Z. (2011). Maladaptive schemas and depression: Tests of stress generation and diathesis–stress models. Journal of Social and Clinical Psychology, 30(1), 75–104.

Eells, T. D., Barrett, M. S., Wright, J. H., & Thase, M. (2014). Computer-assisted cognitive-behavior therapy for depression. Psychotherapy, 51(2), 191–197.

Eifert, G. H., Beach, B. K., & Wilson, P. H. (1998). Depres- sion: Behavioral principles and implications for treatment and relapse prevention. In J. J. Plaud & G. H. Eifers (Eds.), From behavior theory to behavior therapy (pp. 68–97). Bos- ton: Allyn & Bacon.

Eisendrath, S., Chartier, M., & McLane, M. (2011). Adapt- ing mindfulness-based cognitive therapy for treatment-re- sistant depression: A clinical case study. Cognitive Behav- ioral Practice, 18(3), 362–370.

Elkin, I., Gibbons, R. D., Shea, M. T., & Shaw, B. F. (1996). Science is not a trial (but it can sometimes be a tribula- tion). Journal of Consulting and Clinical Psychology, 64(1), 92–103.

Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., et al. (1989). National Institute of Mental Health Treatment of Depression Collaborative Research Program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971–982.

Evans, M. D., Hollon, S. D., DeRubeis, R. J., Piaseki, J. M., Grove, W. M., Garvey, M. J., et al. (1992). Differential relapse following cognitive therapy and pharmacotherapy for depression. In D. S. Janowsky (Ed.), Psychotherapy in- dication and outcomes (pp.  802–808). Washington, DC: American Psychiatric Press.

Cognitive Therapy for Depression 309

Farrell, J., & Shaw, I. A. (2012). Group schema therapy for bor- derline personality disorder: A step-by-step treatment manual with patient workbook. Malden, MA: Wiley-Blackwell.

Farrell, J., Shaw, I. A., & Webber, M. (2009). A schema- focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized con- trol trial. Journal of Behavior Therapy and Experimental Psychiatry, 40, 317–328.

Fava, G. A., Rafanelli, C., Grandi, S., Canestrari, R., & Mor- phy, M. A. (1998a). Six-year outcome for cognitive behav- ioral treatment of residual symptoms in major depression. American Journal of Psychiatry, 155(10), 1443–1445.

Fava, G. A., Rafanelli, C., Grandi, S., Conti, S., & Belluardo, P. (1998b). Prevention of recurrent depression with cogni- tive behavioral therapy: Preliminary findings. Archives of General Psychiatry, 55(9), 816–820.

Feldman, G., Harley, R., Kerrigan, M., Jacobo, M., & Fava, M. (2009). Change in emotional processing during a dia- lectical behavior therapy-based skills group for major de- pressive disorder. Behaviour Research and Therapy, 47(4), 316–321.

Feng, C. Y., Chu, H., Chen, C. H., Chang, Y. S., Chen, T. H. Chou, Y. H., et al. (2012). The effect of cognitive behav- ioral group therapy for depression: A meta-analysis 2000– 2010. Worldviews Evidence Based Nursing, 9(1), 2–17.

Forte, A., Baldessarini, R. J., Tondo, L., Vásquez, G. H., Pompili, M., & Girardi, P. (2015). Long-term morbidity in bipolar-I, bipolar-II, and unipolar major depressive dis- orders. Journal of Affective Disorders, 178, 71–78.

Fournier, J. C., De Rubeis, R. J., Shelton, R. C., Gallop, R., Amsterdam, J. D., & Hollon, S. D. (2008). Antidepressant medications versus cognitive therapy in depressed patients with or without personality disorder. British Journal of Psy- chiatry, 192(2), 124–129.

Fox, M. G., & Sokol, L. (2011). Think confidence, be confident for teens: A cognitive therapy guide to overcoming self-doubt and creating unshakable self-esteem. Oakland, CA: New Harbinger.

Francis, J. L., & Kumar, A. (2013). Psychological treatment of late-life depression. Psychiatric Clinics of North America, 36(4), 561–575.

Frank, E. (1996). Long-term treatment of depression: Inter- personal psychotherapy with and without medication. In C. Mundt & M. J. Goldstein (Eds.), Interpersonal factors in the origin and course of affective disorders (pp. 303–315). London: Gaskell/Royal College of Psychiatrists.

Franklin, G., Carson, A. J., & Welch, K. A. (2016). Cogni- tive behavioural therapy for depression: Systematic review of imaging studies. Acta Neuropsychiatrica, 28(2), 61–74.

Free, M. L., Oei, T. P. S., & Appleton, C. (1998). Biological and psychological processes in recovery from depression during cognitive therapy. Journal of Behavior Therapy and Experimental Psychiatry, 29, 213–226.

Freeman, A., & Davison, M. R. (1997). Short-term therapy

for the long-term patient. In L. Vandecreek, S. Knapp, & T. L. Jackson (Eds.), Innovations in clinical practice: A source book (pp. 5–24). Sarasota, FL: Professional Resource Press.

Friedman, M. A., Detweiler-Bedell, J. B., Leventhal, H. E., Horne, R., Keitner, G. I., & Miller, I. W. (2004). Com- bined psychotherapy and pharmacotherapy for the treat- ment of major depressive disorder. Clinical Psychology: Sci- ence and Practice, 11, 47–68.

Friedrich, M. (2017). Depression is the leading cause of dis- ability around the world. Journal of the American Medical Association, 317(15), 1517.

Futterman, A., Thompson, L., Gallagher-Thompson, D., & Ferris, R. (1995). Depression in later life: Epidemiology, assessment, etiology, and treatment. In E. E. Beckham & W. R. Leber (Eds.), Handbook of depression (2nd ed., pp. 494–525). New York: Guilford Press.

Garyfallos, G., Adarnopoulo, A., Karastergiou, A., Voikli, M., Sotiropoulo, A., Donias, S., et al. (1999). Personality disorders in dysthymia and major depression. Acta Psychi- atrica Scandinavica, 99(5), 332–340.

GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. (2018). Global, regional, and national in- cidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet, 392, 1789–1858.

Geddes, J. R., Carney, S. M., Davies, C., Furukawa, T. A., Kupfer, D. J., Frank, E., et al. (2003). Relapse prevention with antidepressant drug treatment in depressive disor- ders: A systematic review. Lancet, 361, 653–661.

Gelder, M. G. (1994). Cognitive therapy for depression. In H. Hippius & C. N. Stefanis (Eds.), Research in mood dis- orders: An update (Vol. 1, pp. 115–124). Göttingen, Ger- many: Hogrefe & Huber.

Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T., et al. (2006). Outpatient psychotherapy for borderline personality disorder: A ran- domized trial of schema-focused therapy vs. transference- focused therapy. Archives of General Psychiatry, 63, 649– 658.

Gilson, M., Freeman, A. M., Yates, J., & Freeman, S. M. (2009). Overcoming depression: A cognitive therapy approach (2nd ed.). New York: Oxford University Press.

Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49, 59–72.

Halvorsen, M., Wang, C. E., Eisemann, M., & Waterloo, K. (2010). Dysfunctional attitudes and early maladaptive schemas as predictors of depression: A 9-year follow-up study. Cognitive Therapy Research, 34, 368–379.

Halvorsen, M., Wang, C. F., Richter, J., Myrland, I., Peder- sen, S. K., Eisemann, M., et al. (2009). Early maladaptive

310 CliniCAl HAnDbook of PsyCHologiCAl DisorDers

schemas, temperament and character traits in clinically depressed and previously depressed subjects. Clinical Psy- chology and Psychotherapy, 16(5), 394–407.

Hardeveld, F., Spijker, J., de Graaf, R., Nolen, W. A., & Beek- man, A. T. F. (2010). Prevalence and predictors of recur- rence of major depressive disorder in the adult population. Acta Psychiatrica Scandinavia, 122, 184–191.