Avoiding Treatment Failures in the Anxiety Disorders (eBook)

Michael W. Otto, Ph.D., Professor of Psychology, Boston University.  Dr. Otto specializes in the cognitive-behavioral treatment of anxiety, mood, and substance use disorders, and has developed clinical-research programs for the treatment of panic disorder, posttraumatic stress disorder, social phobia, bipolar disorder, psychotic disorders, substance dependence, and medication discontinuation in patients with panic disorder. Dr. Otto's research activities are closely tied to his clinical interests and target investigations of the etiology and treatment of anxiety, mood, and substance-use disorders. Of particular interest to Dr. Otto is the development and testing of new treatments, including the combination of pharmacologic and cognitive-behavioral strategies for treatment-refractory and substance abusing patients, and the modification of treatment packages for novel populations (e.g., Cambodian refugees). He has published over 200 articles, book chapters, and books spanning these research interests. Dr. Otto is President-Elect for the Association for Advancement of Behavior Therapy, a fellow of the American Psychological Association, and a member of the Scientific Advisory Board for the Anxiety Disorders Association of America. He also serves as a section editor for Cognitive and Behavioral Practice, and on the editorial boards of Anxiety, Behavior Research and Therapy, Clinical Psychology: Science and Practice, Journal of Anxiety Disorders, Journal Watch in Psychiatry, and Psychotherapy and Psychosomatics. Dr. Otto is a regular provider of continuing education and continuing medical education workshops across the United States and abroad. Stefan G. Hofmann, Ph.D., is professor of psychology at Boston University. He was born in Germany and lives with his wife and two children in Boston, Massachusetts. He is an expert on anxiety disorders. His scientific work has been supported by grants from the National Institute of Mental Health and various private foundations. His research focuses on the mechanisms of treatment change and the effects of emotion regulation strategies on psychological well-being. He is the former editor for Cognitive and Behavioral Practice, and associate editor for Cognitive Behavioral Therapy, the International Journal of Psychology, and the International Journal of Cognitive Therapy. He has published more than 150 scientific papers and 6 books, including including "Cognitive Behavioral Therapy for Social Anxiety Disorder: Evidence-Based and Disorder-Specific Treatment Techniques," "From Social Anxiety to Social Phobia: Multiple Perspectives," "Treating Chronic and Severe Mental Disorders: A Handbook of Empirically Supported Treatments," and "The Art and Science of Psychotherapy." He also works as a psychotherapist using Cognitive Behavioral Therapy.

Preface 6
Contents 7
Contributors 9
Part I General Aspects of Treatment Complications 12
Introduction 13
References 15
A Case Formulation Approach to Resolve Treatment Complications 16
Using Cognitive Behavioral Case Formulation to Resolve Treatment Complications 17
Problem List 17
Five-Axis DSM Diagnoses 19
Primary Diagnosis 20
Nomothetic Formulation 21
Individualize the Formulation 23
Hypotheses About the Basis of Mechanisms Maintaining the Disorder 24
Precipitants of Illness 26
Using Different Modalities of Case Formulation to Resolve Treatment Complications 28
Using Case Formulation to Decide to Add or Change Treatment Strategies 30
Treatment Complication 1: Lack of Motivation or Difficulty with Follow-Through 31
Treatment Complication 2: Interpersonal Problems 32
Treatment Complication 3: Emotion Regulation Difficulties 32
Treatment Complication 4: Difficulties with Relaxation and Acceptance 33
Treatment Complication 5: Information Processing Biases and Rigid Thinking 34
Treatment Complication 6: Low Self-Efficacy and Losing Treatment Gains 35
Conclusion 35
References 36
Helping Exposure Succeed: Learning Theory Perspectives on Treatment Resistance and Relapse 40
Exposure Is New Learning 40
Context Effects 43
Safety Behaviors 46
Considering Exposure Parameters 49
Exposure Duration and Spacing 49
Distribution of Sessions 50
Stimulus Properties (Imaginal, In Vivo, Virtual Reality) 51
Gradation of Exposure 51
Fear Activation 52
Focus of Attention and Behavior During Extinction 52
Concluding Comments 53
References 54
Therapeutic Alliance and Common Factors in Treatment 59
The Concept of Therapeutic Alliance 60
Empirical Support for the Therapeutic Alliance 60
Motivation for Treatment 63
Role Expectancies 64
Outcome Expectancies 65
Empirical Support for Patient Expectancies 65
Changing Expectancies 67
Post-treatment Expectancies: Attributions About Treatment Gains 67
Treatment Adherence 69
Summary and Conclusions 70
References 70
Combined Cognitive Behavioral and Pharmacologic Treatment Strategies: Current Status and Future Directions 75
The Efficacy of Cognitive-Behavioral and Pharmacological Treatments 75
The Efficacy of Acute-Phase Combined Treatments 76
Outcomes After Treatment Discontinuation 78
Possible Mechanisms of Relapse Following Discontinuation of Combined Treatments 79
Starting CBT as a Strategy for Discontinuation of Pharmacotherapy 80
Starting CBT when Pharmacotherapy Fails 81
Starting Pharmacotherapy when CBT Fails 81
Clinical Considerations 81
Novel Combination Strategies 84
References 85
Cultural Considerations and Treatment Complications 90
Introduction 90
Prevalence of Psychological Disorders Among Ethnic and Racial Minorities 91
Culture and Treatment Complications 93
Culture and Treatment Resistance 93
Culture and Language 95
Culture and Idioms of Distress 96
Resolving Treatment Complications 98
Culturally Appropriate Psychological Assessment 98
Culturally Appropriate Treatment Adaptations 99
Conclusion 103
References 103
Part II Avoiding Treatment Failures: Disorder-Specific Perspectives 108
Avoiding Treatment Failures in Panic Disorder 109
Core Elements of Treatment 111
Non-essential Elements of Treatment 113
Format of Treatment 114
Treatment Example Interoceptive Exposure 114
Efficacy of CBT Treatment 117
Depression Comorbidity and Treatment Resistance 118
Comorbid Anxiety Disorders and Treatment Resistance 119
Alcohol and Substance Use and Treatment Resistance 120
Personality Disorders and Treatment Resistance 121
Medical Factors 122
Life Stressors 122
Addressing Inadequate Treatment Response 122
Other Psychosocial Treatments 125
Medication Treatments 125
Conclusions 126
References 126
Avoiding Treatment Failures in Obsessive Compulsive Disorder 131
The Case of Maria: Only a Horrible Mother Would Have These Thoughts 131
Overview of Obsessive-Compulsive Disorder 132
Comorbidities 133
Diagnostic Challenges 134
Treatment for OCD 136
Overview of CBT Strategies 136
Treatment Response 138
Predictors of Treatment Non-response 139
Challenges in Treatment Delivery for OCD 141
Future Developments 145
References 146
Avoiding Treatment Failures in PTSD 152
Introduction 153
Core Components of PTSD Treatment 154
Challenges Clinicians May Encounter when Implementing CBT for PTSD 155
Using the Case Formulation Approach to Guide Treatment 157
Case Formulation 158
Strategies and Tools for Troubleshooting 159
Handling Multiple Trauma Memories 159
The Influence of Other Emotions: Sadness, Guilt, Shame, and Anger 161
Sadness 161
Shame and Guilt 162
Anger 163
Overcoming Guilt, Shame, and Anger 163
Facilitating Affect Regulation 164
Working Through Psychosocial Crises 165
Substance Use Disorders 166
Titrating Engagement with Emotions During Exposure Therapy 167
Summary 169
References 169
Avoiding Treatment Failures in Social Anxiety Disorder 174
The Case of Paul 174
Psychosocial History 174
Diagnostic Information 175
Case Conceptualization 175
Psychological Interventions 177
Potential Predictors of Poor Treatment Response 180
Generalized Subtype and Avoidant Personality Disorder 180
Depression 181
Social Skills 181
Core Elements of Treatment and Common Sticking-Points in Therapy 181
Motivation for Therapy 182
Challenging Cognitive Errors 183
Eliminating Avoidance Behaviors 184
Flexibility for Dealing with Challenging Cases 185
Summary 186
References 186
Avoiding Treatment Failures in Generalized Anxiety Disorder 190
Resolving Treatment Complications in Generalized Anxiety Disorder 190
Predictors of Response to Treatment 191
Theoretical Conceptualization of Worry 192
Self-Monitoring 194
Relaxation Training 196
Self-Control Desensitization 198
Stimulus Control 198
Cognitive Therapy 199
Interpersonal and Emotional Processing 204
Future Directions 208
References 210
Avoiding Treatment Failures in Specific Phobias 214
Treatment Complications in Specific Phobias 214
The Origin of Specific Phobias 215
Differential Diagnosis and Comorbidity 216
Gold Standard for Therapy: Exposure 217
Efficacy of Exposure 217
Core Elements of CBT 219
Cognitive Preparation or Psychoeducation 219
Exposure to Fear Cues 220
A Case Example: Treating Spider Phobia 220
Factors that May Interfere with Exposure Success 221
Treatment Engagement 221
Duration of Exposure 221
Multiple Phobias 222
When Other Unpleasant Emotions/Sensations Come into Play 222
When Skill Deficits Accompany the Phobia 223
When Anticipation Is Worse than Exposure 224
When Patients Use Cognitive Avoidance During Exposure 224
Vigilance to Threat 225
When Self-Report Is Not Predictive of Emotional Processing 225
Enhancing Memory of Success 226
Conclusion 226
References 227
Part III Treatment Complications in Special Populations 233
Resolving Treatment Complications Associated with Comorbid Depression 234
The Impact of Comorbid Depression on Treatment for Anxiety 234
The Impact of Comorbid Depression 235
Impact of Comorbid Depression on Anxiety Treatment Outcome 236
Panic Disorder 236
Social Anxiety Disorder 237
OCD 238
PTSD 239
Conclusions from the Treatment Outcome Literature 239
Impact of CBT for Anxiety Disorders on Depression Symptoms 240
Treatment Considerations for Comorbid Anxiety and Depression 242
Box 1 Case Examples 243
Box 2 Using Exposure Principles to Target Maladaptive Beliefs 246
Concluding Comments 247
References 248
Resolving Treatment Complications Associated with the Presence of Comorbid Personality Disorders 253
The Nature of Personality Disorders 254
Comorbidity of Personality Disorders and Anxiety Disorders 256
Complications Associated with the Presence of a Comorbid Personality Disorder 258
Resolving Treatment Complications 260
Conclusion 266
References 267
Resolving Treatment Complications Associated with Comorbid Anxiety and Substance Use Disorders 272
Link Between Anxiety Disorders and Substance Use Disorders 273
Recommendations from Assessment through Treatment 274
Assessment Issues 275
Temporal and Functional Relationship Between Anxiety Disorders and SUDs 275
Specificity Across Disorder Categories 276
Selection of Assessment Measures 277
Treatment 280
Willingness to Change 280
Issues to Consider in Combining Stand-Alone Treatments for Anxiety Disorders and SUDs 282
Specialized Integrative Treatments 283
Case Illustrations 285
References 287
Resolving Treatment Complications Associated with Comorbid Eating Disorders 292
Introduction 292
Likelihood of Encountering Anxiety Patients with Co-occurring EDs 292
Assessment of EDs in Anxiety Patients 295
Overview of Empirically Supported and Promising Treatments for EDs 299
CBT-BN and CBT-E 300
Commonly Used CBT Strategies for Treating EDs and General Treatment Issues 301
Other ED Treatments with Empirical Support 303
Using the Case Formulation Approach to Guide Treatment Planning for Anxiety Patients with Comorbid EDs 304
OCD Case Example 304
Case Description 304
Case Formulation 306
Treatment Plan 308
Social Phobia Case Example 309
Case Description 309
Treatment Plan 312
Ordering of Treatment: Factors to Consider 312
Conclusion 314
References 314
Resolving Treatment Complications Associated with Comorbid Medical Conditions 318
Introduction 318
Anxiety Comorbid with Cancer 320
Cancer-Related Symptoms, Treatment Side Effects, and Quality of Life 322
Psychological Interventions for Anxiety Comorbid with Cancer 323
Complications in Treating Anxiety Comorbid with Cancer 323
Resolving Treatment Complications for Anxiety Comorbid with Cancer 324
Anxiety Comorbid with Coronary Heart Disease 326
Anxiety as Risk Factor for Coronary Heart Disease 327
Persistent Effects of Anxiety and Quality of Life in Patients with Coronary Heart Disease 328
Psychological Interventions for Anxiety Comorbid with Coronary Heart Disease 328
Complications in Treating Anxiety Comorbid with Coronary Heart Disease 329
Resolving Treatment Complications for Anxiety Comorbid with Coronary Heart Disease 330
Anxiety Comorbid with Asthma 332
Hypotheses for Comorbidity Between Asthma and Anxiety Disorders 333
Effect of Anxiety on Quality of Life Related to Asthma 334
Psychological Interventions for Anxiety Comorbid with Asthma 335
Treatment Complications for Anxiety Comorbid with Asthma 335
Resolving Treatment Complications for Anxiety Comorbid with Asthma 336
Summary and Conclusions 337
References 338
Resolving Treatment Complications in Children and Adolescents 348
Comorbidity 349
Treating Comorbid Anxiety and Depressive Disorders 349
Prevalence 349
Patient Characteristics and Treatment Response 350
Modifications for Treating Children with Comorbid Depression 351
Case Example 352
Treating Comorbid Anxiety and Externalizing Disorders 353
Prevalence 353
Patient Characteristics and Treatment Response 354
Modifications for Treating Comorbid ADHD and ODD 355
Case Example 356
Parenting Behaviors and Parental Anxiety 358
Parenting Behavior and Child Anxiety 359
Warmth and Control 359
Parental Modeling and Communications About Threat 360
Parenting-Based Modifications and Treatment Response 361
Case Example 362
Additional Complicating Factors in Child Anxiety Treatment 364
Sociodemographic Characteristics 365
ParentChild Symptom Agreement 365
Summary and Future Directions 366
References 367
Index 372