Treating Variants and Complications in Anxiety Disorders Handbook of Treating Variants and Complications in Anxiety Disorders

Eric A. Storch Dean McKay Editors

Handbook of Treating Variants and Complications in Anxiety Disorders Handbook of Treating Variants and Complications in Anxiety Disorders

Eric A. Storch • Dean McKay Editors

Handbook of Treating Variants and Complications in Anxiety Disorders Editors Eric A. Storch Dean McKay Departments of Pediatrics and Psychiatry & Department of Psychology Behavioral Neurosciences Fordham University University of South Florida Bronx, NY, USA Tampa, FL , USA

ISBN 978-1-4614-6457-0 ISBN 978-1-4614-6458-7 (eBook) DOI 10.1007/978-1-4614-6458-7 Springer New York Heidelberg Dordrecht London

Library of Congress Control Number: 2013933719

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Springer is part of Springer Science+Business Media (www.springer.com) To my beautiful wife and children (Maya and Noah) for your endless love, faith, and support. You are my ‘best’! Eric A. Storch To my graduate school professors, who taught me the importance of evaluating the full domain of functioning and to think beyond mere diagnoses Dean McKay

Contents

Part I Overview of Complexities in Anxiety Disorders 1 Nature and Etiological Models of Anxiety Disorders ...... 3 Marie S. Nebel-Schwalm and Thompson E. Davis III 2 Prognostic Indicators of Treatment Response for Adults with Anxiety ...... 23 Amanda R. Mathew, Lance D. Chamberlain, Derek D. Szafranski, Angela H. Smith, and Peter J. Norton 3 Prognostic Indicators of Treatment Response for Children with Anxiety Disorders ...... 37 Lara J. Farrell, Allison M. Waters, Ella L. Milliner, and Thomas H. Ollendick 4 Continuing to Advance Empirically Supported Treatments: Factors in Empirically Supported Practice for Anxiety Disorders ...... 57 Colleen M. Cummings, Kendra L. Read, Douglas M. Brodman, Kelly A. O’Neil, Marianne A. Villaboe, Martina K. Gere, and Philip C. Kendall

Part II Complexities in Childhood and Adolescent Anxiety Disorders 5 Treatment of Childhood Anxiety in Autism Spectrum Disorders ...... 83 C. Enjey Lin, Jeffrey J. Wood, Eric A. Storch, and Karen M. Sze 6 Treatment of Comorbid Anxiety and Disruptive Behavior in Youth...... 97 Omar Rahman, Chelsea M. Ale, Michael L. Sulkowski, and Eric A. Storch 7 Diagnosis and Cognitive Behavioral Treatment of Anxiety Disorders in Young Children ...... 109 Klaus Minde

vii viii Contents

8 Treating Obsessive-Compulsive Disorder in the Very Young Child ...... 125 Christopher A. Flessner, Abbe Garcia, and Jennifer B. Freeman 9 Treatment of Childhood Tic Disorders with Comorbid OCD ...... 135 Martin E. Franklin, Julie Harrison, and Kristin Benavides 10 Treatment of Childhood Anxiety in the Context of Limited Cognitive Functioning ...... 149 Jill Ehrenreich-May and Cara S. Remmes 11 Special Considerations in Treating Anxiety Disorders in Adolescents ...... 163 Katharina Manassis and Pamela Wilansky-Traynor 12 Social Anxiety and Socialization Among Adolescents ...... 177 Emily A. Voelkel, Kelly M. Lee, Catherine W. Abrahamson, and Allison G. Dempsey 13 PANDAS: Immune-Related OCD ...... 193 Tanya K. Murphy and Megan Toufexis

Part III Complexities in Adult Anxiety Disorders 14 Treatment of Posttraumatic Stress Disorder and Comorbid Borderline Personality Disorder ...... 203 Melanie S. Harned 15 Treatment of Anxiety and Comorbid Cluster A Personality Disorders ...... 223 Han-Joo Lee and Jennifer E. Turkel 16 Treatment of Comorbid Depression ...... 243 Jonathan S. Abramowitz and Lauren Landy 17 Limited Motivation, Patient-Therapist Mismatch, and the Therapeutic Alliance ...... 255 Alessandro S. De Nadai and Marc S. Karver 18 Substance Abuse and Anxiety Disorders: The Case of Social Anxiety Disorder and PTSD ...... 285 Lindsay S. Ham, Kevin M. Connolly, Lauren A. Milner, David E. Lovett, and Matthew T. Feldner

Part IV Cross Developmental Complexities 19 Treatment of Comorbid Anxiety Disorders Across the Life span ...... 309 Caleb W. Lack, Heather Lehmkuhl Yardley, and Arpana Dalaya Contents ix

20 Family Conﬂict and Childhood Anxiety ...... 321 Heather L. Smith-Schrandt, Casey D. Calhoun, Marissa A. Feldman, and Eric A. Storch 21 Assessment and Treatment of Comorbid Anorexia Nervosa and ObsessiveÐCompulsive Disorder ...... 337 Adam B. Lewin, Jessie Menzel, and Michael Strober 22 Cluster C Personality Disorders and Anxiety Disorders ...... 349 Nicole M. Cain, Emily B. Ansell, and Anthony Pinto 23 Therapist Barriers to the Dissemination of Exposure Therapy ...... 363 Brett J. Deacon and Nicholas R. Farrell 24 Harnessing the Web: Internet and Self-Help Therapy for People with ObsessiveÐCompulsive Disorder and Posttraumatic Stress Disorder ...... 375 Steffen Moritz, Kiara R. Timpano, Charlotte E. Wittekind, and Christine Knaevelsrud 25 Where Do We Go from Here? How Addressing Clinical Complexities Will Result in Improved Therapeutic Outcomes ...... 399 Eric A. Storch and Dean McKay About the Editors ...... 403 Index ...... 405

Contributors

Catherine W. Abrahamson Department of Educational Psychology , University of Houston , Houston , TX , USA Jonathan S. Abramowitz , Ph.D. Department of Psychology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA Chelsea M. Ale , Ph.D. Department of Psychiatry and Psychology , Mayo Clinic , SW Rochester , MN , USA Emily B. Ansell , Ph.D. Department of Psychiatry , Yale University School of Medicine , New Haven , CT , USA Kristin Benavides University of Pennsylvania School of Medicine , Philadelphia , PA , USA Douglas M. Brodman Department of Psychology , Temple University , Philadelphia , PA , USA Nicole M. Cain , Ph.D. Department of Psychology , New York-Presbyterian Hospital, Weill Cornell Medical College , White Plains , NY , USA Department of Psychology , Long Island University — Brookville Campus, Brooklyn, NY , USA Casey D. Calhoun Department of Psychology , University of North Carolina , Chapel Hill , NC , USA Lance D. Chamberlain , M.A. Department of Psychology, University of Houston , Houston , TX , USA Kevin M. Connolly , Ph.D. G.V. (Sonny) Montgomery VAMC and University of Mississippi Medical Center , Jackson , MS , USA Colleen M. Cummings Department of Psychology , Temple University , Philadelphia , PA , USA Arpana Dalaya , B.A. Department of Psychology , University of Central Oklahoma , Edmond , OK , USA Thompson E. Davis III , Ph.D. Department of Psychology , Louisiana State University , Baton Rouge , LA , USA Alessandro S. De Nadai , M.A. Department of Psychology , University of South Florida , Tampa , FL , USA

xi xii Contributors

Brett J. Deacon , Ph.D. Department of Psychology , University of Wyoming , Laramie , WY , USA Nicholas R. Farrell , M.A. Department of Psychology , University of Wyoming, Laramie , WY , USA Allison G. Dempsey Department of Pediatrics , University of Texas Health Science Center at Houston , Houston , TX , USA Jill Ehrenreich-May , Ph.D. Department of Psychology , University of Miami , Coral Gables , FL , USA Lara J. Farrell , Ph.D. School of Applied Psychology, Grif ﬁ th Health Institute, Grifﬁ th University, Gold Coast, QLD , Australia Nicholas R. Farrell , M.A. Department of Psychology , University of Wyoming , Laramie , WY , USA Marissa A. Feldman Department of Psychology , University of South Florida , Tampa , FL , USA Matthew T. Feldner , Ph.D. Department of Psychological Science , University of Arkansas , Fayetteville , AR , USA Christopher A. Flessner , Ph.D. Rhode Island Hospital, Child and Adolescent Psychiatry, Bradley/Hasbro Children’s Research Center , Providence , RI , USA Warren Alpert School of Medicine at Brown University , Providence , RI , USA Martin E. Franklin University of Pennsylvania School of Medicine , Philadelphia , PA , USA Jennifer B. Freeman , Ph.D. Rhode Island Hospital, Child and Adolescent Psychiatry, Bradley/Hasbro Children’s Research Center , Providence , RI , USA Warren Alpert School of Medicine at Brown University , Providence , RI , USA Abbe Garcia , Ph.D. Rhode Island Hospital, Child and Adolescent Psychiatry, Bradley/Hasbro Children’s Research Center , Providence , RI , USA Warren Alpert School of Medicine at Brown University , Providence , RI , USA Martina K. Gere Center for Child and Adolescent Mental Health, Eastern and Southern Norway , Oslo , Norway Lindsay S. Ham , Ph.D. Department of Psychological Science, University of Arkansas, Fayetteville, AR, USA Melanie S. Harned , Ph.D. Department of Psychology , University of Washington , Seattle , WA , USA Julie Harrison University of Pennsylvania School of Medicine , Philadelphia , PA , USA Marc S. Karver , Ph.D. Department of Psychology , University of South Florida , Tampa , FL , USA Philip C. Kendall Department of Psychology , Temple University , Philadelphia , PA , USA Contributors xiii

Christine Knaevelsrud Clinical Psychology and Psychotherapy , Free University Berlin , Berlin , Germany Caleb W. Lack , Ph.D. Department of Psychology , University of Central Oklahoma , Edmond , OK , USA Lauren Landy , B.A. Department of Psychology , University of Colorado at Boulder , Boulder, CO , USA Kelly M. Lee Department of Educational Psychology , University of Houston , Houston , TX , USA Han-Joo Lee Department of Psychology , University of Wisconsin- Milwaukee , Milwaukee , WI , USA Adam B. Lewin , Ph.D. Department of Pediatrics , Rothman Center for Neuropsychiatry, University of South Florida College of Medicine , Child Rehabilitation and Development Center, St. Petersburg , FL , USA C. Enjey Lin , Ph.D. Departments of Education and Psychiatry and Biobehavioral Sciences, University of California , Los Angeles , CA , USA David E. Lovett , B.S. Department of Psychological Science, University of Arkansas , Fayetteville , AR , USA Katharina Manassis Department of Psychiatry, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada Amanda R. Mathew , M.A. Department of Psychology, University of Houston , Houston , TX , USA Dean McKay , Ph.D., ABPP Department of Psychology , Fordham University , New York , NY , USA Jessie Menzel , M.A. Department of Pediatrics , Rothman Center for Neuropsychiatry, University of South Florida College of Medicine , Child Rehabilitation and Development Center, St. Petersburg , FL , USA Ella L. Milliner , D.Psych (Clin) School of Applied Psychology, Grif ﬁ th Health Institute , Grif ﬁ th University, Gold Coast , QLD , Australia Lauren A. Milner , M.S. Department of Psychological Science, University of Arkansas, Fayetteville, AR, USA Klaus Minde , M.D. Department of Psychiatry and Pediatrics , McGill University , Montreal , QC , Canada Steffen Moritz Department of Psychiatry and Psychotherapy , University Medical Center in Hamburg-Eppendorf , Hamburg , Germany Tanya K. Murphy , M.D. Department of Psychiatry , University of South Florida , St. Petersburg , FL , USA Marie S. Nebel-Schwalm , Ph.D. Department of Psychology , Illinois Wesleyan University , Bloomington , IL , USA Peter J. Norton , Ph.D. Department of Psychology, University of Houston , Houston , TX , USA xiv Contributors

Kelly A. O’Neil Department of Psychology , Temple University , Philadelphia , PA , USA Thomas H. Ollendick , Ph.D. Child Study Centre, Virginia Tech University , Blacksburg , VA , USA Anthony Pinto , Ph.D. Department of Psychiatry , Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute , New York , NY , USA Omar Rahman , Ph.D. Department of Pediatrics , University of South Florida , South, St. Petersburg , FL , USA Kendra L. Read Department of Psychology , Temple University , Philadelphia , PA , USA Cara S. Remmes , B.S. Department of Psychology , University of Miami , Coral Gables , FL , USA Angela H. Smith, M.A. Department of Psychology , University of Houston , Houston , TX , USA Heather L. Smith-Schrandt Department of Psychology , University of South Florida , Tampa , FL , USA Eric A. Storch , Ph.D. Department of Pediatrics , Psychiatry, and Psychology, University of South Florida , Tampa , FL , USA Michael Strober , Ph.D. Department of Psychiatry & Biobehavioral Sciences , Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California , Los Angeles , CA , USA Michael L. Sulkowski , Ph.D. Department of Disability and Psychoeducational Studies , University of Arizona , Tucson , AZ , USA Derek D. Szafranski , M.A. Department of Psychology, University of Houston , Houston , TX , USA Karen M. Sze , Ph.D. Departments of Education and Psychiatry and Biobehavioral Sciences, University of California , Los Angeles , CA , USA Kiara R. Timpano Department of Psychology , University of Miami , Coral Gables , FL , USA Megan Toufexis , DO Department of Psychiatry , University of South Florida , St. Petersburg , FL , USA Jennifer E. Turkel Department of Psychology , University of Wisconsin-Milwaukee , Milwaukee , WI , USA Marianne A. Villaboe Center for Child and Adolescent Mental Health, Eastern and Southern Norway , Oslo , Norway Emily A. Voelkel Department of Educational Psychology , University of Houston , Houston , TX , USA Allison M. Waters , Ph.D. School of Applied Psychology, Grif ﬁ th Health Institute, Grif ﬁ th University , Mt Gravatt , QLD , Australia Contributors xv

Charlotte E. Wittekind Department of Psychiatry and Psychotherapy , University Medical Center in Hamburg-Eppendorf , Hamburg , Germany Pamela Wilansky-Traynor Ontario Shores Centre for Mental Health Sciences, University of Toronto, Toronto , ON , Canada Jeffrey J. Wood , Ph.D. Departments of Education and Psychiatry and Biobehavioral Sciences, University of California , Los Angeles , CA , USA Heather Lehmkuhl Yardley , Ph.D. Nationwide Children’s Hospital , Columbus , OH , USA Part I Overview of Complexities in Anxiety Disorders Nature and Etiological Models of Anxiety Disorders 1

Marie S. Nebel-Schwalm and Thompson E. Davis III

The nature of anxiety is both familiar and complex. Anxiety has been de fi ned as “the tense antici- It is a common human experience that has served pation of a threatening but vague event; a feeling adaptive and protective purposes in our evolu- of uneasy suspense” (Rachman, 1998 , p. 2) and as tion as a species. Yet, the consequences, and the “future-oriented mood state” when one makes even the presentation, of anxiety can differ dras- preparations to deal with potentially aversive situ- tically. On the one hand, anxiety can serve a use- ations (Barlow, 2002 , p. 64). The closely related ful and adaptive purpose by keeping one from concept of fear is sometimes used synonymously harm. If one is looking over the Grand Canyon, with anxiety, but researchers have pointed to dis- it behooves the individual to be anxious enough tinctions between them. Fear is defi ned as “an to stay several feet back from the edge. In this emotional reaction to a speci fi c perceived danger” way, anxious feelings prompt us to be cautious, (Rachman, 1998 , pp. 2–3) and as a “primitive and this can protect us. However, anxiety can alarm in response to present danger” (Barlow, also be problematic—usually when it is experi- 2002 , p. 104). The key distinctions between enced in greater proportions than a situation anxiety and fear are the orientation with regard typically calls for or experienced in situations in to a threat (i.e., in the future or in the present) which there is no identi fi able harm or danger. and whether the trigger is ambiguous or speci fi c. For example, experiencing intense sensations of A third related concept is worry. Whereas anxiety trepidation, anxiety, and fear every time one has and fear are considered emotional responses, to leave the house may be cause to suspect the worry can be understood as a primarily verbal presence of a clinical disorder. It is these thought process (rather than imagery-based) that instances in which anxiety is maladaptive that is centered on potential negative outcomes are problematic and cause for concern—typi- (Borkovec, Ray, & Stober, 1998 ) . Lang (1968 ) cally when there is anxiety of unusual intensity included worry as one of three core systems of the or anxiety that is particularly interfering in one’s fear response: cognitive (e.g., thoughts and worry), ability to live a productive life. behavioral (e.g., avoiding situations and seeking safety), and physiological (e.g., arousal and muscle tension). Because fear and anxiety refer to mood states (and worry is a negative cognitive M. S. Nebel-Schwalm , Ph.D. (*) rumination), theories typically address the etiol- Department of Psychology , Illinois Wesleyan University , ogy of fear and anxiety, and worry is treated as a 1312 Park Street , Bloomington , IL 61701 , USA e-mail: [email protected] potential symptom of these mood states. When anxiety and fear are suffi ciently intense T. E. Davis III , Ph.D. Department of Psychology , Louisiana State University , and interfering to the point of becoming a clini- Baton Rouge , LA , USA cal disorder, there is usually cause for concern.

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 3 DOI 10.1007/978-1-4614-6458-7_1, © Springer Science+Business Media New York 2013 4 M.S. Nebel-Schwalm and T.E. Davis III

There are nine main anxiety disorders according (Rachman, 1998 ) . The acquisition of fear or to the Diagnostic and Statistical Manual of anxiety by way of classical conditioning refers to Mental Disorders Fourth Edition Text Revision anxiety or fear being associated with a stimulus ( DSM - IV - TR ; APA, 2000 ) : separation anxiety or situation based on direct experience (e.g., disorder (SAD) (most commonly a childhood someone who was bitten by a dog develops a onset), panic disorder, agoraphobia, specifi c phobia of dogs). This notion was famously docu- phobia, social phobia, obsessive–compulsive dis- mented by Watson and Rayner’s work with an order (OCD), posttraumatic stress disorder infant (1920/ 2000 ) . After initially demonstrating (PTSD), acute stress disorder, and generalized that an 11-month-old boy, Little Albert, did not anxiety disorder (GAD). Understanding the fear rats, Watson and Rayner classically condi- nature and causes of impairing levels of fear and tioned a fear in him by pairing exposure to the rat anxiety can lead to better treatments and out- with a loud noise. This resulted in a newly devel- comes for those who are suffering. Toward this oped fear response by Albert when presented end, etiological theories for anxiety and fear will with a rat. Results of this experiment described be discussed followed by a review of each of the Albert as crying and trying to leave when shown main disorders individually (e.g., nosology, age a rat, in direct contrast to his early reactions of onset, prevalence rates, and course). before going through the conditioning. An important contribution to this understanding of anxiety and fear maintenance was Mowrer’s Etiology two-factor theory of learning ( 1951 ) . Although classical conditioning is involved with fear acqui- Several theories have attempted to explain why sition, operant conditioning (i.e., speci fi cally people develop anxiety symptoms and disorders. negative reinforcement) is also thought to main- Typically, these theories have variously empha- tain the anxiety. In other words, while the initial sized the infl uence of four pathways: direct learn- fear response to a stimulus may have its origins in ing (i.e., classical conditioning), indirect learning classical conditioning, it is the individual’s desire (i.e., modeling and negative information transmis- to alleviate or avoid fearful sensations that per- sion), a biological preparedness pathway, and a petuates the fear (i.e., avoiding leads to a reduc- non-associative pathway that presumes no condition in uncomfortable sensations which is thought tioning experiences (Coelho & Purkis, 2009) . The to reinforce the avoidance response). Decades of latter model has received considerable debate (e.g., research, however, have indicated several limita- see Poulton & Menzies, 2002 and subsequent tions with this theory. For example, a classical commentaries). Many theories feature one primary conditioning model has dif fi culty explaining situ- mechanism or factor; however, the current consen- ations where people are exposed to a distressing sus favors integrating explanations to address the event (e.g., a snake bite) but do not develop a combined infl uence of multiple factors (e.g., phobia. Conversely, there are instances of people Barlow’s triple vulnerabilities theory, 2002, and who develop extreme anxiety and/or fear without Mineka and Zinbarg’s contemporary learning the- experiencing an aversive event. Additionally, if ory, 2006) . The following is a review of these com- over time one is negatively reinforced for avoid- ponents, including cognitive and biological ing the feared stimulus, why does extinction not theories, followed by a brief introduction to sev- occur and the fear dissipate? Additional compo- eral key theories in the fi eld of anxiety etiology. nents involved in the creation and maintenance of fear and anxiety were obviously missing. The basis for these missing components would Classical Conditioning be found in additional theory and research on cognition and the nature of the cues being pre- The role of learning is emphasized in the fi rst three sented to the individual as well as additional vari- theories: classical conditioning, observational ables affecting the situation. For example, increasingly learning, and negative information transfer many of the cues associated with anxiety disorders 1 Nature and Etiology of Anxiety 5

(and especially panic disorder) were understood although initially not fearful of a snake, can learn to incorporate interoceptive and exteroceptive to behave fearfully after observing their wild- cues (Bouton, Mineka, & Barlow, 2001 ) . raised parents’ reactions to a real or toy snake Moreover, theorists began to integrate cognitive (Mineka, Davidson, Cook, & Keir, 1984 ) . science with classical conditioning leading to the Interestingly, lab-raised monkeys can also learn hypothesis that thoughts themselves could even not to fear, despite observing a fearful monkey serve as conditioned stimuli and trigger panic (Mineka & Cook, 1986 ) . In that study, three (Bouton et al.). The deceptively straightforward groups of monkeys were given the same amount notion of a “simple” classical conditioning expla- of exposure across six sessions. Group 1 watched nation has become increasingly complex as there a non-fearful monkey behave calmly with snakes, are problems with de fi ning and determining the group 2 interacted calmly with snakes, and group role of the actual conditioned stimulus (e.g., con- 3 watched a non-fearful monkey behave calmly ditioned stimuli can trigger a response, modulate with neutral stimuli. All three groups then other responses, or even be impacted by other watched six sessions of a monkey behaving fear- variables themselves; Bouton et al.). As a result, fully with snakes. When later placed directly with more integrated theories (discussed later) have snakes, monkeys from group 1 showed come to accentuate, detail, and expand on the signifi cantly fewer signs of fear acquisition as basic concept of classically conditioned anxiety compared to the other groups. This phenomenon and phobia. is referred to as latent inhibition and is a component of the integrated theory proposed by Mineka and Zinbarg (2006 ) that is reviewed later in this Observational Learning section. Clearly, there are interesting implications for Fears can also be learned vicariously through prevention from these results. Thus, providing a observational learning—observing the actions positive model (as shown in Mineka & Cook, and outcomes of others. Bandura demonstrated 1986) can buffer the effects of later negative observational learning of aggressive behaviors by models. However, it is not clear why the group of children who watched an adult act aggressively monkeys who had calm exposure prior to watch- (Bandura, Ross, & Ross, 1963 ) . More recently, ing the fearful interactions did not also benefi t the modeling of anxiety was examined in a study from this experience. Perhaps it is because group on parental modeling with 25 parent–child dyads 1 shared the observation modality across both (Burnstein & Ginsburg, 2010 ) . Dyads were ran- sessions (watching a non-fearful and then a fear- domly assigned to either an anxious or non-anxious ful monkey) whereas group 2 personally experi- condition. Parents in the anxious condition were enced snakes and then observed a fearful monkey. trained to make anxious statements about an The idea that previous exposure can create resil- upcoming spelling test for their child (e.g., “this ience is similarly re fl ected in the concept of stress test looks way too hard,” “I don’t think you can inoculation. However stress inoculation pre- do this”) and to pace around the room. Parents in sumes that the experience of mildly distressing the non-anxious condition were instructed to events can buffer severe reactions to more aver- make statements such as, “I think you can do well sive events that occur later (Lyons, Parker, Katz, on this test” and to look about the room. After & Schatzberg, 2009 ) . seeing their parents behave in these manners, the children took a spelling test. The groups did not differ in spelling performance, but self-reported Negative Information Transfer anxiety levels were signi fi cantly higher among children in the anxious group. A third etiological in fl uence on anxiety and fear Animal research has also demonstrated this has come to be called negative information trans- effect. Experimental research with rhesus mon- fer—the idea that one can learn to be anxious by keys has shown that laboratory-raised monkeys, hearing others talking negatively (or anxiously) 6 M.S. Nebel-Schwalm and T.E. Davis III about a subject. Support for this theory has often snakes, spiders, and angry faces) were more easily used retrospective reporting (see King, Gullone, conditioned and less likely to be extinguished & Ollendick, 1998 ) ; however, other observational than non-fear-relevant stimuli (e.g., fl owers, tri- and experimental methodologies have also dem- angles, and happy faces; McNally, 1987 ) . More onstrated this effect. When observing comments recent studies have also found evidence for bio- parents made to their children at a playground, logical preparedness. This was demonstrated in parents of anxious children were more likely to observational learning studies where lab-reared say “be careful” and “don’t climb too high” than rhesus monkeys showed faster fear acquisition to parents of non-anxious children (Beidel & Turner, snakes and crocodiles as compared to fl owers and 1998 ) . Further, the infl uence of family discus- rabbits, even when controlling for the intensity of sions was demonstrated in experiments that used fear that was displayed by the observed monkey ambiguous vignettes (Barrett, Rapee, Dadds, & (Mineka & Ohman, 2002a ) . This theory presumes Ryan, 1996) . First, by themselves, children were the individual has had a conditioning event (which asked to answer questions to situations such as distinguishes it from the non-associative account what would you do if you found some kids play- that is discussed later). It also proposes that fears ing a “great game?” Then, they were asked to and phobias of modern dangerous stimuli (e.g., answer the same question in a room with their guns and moving vehicles) are signi fi cantly less parents. Finally, they were asked to talk it over common than, for example, spiders, snakes, and with their parents and indicate their answer one heights because the modern stimuli have not had last time. Even when anxious children initially enough time (evolutionarily speaking) to be natu- endorsed wanting to join in the game, after the rally selected as being fear inducing. family discussion, they were more likely to endorse avoidance of the hypothetical situation. Experimental tests carried out with research Non-associative Theory assistants, rather than parents, has also shown the effect of negative information. A study featuring Despite support for the previous associative or a fi ctitious monster character (Field, Argyris, & learning-based theories, in some cases people do Knowles, 2001 ) and one about unfamiliar ani- not report any direct or vicarious events when dis- mals (Field & Lawson, 2003 ) demonstrated that cussing the onset of their anxiety and fear. For children hearing negative information about example, researchers studying water phobia found novel stimuli had more fearful beliefs. Further, that most people did not know how the fear started children who heard positive information were (Menzies & Clark, 1993 ) . This lack of clear etiol- less likely to be fearful of the novel stimuli than ogy that is unrelated to a learning event (i.e., an those who received no information. associative event) is sometimes called the non-associative theory, and similar to biological preparedness, it is thought to have an evolutionary basis. Biological Preparedness There is some debate about the state of this non-associative theory (see Mineka & Ohman, As classical conditioning would predict, having 2002b; Poulton & Menzies, 2002 ) , and some an aversive interaction with a stimulus can lead to have proposed a renaming of this theory to the development of a phobic response. However, “nonspeci fi c” rather than non-associative the types of stimuli that are feared do not appear (Davey, 2002 ) . While the biological and genetic to be randomly distributed. Seligman (1971 ) contributions of fear and anxiety are not disputed, stated that this nonrandom distribution of easily their role to the exclusion of associative accounts conditioned stimuli is because people are biologi- has been called into question. For example, a cally prepared to learn to fear stimuli that could great deal of retrospective research examining threaten their survival. A review of studies found the etiology of fear and anxiety has interpreted evidence that “fear-relevant” stimuli (such as “I don’t know how my fear/anxiety started” 1 Nature and Etiology of Anxiety 7 responses as support for this account. Limitations participants were exposed to the same level for to this type of interpretation, however, include 20 min. The frequency of catastrophic thoughts problems with memory recall (and the use of ret- was higher among those in the “no-control” con- rospective studies), confusion about what is dition, and these participants were more likely to included in the de fi nition of unconditioned stim- experience panic attacks (80%) compared to uli (e.g., exteroceptive and/or interoceptive stim- those in the “with-control” condition (20%). uli), and the lack of alternate explanations for current fi ndings (e.g., that implicit memory may be involved; Mineka & Ohman, 2002b ) . The Biological Theories issue is in all likelihood less one of anxiety and fear being caused by associative or non-associa- Several biological factors have been proposed to tive means, but rather an examination of how play a role in the etiology of anxiety. While there much associative experience is required for a are numerous biological aspects to anxiety and given individual given his or her unique biologi- phobia, two particular factors are important to cal and genetic predisposition (Marks, 2002 ) . discuss in the brief space available here. Current research into the genetic origins and heritability of anxiety (e.g., the results of twin studies) as Cognitive Theories well as the early temperamental foundations— especially behavioral inhibition—of anxiety and Cognitive and cognitive–behavioral theorists gen- worry have been very important. erally accept the role associative and non-associative accounts play in anxiety acquisition, but their Genetic Heritability focus is more on how one interprets and processes Family concordance rates, particularly twin studies, events (Rachman, 1998 ) . Clark’s model of panic provide evidence that having a parent with an anx- attacks (1986 ) places the appraisal of threat as the iety disorder puts one at a higher risk of developing beginning feature of the development of panic, an anxiety disorder (Beidel & Turner, 2005 ) . which is followed by physical sensations and cat- Although, rates of heritability are modest, rang- astrophic interpretations. Beck’s (1996 ) theory of ing from 30 to 40% (Hettema, Prescott, & anxiety states that activated schema prime anx- Kendler, 2001 ) . Overall, a general tendency ious beliefs and effect how information is orga- toward being anxious is implicated as opposed to nized in one’s memory. Analysis of thought a specifi c 1–1 risk of inheriting a particular disor- content can reveal information about a person’s der. For example, this general risk (vs. speci fi c emotional functioning. Individuals with depres- risk) is supported by twin studies. Namely, if one sion tend to think of loss whereas those with anxi- twin has GAD, the other is likely to have an anxiety think of harm and danger (Clark, Beck, & ety disorder, but it may be social anxiety (Hettema Brown, 1989 ) . Also, impaired cognitions have et al.; Kendler, Neale, Kessler, Heath, & Eaves, been found among those with anxiety, including 1992a ) . This general psychopathology risk was biased information-processing that selectively also found with twin studies that identi fi ed a (and hypervigilantly) perceives threat (Rapee, genetic link between anxiety disorders and Schniering, & Hudson, 2009 ) and overpredicts depression (Thapar & McGuffi n, 1997 ) . Eley and the anticipation of fear (Rachman, 1994 ) . Stevenson (1999 ) speculated that environmental An interesting test of how perceptions affect infl uences are responsible for the specifi c disor- anxious symptoms was done using CO 2 -enriched der that is expressed among those with a general air (Sanderson, Rapee, & Barlow, 1989 ) . Half of genetic predisposition. the participants were told they could control the level of CO2 when a light was lit, the other half Temperament were not given this option. In reality, participants One’s predisposition to be inhibited behaviorally and had no control over the amount of CO2 and all shy is arguably an innate aspect that is observable 8 M.S. Nebel-Schwalm and T.E. Davis III in young children. Of course, fearful behavior in general psychological vulnerability, and speci fi c children is adaptive (e.g., “stranger danger” reac- psychological vulnerability. The general biological tions); however, the persistence of this behavior vulnerability refers to ones temperament, such as into older childhood appears to comprise an behavioral inhibition, and is based in part on inhibited temperament. Commonly referred to as Gray’s (1982 ) behavioral inhibition system (BIS), behavioral inhibition, this concept has also been behavioral approach system (BAS), and the associated with anxiety proneness and anxiety fi ght/ fl ight system (FFS). Gray proposes that sensitivity (Beidel & Turner, 2005 ) . Behavioral individuals with anxiety have an overactive BIS inhibition is characterized by the tendency to in response to novel stimuli. The FFS system respond to novel situations with feelings of anxi- roughly corresponds with escape or aggressive ety, avoidant behaviors, and increased distress. reactions and is thought to be correlated with fear Some evidence suggests behavioral inhibition is and panic responses. The BAS is thought to be a speci fi c risk factor the later development of indicative of extraverted reactions and impulsiv- social anxiety disorder (Prior, Smart, Sanson, & ity. Whether a person will approach or withdraw Oberklaid, 2000 ) . The stability of behavioral from certain situations is thought to be related to inhibition may go beyond biological vulnerabil- one’s temperament, and personality traits (e.g., ity and involve parental in fl uences. As discussed introversion and extraversion) are genetically in the section on negative information transmis- determined to some degree. Estimates of the sion, parents play an important role in their chil- genetic contributions of personality traits (e.g., dren’s anxiety and fear-based beliefs and the big fi ve traits) range from 41 to 61% (Jang, behaviors. Parents who model encouragement, Livesley, & Vemon, 1996 ) . warmth, and encourage opportunities for positive The general psychological vulnerability novel interactions may help reduce feelings of includes feeling a lack of control; attributing neg- anxiety in their children (Asendorpf, 1990 ) . ative events to internal, global, and stable factors; and parenting styles (i.e., whether parents foster autonomy in a warm, sensitive, consistent, and Integrated Theories contingent manner; Suarez, Bennett, Goldstein, & Barlow, 2009 ) . For some disorders (i.e., GAD While the different pathways and in fl uential com- and depression), the two general vulnerabilities ponents said to cause and/or maintain anxiety and may suf fi ciently explain their onset (Suarez fear are extensive (only a brief overview was pre- et al.). However, other disorders require the third sented to this point), these individual variables act- dimension of a speci fi c psychological vulnerabil- ing in isolation are not generally considered to be ity. The specifi c vulnerability is referred to as the complete etiological picture. Increasingly, the “learning what is dangerous” (Barlow, 2002 , p. 279), fi eld has attempted to integrate various variables of and its content is a function of the particular anxi- interest in the development of fear and anxiety to ety disorder. These vulnerabilities can develop create a clearer picture of how associative and many ways, including through direct exposure to non-associative backgrounds, along with various a dangerous situation, having a false alarm in a other psychological variables, result in an anxiety specifi c situation (i.e., a physiological response disorder. Two such theories are brie fl y reviewed that comes to be incorrectly associated with a below, Barlow’s triple vulnerability theory and stimulus or situation), and through vicarious con- Mineka and Zinbarg’s update to traditional learn- ditioning (such as observing or being told some- ing theory and associative accounts. thing is dangerous; Suarez et al., 2009 ) . Some examples include feeling that physical sensations Triple Vulnerability Theory (Barlow, 2002 ) are alarming or dangerous (panic disorder), hav- Barlow (2002 ) includes three main vulnerabilities ing been in speci fi c situations that are dangerous in his integrative theory of anxiety etiology. They (speci fi c phobia), feeling that social situations are are general genetic (or biological) vulnerability, to be feared and avoided (social anxiety disorder), 1 Nature and Etiology of Anxiety 9 and irrationally believing thoughts have danger- (Mineka & Cook, 1986 ) . Within the theory, this ous power (OCD). illustrates the impact of prior experiences on The role of true and false alarms differs depend- learning and has potential for treatment utility in ing on the specifi c disorder. For example, panic the prevention of fears and/or anxiety. Previous disorder is said to be characterized by false alarms, experiences can also include one’s history of feel- whereas specifi c phobias are more likely to be ing mastery and control over one’s circumstances. related to true alarms. Specifi c vulnerabilities for Control can also play a role in the contextual social phobia can include a true alarm (being domain-meaning (e.g., in the moment one is expe- laughed at in a social situation) or a false alarm riencing a traumatic event, is there the perception (feeling panic when interacting socially). Some of control such as being able to escape?). Another do not experience any alarm but may think they contextual domain is the properties of the condi- lack social skills (regardless of how accurate their tioned stimulus. This may include whether the appraisal is). A key thought that is implicated in stimulus was fear-relevant or fear-irrelevant, the etiology of social phobia is “social evaluation interoceptive or exteroceptive, and the temporal is dangerous” (Barlow, 2002 , p. 462). Lastly, with proximity to stressful events. Lastly, an example regard to OCD, a specifi c psychological vulnera- of a post-conditioning variable is the infl ation bility includes the belief that some thoughts are effect. This occurs when a person experiences a “dangerous and unacceptable” (Barlow, p. 536). minor trauma that does not lead to a phobia, but later, after a more intense trauma (even if it has Contemporary Learning Theory (Mineka nothing to do with the initial mild trauma), a pho- & Zinbarg, 2006 ) bia develops. For example, a person who experi- Mineka and Zinbarg (2006 ) proposed a revision ences a minor trauma with a dog later develops a to the older, problematic associative accounts and speci fi c phobia of dogs following an intense integrated many factors in one updated, compre- trauma that was unrelated to dogs (e.g., a severe hensive learning theory. They included two car accident; Mineka & Zinbarg, 2006 ) . domains of vulnerabilities (genetic/temperament and previous learning experiences) with three contextual domains (perceptions of controllabil- The Nature and Description of Current ity and predictability, direct or vicarious condi- Anxiety Disorders tioning, and properties of the conditioned stimulus). These pathways converge on the expe- While the theories surrounding anxiety and pho- rience of an anxiety disorder, which is further bia etiology have grown and become increasingly affected by post-conditioning factors, including complex, those theories are frequently consid- unconditioned stimulus infl ation/reevaluation ered and applied broadly to a circumscribed set and the presence of inhibitory or excitatory con- of anxiety disorders. These disorders have largely ditioned stimuli. grown to represent and capture certain aspects of With regard to the development of specifi c fear or anxiety (e.g., matters of intensity or phobias, it is important to mention the phenome- degree) or the target of the emotional response. non of latent inhibition (which was previously For example, GAD encompasses problems with discussed in the “Observational Learning ” sec- broad, pervasive worry, while social phobia is tion). For example, recall the previously described limited to specifi c instances in which one is anx- study where rhesus monkeys were exposed to a ious about social interactions and being evaluated particular sequence of conditions (i.e., fi rst they by others. Given the unique characteristics and viewed a calm model interact with a snake, then a aspects of each anxiety disorder, the common fearful one). The monkeys experiencing this con- DSM -IV - TR anxiety disorder diagnoses will dition were calmer when they were subsequently briefl y be described and reviewed below (though placed directly with snakes as compared to mon- with the forthcoming DSM - 5, some revision to keys who did not initially observe the calm model these diagnoses and groups may occur). 10 M.S. Nebel-Schwalm and T.E. Davis III

Generalized Anxiety Disorder reinstating the shorter symptom duration requirement to 1 or 3 months (Andrews et al., 2010 ) . GAD’s hallmark symptom is excessive, Reasons for lowering the threshold include the uncontrollable worry over many domains (e.g., noted dif fi culty of reliably reporting symptoms work, school, health, relationships, fi nances, and as long ago as 6 months and the bene fi t of identi- politics). The worry must be pervasive and long fying and treating individuals with impairing lasting (i.e., at least 6 months). To meet criteria, symptoms earlier. one must experience at least 3 of the 6 DSM - IV - There is evidence that GAD is a chronic and TR symptoms (with the exception of children, unremitting disorder (e.g., Weisberg, 2009 ; who only need one of the following): restless- Wittchen & Hoyer, 2001 ; Woodman, Noyes, ness, easily fatigued, dif fi culty concentrating, Black, Schlosser, & Yagla, 1999 ) , although some irritability, muscle tension, and sleep disturbance studies have found evidence that most individuals (APA, 2000 , p. 476). In addition, there must be had periods of remission and recurrence, as impairment and interference in daily routines, opposed to persistent chronicity (Angst et al., work, academics, or other areas of functioning. 2009 ) . This may be due to differences between A longitudinal study using a European sample early and late onset of GAD. Early-onset GAD recorded the onset of GAD symptoms (vs. a GAD typically follows a more gradual increase in diagnosis; Angst, Gamma, Baldwin, Ajdacic- symptoms and with greater chronicity, whereas Gross, & Rossler, 2009 ) . They found the vast late-onset GAD is more likely to follow a stress- majority of individuals (75%) displayed their fi rst ful life event (Brown, 1997 ) . “GAD symptoms” before the age of 20 years, and the average age of symptom onset was 15.6 years. Studies done in the United States reported Obsessive–Compulsive Disorder on the age of onset for individuals meeting full DSM - IV criteria for GAD (Kessler, Berglund, OCD is characterized by distressing, intrusive, et al., 2005 ) . They found the median age of onset and uncontrollable thoughts (obsessions) that for GAD to be 31 years (which was the oldest cause great anxiety and often compel the person among the anxiety disorders) and the lifetime to perform certain rigidly prescribed behaviors or prevalence to be 5.7% (Kessler, Berglund, et al.). mental acts (compulsions) that are marked by The 12-month prevalence rate in the United States repetition and are not realistically related to the for GAD was 3.1% (Kessler, Chiu, Demler, distressing obsession (APA, 2000 ) . For example, Merikangas, & Walters, 2005 ) . “If I don’t touch the light switch three times When considering previous DSM versions, it exactly, something bad will happen to my fam- is notable that the impairing nature of GAD has ily.” Individuals with OCD (as opposed to those not always been appreciated (Brown, 1997 ; with a psychotic disorder, for example) are aware Persons, Mennin, & Tucker, 2001 ) . Earlier ver- that the thoughts and impulses are the result of sions of the DSM listed GAD as a condition that their internal processes, rather than external could be comorbid with other disorders, but not a in fl uences. Compulsions are commonly reported primary diagnosis. Another change across revi- to relieve anxiety, which further reinforces sions is the required duration of symptoms: pre- these behaviors. The obsessions and compulsions viously one needed to show that the symptoms are time-consuming (at least 1 h a day but can be lasted 1 month or longer; currently the require- considerably more time-consuming) and/or ment is 6 months or longer. Preliminary recom- cause signifi cant distress or impairment. Usually mendations for the upcoming DSM -5 include the individual becomes aware that the obsessions renaming GAD as generalized worry disorder, and compulsions are excessive or unreasonable; pathological worry disorder, or major worry dis- however, it is possible not to have this awareness, order to more accurately capture its distinguish- which is indicated by the “with poor insight” ing feature among the anxiety disorders and specifi er (APA). Though rare, an individual can 1 Nature and Etiology of Anxiety 11 have only obsessions or compulsions, though the fear of illness, need for exactness or symmetry, common presentation is the combination of both. and religiosity (Swedo, Rapoport, Leonard, The median age of onset for OCD is 19 years of Lenane, & Cheslow, 1989 ; Toro, Cervera, Osejo, age, its 12-month prevalence is 1.0% (Kessler, & Salamero, 1992) and the most common themes Chiu, et al., 2005 ) , and its lifetime prevalence is for adults were sexuality and aggression among the lowest of anxiety disorders (1.6%; (Rasmussen & Tsuang, 1986 ) . Kessler, Berglund, et al., 2005 ) . The onset is not Recent conceptualizations have discussed the normally distributed, however. In one study, the merits of rede fi ning OCD as a spectrum that vast majority (82%) of individuals reported the features OCD, body dysmorphic disorder, tricho- onset to be before 18 years, while the remaining tillomania, and possibly tic disorders, hypochon- 18% had adult onset (most of which were between driasis, and obsessive–compulsive personality 19 and 35 years; Pauls et al., 1995 ). disorder (Phillips et al., 2010 ) . Should such a Unfortunately, OCD can cause considerable change occur, this spectrum is recommended to impairment, including the inability to carry out be subsumed under an “anxiety and obsessive– basic day-to-day activities and functions (Barlow, compulsive spectrum disorder” category (Phillips 2002 ) , sleep disturbances, job loss, dropping out et al., p. 528). of school, and poor quality of life (Markarian Another issue is whether it is necessary to dis- et al., 2010) . The experience of intrusive thoughts tinguish between hoarding and OCD as separate that are unwanted is often very distressing to the entities (Pertusa, Frost, & Mataix-Cols, 2010 ; individual. Thoughts may include contamination, Rachman, Elliott, Shafran, & Radomsky, 2009 ) . sexual, aggressive, or religious themes (such as Confusion exists about the status of hoarding associating words with the devil; Barlow, 2002 ) . (which is not in the DSM -IV -TR , except under The course of OCD is being increasingly rec- obsessive–compulsive personality disorder). When ognized as heterogeneous. Men with OCD have comparing OCD and hoarding, hoarding occurs an earlier age of onset, a higher comorbidity with more commonly and has a higher likelihood of tic disorders, and a slightly worse prognosis, poor insight (Rachman et al.). It has been proposed whereas women’s symptoms seem to fl uctuate that, although comorbidity is possible between based on hormonal changes (e.g., menstruation OCD and hoarding, most individuals with this and postpartum; Lochner et al., 2004 ) . More so behavior represent a distinct clinical syndrome that than the other anxiety disorders, support for OCD should receive its own diagnostic label of “hoard- as a genetically based disorder has been strong ing disorder” (Pertusa et al., 2010 , p. 1012). (Nicolini, Arnold, Nestadt, Lanzagorta, & Kennedy, 2009 ) , with reports as high as a 6.2- fold risk of OCD among fi rst-degree relatives Posttraumatic Stress Disorder (Grabe et al., 2006 ) . Research is underway to understand specifi cally what is transmitted (i.e., The current diagnostic criteria for PTSD include speci fi c genetic markers and nongenetic attri- four main criterion groups and specify that symp- butes; Rector, Cassin, Richter, & Burroughs, toms must have persisted longer than 1 month 2009 ) . Some fi ndings have shown fi rst-degree ( DSM - IV - TR ). Criterion A is exposure to a trauma relatives of individuals with OCD to score higher that involved threat of serious injury or death to on personality traits such as neuroticism (Samuels self or others and the experience of intense fear, et al., 2000 ) , maladaptive perfectionism (rumi- helplessness, or horror. Criterion B is reexperi- nating about mistakes vs. adaptively having high encing the event in one or more ways (including standards), and an in fl ated sense of responsibility dreams, physiological reactivity, and intense dis- (e.g., that one is responsible for the safety of oth- tress when exposed to cues of the event). Criterion ers; Salkovskis, Shafran, Rachman, & Freeston, C is persistently avoiding stimuli and having 1999) . The most commonly reported obsessions reduced responsiveness via feeling detached, among adolescents with OCD are contamination, inability to recall important aspects of the trauma, 12 M.S. Nebel-Schwalm and T.E. Davis III avoiding thoughts or discussions about the Although it is a prominent feature of PTSD, trauma, avoiding people or places that remind controversy exists regarding criterion A. one of the trauma, diminished interest in Dif fi culties arise with how broadly or narrowly to signi fi cant activities, restricted range of affect, de fi ne “trauma” (Weathers & Keane, 2007 ) . and a sense of foreshortened future; and criterion For DSM - 5, some have proposed that criterion D is two or more symptoms of arousal, including A be dropped entirely (Brewin, Lanius, Novac, sleep disturbances, anger outbursts, diffi culty Schnyder, & Galea, 2009 ) . A related problem is concentrating, hypervigilance, and exaggerated the need for more developmentally appropriate startle response (APA, 2000 ) . One can be diag- standards for diagnosing PTSD in children and nosed with acute PTSD if symptoms emerge 1 adolescents (Pynoos et al., 2009 ) . If criterion A is month after a trauma and last less than 3 months; retained, it is important to note that what may chronic PTSD is when symptoms remain beyond qualify as a trauma for children may not neces- 3 months post-trauma, and delayed onset is when sarily be the same as for an adult (e.g., witnessing symptoms did not appear until 6 months or lon- domestic violence or experiencing a severe dog ger after the trauma. bite). Also, trauma-related sequelae in children The 12-month prevalence of PTSD among a and adolescents often differ from that of adults. sample of over 5,000 adults was 3.5% (Kessler, Children may seek close proximity to their parent Chiu, et al., 2005 ) . Lifetime prevalence was or caregiver, be preoccupied with being safe, 6.8% and median age of onset was 23 (Kessler, regress with regard to developmental skills (e.g., Berglund, et al., 2005 ) . However the prevalence toileting and speech), and develop new fears of a potentially traumatic event is estimated to (Pynoos et al.; Scheeringa, Pebbles, Cook, & be 25% by the age of 16 years (Costello, Zeanah, 2001 ) . Adolescents may exhibit more Erkanli, Fairbank, & Angold, 2002 ) . PTSD can reckless and risky behaviors (such as thrill seek- be extremely debilitating and is a robust predic- ing and substance use; Pynoos et al., 2009 ) . tor of suicide attempts among adolescents (Wilcox, Storr, & Breslau, 2009 ) . When comparing physical anxiety symptoms among indi- Acute Stress Disorder viduals with panic disorder or PTSD, individuals with PTSD had briefer symptom-free periods, Acute stress disorder was fi rst introduced in the experienced greater fl uctuation, greater unpre- DSM -IV , in 1996. It shares criterion A (experi- dictability, and greater uncontrollability (Pfaltz, encing a trauma) with PTSD, but it differs regard- Michael, Grossman, Margraf, & Wilhelm, ing the timeline of symptoms. Posttraumatic 2010 ) . Responses vary depending on the type stress disorder can be diagnosed 1 month follow- of trauma. Early-onset, chronic, and interper- ing a trauma, whereas acute stress disorder can sonal traumas (e.g., emotional, physical, or be diagnosed in the immediate aftermath, up until sexual child abuse) are associated with more 1 month post-trauma. It also emphasizes the impaired emotional regulation than single- experience of dissociative symptoms. One must event, non-interpersonal traumas (Ehring & display at least three of the following: sense of Quack, 2010 ) . Perhaps the most debilitating numbing/detachment, reduced awareness of sur- trauma for children and adolescents is child- roundings, derealization, depersonalization, and hood sexual abuse. Adolescents with a history dissociative amnesia (APA, 2000 ) . of sexual abuse account for 20% of all adoles- Prevalence rates to date seem to be trauma- cent suicide attempts (Fergusson, Horwood, & specifi c. Interestingly, the same rate (16%) was Lynskey, 1996 ) . Because of the serious nature reported for survivors of injuries requiring hospi- of chronic abuse, some have criticized the cur- talization (Mellman, David, Bustamante, Fins, & rent description of PTSD as being too focused Esposito, 2001) , as was reported for moving- on single-trauma events rather than chronic vehicle accident survivors (Harvey & Bryant, trauma exposure (Briere & Spinazzola, 2005 ) . 1999 ) . Because of its recency, information on 1 Nature and Etiology of Anxiety 13 acute stress disorder is not as readily available, about losing control or going crazy, and a and this applies to information regarding children signifi cant change in behavior (APA, 2000 ) . PD and adolescents as well (March, 2003 ) . Another can be diagnosed with or without the presence of problem could be the practical diffi culties of agoraphobia. measuring reactions to trauma so soon after the The 12-month prevalence of PD is 2.7% event. (Kessler, Chiu, et al., 2005 ) . The lifetime preva- Criticisms of acute stress disorder include the lence is 4.7% and the median age of onset was 24 ambiguity of criterion A, its reliance on dissocia- years of age, which is second only to GAD as the tive symptoms, lack of data supporting its diag- oldest median age of onset among anxiety disor- nostic validity, and the fact that a main purpose ders (Kessler, Berglund, et al., 2005 ) . As many as was to predict the onset of another disorder 80% of individuals PD have a comorbid diagno- (namely, PTSD; O’Donnell, Creamer, Bryant, sis (Olfson et al., 1997 ) , such as major depressive Schnyder, & Shalev, 2003 ) . Studies have found disorder (Roy-Byrne et al., 2000 ) , GAD, sub- various predictors of PTSD, but meeting a diag- stance abuse (Otto, Pollack, Sachs, O’Neil, & nosis of acute stress disorder is not consistently Rosenbaum, 1992 ) , and bipolar disorder one of them (Bryant, Harvey, Guthrie, & Moulds, (Goodwin & Hoven, 2002 ) . Research on sub- 2003 ; Elsesser, Sartory, & Tackenberg, 2005 ; threshold experiences of panic disorder has found Mellman et al., 2001 ) . There is some evidence it to be common (when counted with full thresh- that dissociative symptoms may predict PTSD; old panic disorder, the prevalence rate in a com- however, these tend to be subclinical presenta- munity sample is 40%; Bystritsky et al., 2010 ) . tions of acute stress disorder. Other predictors of Subthreshold panic disorder is also associated PTSD include prior traumas, prior psychopathol- with greater rates of depression, dysthymia, psy- ogy, heightened arousal immediately following chosis, GAD, bipolar disorder, and substance use the trauma, as well as avoidant coping and feel- disorders (Bystritsky et al.). ing overwhelmed (Mellman et al.). Certainly Panic symptoms have been noted to occur in more research is needed to better understand the clusters (e.g., nocturnal panic, Craske & Tsao, diagnostic validity of acute stress disorder, its 2005 ; respiratory symptoms, Abelson, Khan, predictive validity regarding PTSD, and develop- Lyubkin, & Giardino, 2008; Onur, Alkin, & mental trajectories of trauma-related responses Tural, 2007 ; cognitive, cardiorespiratory, and among children and adolescents (March, 2003 ) . mixed somatic, Meuret et al., 2006 ) leading some to propose that these clusters may represent meaningful subtypes of panic disorder. For exam- Panic Disorder (PD) ple, Meuret et al. (2006 ) found three subtypes using factor analysis and determined whether Panic attacks are sudden and intense experiences these clusters signi fi cantly predicted various of physical symptoms (e.g., chest pain, feelings aspects of PD (such as intensity, frequency, inter- of choking) that peak within 10 min and can lead ference, distress, and worry). Among the predic- the individual to believe they are experiencing a tions, cardiorespiratory symptoms (i.e., heart real medical emergency (e.g., commonly patients palpitations, shortness of breath, choking, chest experiencing a panic attack believe they are hav- pain, and numbness) predicted the severity and ing a heart attack). Panic attacks, by themselves, frequency of panic and distress. Mixed somatic are not a diagnosable disorder; rather, they are a (i.e., sweating, trembling, nausea, chills, hot prominent feature in the diagnosis of PD (but can fl ashes, and dizziness) predicted severity, inter- occur with any anxiety disorder). The main crite- ference with life, distress, and worry. Lastly, the ria for PD are the presence of recurrent and unex- cognitive subtype (i.e., thoughts that one is going pected panic attacks with at least one of the crazy, losing control, and a feeling of unreality) following symptoms for 1 month or longer: per- predicted worry, distress, interference, and severity sistent concern about subsequent attacks, worry (Meuret et al.). However, Kircanski, Craske, Epstein, 14 M.S. Nebel-Schwalm and T.E. Davis III and Wittchen (2009 ) reviewed the literature them as different disorders and allowing for and did not fi nd adequate support for symptom comorbid diagnoses when appropriate (Wittchen, subtypes. Although there is initial support for the Gloster, Beesdo-Baum, Fava, & Craske, 2010 ) . idea of meaningful symptom clusters, they con- Because the task force was not unanimous in cluded that the research has not yet demonstrated their proposed changes, they recommended a suf fi cient external validation criteria with regard careful reanalysis of clinical data sets in order to to functional differences between subtypes facilitate a more consensual decision about this (Kircanski et al.). Lastly, the task force that issue. reviewed the current DSM criteria of PD did not recommend including subtypes for DSM - 5 and recommended mostly minor changes (e.g., chang- Speci fi c Phobias ing the wording of “hot fl ushes” to “heat sensations”; Craske et al., 2010 ) . The key feature of a speci fi c phobia is a marked and persistent fear of a certain circumscribed stimulus or situation ( DSM - IV - TR ). While poten- Agoraphobia tially not as broad and debilitating as other more pervasive disorders, speci fi c phobias are associ- The DSM - IV - TR does not allow one to be diag- ated with signi fi cant long-term psychological and nosed with agoraphobia but rather agoraphobia social effects from childhood even into adulthood without history of panic disorder or panic disor- (Davis, 2009; Davis, Ollendick, & Öst, 2009 ) . der with agoraphobia (APA, 2000 ) . The DSM -IV - Per the diagnostic criteria, exposure to the feared TR describes agoraphobia as anxiety in situations stimulus should evoke anxiety and avoidance (or where escape is dif fi cult or help is not easily distress if escape is not possible; DSM - IV - TR ). In available, and such situations are avoided or adults, one must also realize that the fear is exces- endured with signi fi cant distress. A diagnosis is sive; though children are not required to have this made if one has these symptoms that relate to the degree of insight. Five separate types of specifi c fear of developing panic-like symptoms. However, phobia have been included in the DSM - IV - TR : if the avoidance of situations is limited in scope animal type (e.g., dogs and snakes; includes to either a speci fi c stimulus or social interactions, insects), natural environment type (e.g., storms one should consider the possibility of specifi c and dark), situational type (e.g., small spaces and phobia or social phobia, respectively (APA). airplanes), blood-injection-injury type (e.g., The 12-month prevalence rate of agoraphobia receiving injections or seeing blood), and other without panic disorder was 0.8%, the lowest type (e.g., clowns, vomit, and other fears that do among several anxiety disorders included by not fi t within the other four categories). Kessler, Chiu, et al. (2005 ) . Lifetime prevalence Speci fi c phobias have consistently been found was 1.4% and the median age of onset was 20 to be one of the more common psychological dis- years of age (Kessler, Berglund, et al., 2005 ) . The orders. Current research indicates speci fi c pho- clinical presentation of agoraphobia without PD bias are the most common anxiety disorder with is low compared to population-based prevalence a lifetime prevalence rate of 12.5% and a rates. This might be due to lower rates of treatment 12-month prevalence rate of 8.7% (Kessler, seeking among individuals with agoraphobia Berglund, et al., 2005 ; Kessler, Chiu, et al., 2005 ) . without PD (Mosing et al., 2009 ) . Controversy also The average age of onset for a speci fi c phobia has exists as to whether agoraphobia is part of the panic been suggested to be 9–10 years of age (Stinson disorder spectrum (Andrews & Slade, 2002 ) or a et al., 2007 ) ; however, it is generally accepted distinct disorder (Nocon et al., 2008 ) . Among the that there is a great deal of variability depending recent proposals by the DSM - 5 task force was the on the type of fear. As a result, a range of onset is suggestion to eliminate the current hierarchy that typically accepted spanning childhood to early exists between PD and agoraphobia by separating adulthood (Öst, 1987 ) with onset typically 1 Nature and Etiology of Anxiety 15 mirroring the emergence of certain developmental styles (Kendler, Neale, Kessler, Heath, & Eaves, capacities in cognition (i.e., from concrete to 1992b ) . Aspects of parenting that have been increasingly abstract fears; Davis, 2009 ) . In addi- investigated include warmth, control, intrusive- tion, specifi c phobias exact an unexpected toll ness, and lack of encouragement (De Rosnay, on the health care system as well with those Cooper, Tsigaras, & Murray, 2006 ) . Parents have having specifi c phobias accessing medical care even been found to have an in fl uence on how at rates higher than those with OCD and sec- infants react. For example, studies with infants ond only to those with panic disorder (Deacon, have noted the degree to which infants base their Lickel, & Abramowitz, 2008 ) . Unfortunately, reactions on their caretaker’s emotional state most individuals with a specifi c phobia have been (known as social referencing; Murray et al., found to have had it an average of 20 years and 2008) . Two studies with infants illustrate this fewer than 10% have sought treatment (Stinson effect. The fi rst was done with mothers who did et al., 2007 ) . not have social phobia. They were instructed to act either anxiously or non-anxiously when a stranger entered the room. Infants responded with Social Phobia (Also Known as Social more avoidance and fear when their mothers were Anxiety Disorder) anxious (De Rosnay et al., 2006 ) . The second study compared mothers with and without social Social phobia is marked by the fear of perform- phobia. In this study, infants of mothers with ing or interacting socially. It has a generalized social phobia, as compared to controls, were subtype that indicates a person is anxious in most more fearful and avoidant when interacting with or all social situations. Without this subtype, one a stranger (Murray et al., 2008 ) . may be socially anxious only in certain situa- Research regarding the upcoming DSM -5 tions, such as giving a speech. Its key criteria has focused on clarifying some controversial include a marked and persistent fear of social (or aspects of social phobia. One criticism is that it performance) situations, exposure to such situa- is diffi cult to determine whether someone has tions evokes anxiety, the person recognizes the generalized social phobia or avoidant personal- fear is excessive or unreasonable, and social (or ity disorder. Some have proposed that avoidant performance) situations are avoided or endured personality disorder is a severe form of social with great distress (APA, 2000 ) . The 12-month phobia rather than a distinct disorder. A recent prevalence rate for social phobia among an adult review found mixed evidence on this issue and sample was 6.8% (Kessler, Chiu, et al., 2005 ) . indicated the need for further research in order Reported lifetime prevalence rates range from to obtain consensus (Bogels et al., 2010 ) . Some 12.1% (Kessler, Berglund, et al., 2005 ) to 13.3% have also questioned the utility of the “general- (Magee, Eaton, Wittchen, McGonagle, & Kessler, ized” specifi er. Bogels et al. ( 2010 ) found little 1996 ) , and the median reported age of onset was evidence to support this and recommended a 13 years (Kessler, Berglund, et al., 2005 ) . It is the dimensional approach be adopted instead. second most common anxiety disorder (speci fi c However, with regard to speci fi c situations, phobias are the most common). they suggested that a “predominantly perfor- The adolescent median age of onset coincides mance” speci fi er would have clinical utility. with a time when concerns about social evalua- Lastly, they noted that children can reliably be tions increases (Bruch, Heimberg, Berger, & diagnosed with social phobia as young as 6 Collins, 1989 ) ; however, risk factors that occur years of age, validity studies are still needed for prior to adolescence have been identi fi ed. One’s children younger than 9 years, and that young temperament (e.g., being shy or behaviorally children may manifest social phobia as selec- inhibited), even as a young child, is believed to tive mutism, indicating the need for further play a role in the development of social phobia, research to clarify the relationship between along with environmental factors such as parenting these two disorders. 16 M.S. Nebel-Schwalm and T.E. Davis III

Separation Anxiety Disorder studies found 0.2% of 14–19-year-olds to have SAD (Lewinsohn et al.) and 1.2% of 5–15-year-olds It is developmentally appropriate for a young (Ford, Goodman, & Meltzer, 2003 ) . A 6-month child to be distressed when separating from his or prevalence study with 6–14-year-olds reported her parent. This distress typically dissipates 0.9% (Breton et al., 1999 ) , whereas a 12-month between the ages of 3–5 years (Masi, Mucci, & prevalence study with a slightly larger age range Millepiedi, 2001 ) . For children older than this, (children ages 4–17 years) found 1.5% with SAD intense distress when separating from a parent or (Canino et al., 2004 ) . Lastly, lifetime prevalence caregiver can interfere with their social relation- is reported to be 5.2% (Kessler, Berglund, et al., ships and adjustment to day care or school, as 2005 ) . As these fi gures reveal, the age of onset well as disrupt the lives of parents and caregivers. for SAD is primarily in childhood, and there is a Thus, SAD is characterized by excessive and decline in onset as the child matures (Keenan developmentally inappropriate distress when et al., 2009) . The median age of onset is 7-years- anticipating (or experiencing) separation from a old (which is similar to specifi c phobias) and the loved one or one’s home (APA, 2000 ) . A child vast majority of cases occur between the ages of must have three or more symptoms from the fol- 5 and 17 years (Kessler, Berglund, et al., 2005 ) . lowing list: recurrent distress when separated, The DSM stipulates that the disorder’s onset persistent worry that something bad will happen must begin before 18 years of age (APA, 2000 ) ; (e.g., being kidnapped or getting lost), recurrent however, there is growing interest into adult worry about harm coming to a loved one, reluc- onset SAD (Silove, Marnane, Wagner, tance or refusal to go to school or elsewhere, Manicavasagar, & Rees, 2010 ) . An outpatient reluctance or refusal to be alone or to fall asleep sample of 508 adults presenting with mood and alone, the experience of nightmares, and somatic anxiety disorders reported that 41% had adult complaints (e.g., stomachaches and headaches; SAD (20% without a childhood diagnosis and APA). Among these symptoms, the most com- 21% with a childhood diagnosis; Pini et al., monly endorsed ones are separation distress, 2010 ) . Thus some have argued that it is more avoidance of being alone/without an adult, and prevalent than previously realized and that adults avoidance of sleeping away from home. The least with this disorder experience more disabling commonly endorsed symptom is having night- effects as compared to children, who in one study mares (Allen, Lavalee, Herren, Ruhe, & were found to have low levels of impairment Schneider, 2010 ) . In addition to the impairing (Foley et al., 2008 ) . effects of these symptoms, children with SAD often display defi ant and disruptive behaviors during times of separation (e.g., such as going to Conclusion school or going to bed; Pincus, Santucci, Ehrenreich, & Eyberg, 2008 ) . SAD has also been Overall, the etiology and nature of anxiety and shown to be a risk factor for later depression fear are complex and not fully understood at this (Keenan, Feng, Hipwell, & Klostermann, 2009 ; time. Their causes are usually multiply deter- Lewinsohn, Holm-Denoma, Small, Seeley, & mined through various and repeated experiences Joiner, 2008 ) and panic disorder (Lewinsohn over time. While single experiences may be et al.). suf fi cient to cause distress and disorder, the con- Depending on the type of prevalence being sensus at this time is that most anxiety disorders assessed (i.e., point, 6- or 12-month) and which have varied roots extending back through an indi- respondents were queried (parents, adolescents, vidual’s unique learned and biological histories. or both), prevalence rates for SAD among chil- As such, it is not a question of whether anxiety dren and adolescents ranged from 0.2 to 1.5% disorders (or simple anxiety and fear) are the (Canino et al., 2004 ; Lewinsohn, Hops, Roberts, result of nature or nurture but rather nature and Seeley, & Andrews, 1993 ) . Point prevalence nurture. The expression of anxiety and fear has 1 Nature and Etiology of Anxiety 17 also been a topic of debate. Much of the work to Barrett, P. M., Rapee, R. M., Dadds, M. M., & Ryan, S. M. classify and distinguish anxiety disorders has (1996). 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Amanda R. Mathew, Lance D. Chamberlain, Derek D. Szafranski, Angela H. Smith, and Peter J. Norton

As the fi eld has moved beyond initial effi cacy clinically signi fi cant symptoms of both an anxiety trials for the treatment of anxiety disorders, it disorder and another disorder at some time across becomes more crucial to consider the variants the lifespan. Additionally, several therapeutic and complications that may arise in treatment. variables complicate the treatment of anxiety Although ef fi cacious treatments for anxiety dis- disorders. Transdiagnostic and integrative treatments orders have been developed, fi ndings related to are presented as promising means of addressing prognostic indicators of treatment response complications that arise in the treatment of comor- remain an important research priority. In particu- bid and complex presentations of anxiety disorders. lar, clinicians and researchers alike need information on translating nomothetic fi ndings into idiographic treatment plans, addressing related Anxiety Disorders and Axis I conditions that frequently co-occur with anxiety Comorbidity disorders, and overcoming clinical impasses that may complicate treatment. Anxiety disorders are frequently comorbid with other acute conditions. The following sections address Axis I disorders that frequently co-occur Nature of the Problem with anxiety, as well as etiological theories of their co-occurrence and considerations for treatment. This chapter will explore several factors that contribute to complexity in effectively conceptu- Multiple anxiety disorders . Comorbid acute disor- alizing and treating anxiety disorders in adults. ders are complicating factors that may serve as Anxiety is frequently comorbid with other acute important prognostic indicators for the effective and enduring disorders, which has important treatment of anxiety disorders. Co-occurrence of implications for effective treatment (e.g., Brandes two or more anxiety disorders in the same indi- & Bienvenu, 2009; Huppert, 2009; Zahradnik & vidual tends to be more the rule than the exception Stewart, 2009 ) . For the purposes of this chapter, (e.g., Brown & Barlow, 1992 ; Kessler et al., 1996 ; comorbidity is defi ned as having co-occurring Wittchen, Zhao, Kessler, & Eaton, 1994 ) . Brown, Campbell, Lehman, Grisham, and Mancill (2001 ) examined comorbidity among anxiety disorders A. R. Mathew , M.A. ¥ L. D. Chamberlain , M.A. in a clinical sample. Among anxiety disorders, D. D. Szafranski , M.A. ¥ A. H. Smith , M.A. generalized anxiety disorder (GAD) and posttrau- P. J. Norton , Ph.D. (*) matic stress disorder (PTSD) were especially Department of Psychology, University of Houston, 126 Heyne Bldg., Houston , TX 77204-5022 , USA likely to co-occur with other disorders. e-mail: [email protected] Additionally, it is useful to examine comorbidity

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 23 DOI 10.1007/978-1-4614-6458-7_2, © Springer Science+Business Media New York 2013 24 A.R. Mathew et al. as a function of primary disorders. For example, & Kaufman, 2001 ) , higher rates of mental health while Specifi c Phobia has been highly comorbid treatment utilization but poorer treatment with other anxiety disorders, it frequently presents response (Brent et al., 1998; Emslie, Weinberg, as a less severe condition that co-occurs with & Mayes, 1998 ; Lewinsohn et al., 1995 ) , higher other more debilitating anxiety disorders (Brown medical costs (Marciniak et al., 2005 ) , and an et al.). Thus, it may be that some forms of multiple increased risk of recurrence (Emslie et al., 1998 ) . anxiety disorder comorbidity, such as Panic The presence of comorbid depression is also a Disorder and GAD, are more likely to complicate negative prognostic indicator for anxiety disorder prognosis than others, such as any primary anxi- treatment outcome, as it has been shown to ety disorder and secondary Speci fi c Phobia decrease the likelihood of remission of each of (Brown & Barlow, 1992 ) . Although evidence sug- the disorders (Bruce et al., 2005 ) . gests that comorbidity rates decrease after treatment for a primary anxiety disorder (e.g., Borkovec, Anxiety disorders and substance use . Substance Abel, & Newman, 1995 ; Brown, Antony, & use disorders also frequently co-occur with anxi- Barlow, 1995 ) , comorbidity rates tend to be sub- ety disorders, although there appear to be some stantially higher in those with more severe condi- differences among the anxiety disorders in their tions (Kendall, Kortlander, Chansky, & Brady, rates of comorbidity with substance use. First, 1992 ; Kessler et al., 1994 ) and severity serves as although specifi c phobias are relatively prevalent a negative prognostic indicator (Keller et al., in the population, they are less likely to be associ- 1992 ) . As such, comorbidity of anxiety disorders ated with substance use than GAD, Panic may signifi cantly complicate the clinical picture. Disorder, Social Phobia, and PTSD (Zahradnik & Stewart, 2009 ) . Additionally, drug use disorders Anxiety disorders and comorbid depression . are more frequently associated with anxiety dis- Unipolar depression and anxiety are frequently orders than alcohol use disorders (Zahradnik & comorbid in adults, adolescents, and children, in Stewart). As it may be problematic to group drug both clinical and community samples (e.g., Angold, use disorders into a homogenous category, fur- Costello, & Erklani, 1999 ; Lewinsohn, Hops, ther research is needed to explore drug use disor- Roberts, Seeley, & Andrews, 1993 ; Maser & der by speci fi c substances. Cloninger, 1990 ; Merikangas, Dierker, & Szamari, Several models have been proposed to explain 1998 ; Mineka, Watson, & Clark, 1998 ) . Although the co-aggregation of anxiety disorders and sub- comorbidity exists across many disorders, the stance use. Some models suggest that those with strength of association between anxiety and depres- anxiety disorders may use substances to “self- sion denotes a unique relationship (Axelson & medicate,” or reduce emotional distress or affect- Birmaher, 2001 ; Lewinsohn, Rohde, & Seeley, relevant withdrawal symptoms (Kushner, Sher, & 1995 ) . Also, rates of comorbidity between anxiety Beitman, 1990) . Alternatively, it is possible that and depression remain elevated even after control- anxiety symptoms result from chronic substance ling for comorbidity with other disorders (Lewinsohn, use (Kushner, Abrams, & Borchardt, 2000 ) . For Zinbarg, Seeley, Lewinsohn, & Sack, 1997 ) . example, prolonged tobacco use may contribute The overlap between anxiety and depression to the development of panic disorder by produc- is particularly important as those with the comor- ing chronic withdrawal symptoms, reduced health bid condition experience more impairment than quality, or both (Breslau & Klein, 1999 ; McLeish, those with pure presentations of either disorder. Zvolensky, Del Ben, & Burke, 2009 ) . It may also As compared to non-comorbid presentations of be that a third factor related to individual differ- the disorders, comorbid anxiety-depression is ences underlies both anxiety and substance use. associated with greater symptom severity Anxiety sensitivity, or the tendency to fear bodily (Bernstein, 1991 ; Coryell et al., 1988 ; Mitchell, sensations most associated with anxiety, has been McCauley, Burke, & Moss, 1988 ) , higher rates of linked to both anxiety and substance use (Stewart suicidal behavior (Lewinsohn et al., 1995 ; Reich & Kushner, 2001 ) , suggesting its possible role as et al., 1993 ; Rohde, Clarke, Lewinsohn, Seeley, a third variable. 2 Prognostic Indicators 25

Generally, the literature supports the self- medication hypothesis for anxietyÐsubstance use Anxiety Disorders and Comorbid comorbidity (see Zahradnik & Stewart, 2009 for Personality Disorders review). However, self-medication models may be limited in describing the complex relationship Rates of comorbid anxiety and personality disor- between anxiety disorders and substance use fol- ders range from 35 to 65% (Sanderson, Wetzler, lowing the onset of both conditions (e.g., Stewart, Beck, & Betz, 1994; Skodol et al., 1995 ) , and 1996 ) . Other models suggest that anxiety disorders fi ndings with regard to the impact on treatment and substance use reinforce one another over time outcome are mixed. Personality disorders interfere through a mutual maintenance process, and their in instrumental and social relationships and are comorbidity is best explained by a complex trans- thought to impact the therapeutic process as well actional relationship. Thus, anxiety and substance (Crits-Christoph & Barber, 2002 ) . To date, none of use may co-occur through bidirectional negative the ten personality disorders have consistently effects (e.g., Zvolensky, Schmidt, & Stewart, 2003 ) . been related to poor treatment prognosis, and no Anxiety disorder-substance use disorder one anxiety disorder is sensitive to concomitant comorbidity has important implications for effec- personality disorders on treatment outcome tive treatment, as the comorbid conditions often (Dreessen & Arntz, 1998 ) . However, some pat- result in less effective treatment for either condi- terns have emerged in the literature. tion, and higher rates of relapse to substance use (e.g., Bruce et al., 2005 ; Kushner et al., 2000 ) . Models of comorbidity . An important fi rst step is Treatment approaches designed to address anxi- to examine the theoretical underpinnings of the ety-substance use comorbidity generally follow relationship between anxiety and personality dis- one of three treatment formats: sequential, paral- orders. Researchers have proposed several mod- lel, or integrated (Zahradnik & Stewart, 2009 ) . els of the relationship between Axis I and Axis II Sequential treatments fi rst address one disorder disorders, including linear (i.e., causal), nonlin- then move on to the other in discrete stages. As ear (i.e., reciprocal), and common etiological clinicians commonly believe mental health issues models (Brandes & Bienvenu, 2009 ) . Linear cannot be effectively treated until substance use models suggest that either personality disorders is controlled (Riggs & Foa, 2008 ) , substance use are risk factors for anxiety disorders or personal- disorders generally take fi rst treatment priority ity disorders are consequences of anxiety disor- over anxiety disorders. Parallel treatments ensure ders. Support for linear models has been partially treatment for both disorders simultaneously; established by several prospective and longitudi- however, treatment is often conducted by differ- nal studies. For example, controlling for the present providers, so coordination of care represents ence of Axis II disorders in adolescence, negative a potential problem (Randall, Book, Carrigan, & affectivity in adolescence predicted the onset of Thomas, 2008 ) . Lastly, integrated models of anx- anxiety disorders in adulthood (Krueger, 1999 ) . iety-substance use treatment attempt to create a Similarly, higher negative affectivity predicted hybrid treatment comprising intervention strate- four-symptom panic attacks in adolescents gies that are effective in treating each disorder (Hayward, Killen, Kraemer, & Taylor, 2000 ) , and independently (Randall et al.). Ultimately, high neuroticism and low extraversion predicted although integrated treatments may be the most the onset of PTSD in survivors of severe burns promising, quality of care for anxietyÐsubstance (Fauerbach, Lawrence, Schmidt, Munster, & use is limited by systemic issues that tend to Costa, 2000 ) . Additionally, early experiences of focus health care on discrete problems and not anxiety disorders may infl uence developing the full clinical picture (e.g., Weiss, Najavits, & personalities. Anxiety disorders in adolescence Hennessy, 2004 ) . Additionally, development and were shown to predict the development of per- empirical evaluation of integrated treatments sonality disorders later in life, particularly Cluster remains limited. C disorders (Goodwin, Brook, & Cohen, 2005 ; 26 A.R. Mathew et al.

Kasen et al., 2001 ) . Findings that support a causal Anxiety disorders and co-occurring personality relationship in two directions (i.e., that personality disorders have also been identi fi ed empirically. In a disorders infl uence the development of anxiety longitudinal study of patients with anxiety disor- disorders, and that early anxiety impacts the ders, the Harvard/Brown Anxiety Research Project development of personality disorders) suggest (HARP) found 24% of patients to have at least one that a bidirectional, reciprocal model may offer a co-occurring personality disorder, with the most better explanation than either linear model. common diagnoses being Avoidant, Obsessive- Beyond these, models that address common Compulsive, Dependent, and Borderline personal- etiologies and overlap in Axis I and Axis II crite- ity disorders. Patients with Social Phobia and rion are informative. Both anxiety disorders and GAD were more likely to be diagnosed with a Cluster C personality disorders are characterized co-occurring personality disorder than those with by fear and avoidance; therefore, it is not surprising other anxiety disorders (Sanderson et al., 1994 ) . that these Axis I disorders would be particularly Taken together, fi ndings suggest that anxiety disor- susceptible to comorbidity with Cluster C disorders may co-occur with each of the three personal- ders. However, Saulsman and Page (2004 ) found ity disorder clusters but also display some speci fi c that all personality disorders were associated associations (e.g., Social Phobia and Avoidant per- with high neuroticism and disagreeableness, sonality disorder) at particularly high rates. which lends an explanation for the comorbidity Many of the studies examining anxiety disor- between anxiety and Cluster A and B disorders as ders and co-occurring personality disorders have well as Cluster C. Additionally, it has been shown focused the prevalence of the concomitant rela- that anxiety disorders are related to a personality tionship and the relationship with symptom style characterized by behavioral inhibition to the severity rather than the effects on treatment out- unfamiliar (Brandes & Bienvenu, 2009 ) . This come. Additionally, a majority of the studies have personality style may re fl ect a risk factor for the been conducted on individuals with Panic development of anxiety disorders, or it may be a Disorder (with or without Agoraphobia). In one marker of a range of inherited traits that includes study, co-occurring Panic Disorder and personal- anxiety disorders (Bienvenu & Stein, 2003 ) . ity disorders were related to a more severe clinical picture (as indicated by more symptoms and Specifi c associations between personality disor- suicidal behaviors; Ozkan & Altindag, 2005 ) . der clusters and anxiety disorders. Due partly to similarities in diagnostic criteria (e.g., anxious, Effect of comorbidity on prognosis of anxiety dis- fearful traits), Cluster C personality disorders co- orders. In their review of the literature, Crits- occur most often with anxiety disorders (Sanderson Christoph and Barber ( 2002 ) suggest that et al., 1994 ) . Further, speci fi c associations have personality disorders have shown a consistent been supported for particular Axis I and Axis II adverse impact on the treatment outcome of a disorders that commonly co-occur, perhaps due to wide range of Axis I disorders. One way in which etiological relationships. Particularly high rates of personality disorders may impede treatment of PTSD were found in those with Borderline per- anxiety disorders is through dif fi culty establish- sonality disorder while elevated rates of Social ing rapport and strong alliance, which is an indi- Phobia were found in patients with Avoidant per- cator of treatment outcome (Ackerman et al., sonality disorder (McGlashan et al., 2000 ) . Skodol 2002) . Individuals with personality disorders et al. ( 1995 ) found Panic Disorder associated most have dif fi culties developing relationships and highly with Borderline, Avoidant, and Dependent trusting others, which may impair therapeutic personality disorders; Social Phobia associated rapport and lead to early termination and attrition with Avoidant personality disorder; Obsessive- (Ackerman et al.). Second, personality disorders Compulsive Disorder (OCD) associated with may impede treatment simply by heightening the Avoidant and Obsessive-Compulsive personality severity of the pathology in general. Third, per- disorder; and Specifi c Phobia was not associated sonality disorders may impede treatment of Axis with any personality disorder. I disorders because individuals with Axis II 2 Prognostic Indicators 27 pathology frequently show impairments in self- an important role in the interpretability of the insight, which may hinder treatment response. fi ndings. A large body of research supports the However, limited insight is a frequent complica- assertion that personality disorders hinder treat- tion to treatment and is not uniquely associated ment response (for a review, see Crits-Christoph with personality disorders. Finally, unlike the & Barber, 2002 ) . However, it may be that the ego-dystonic nature of Axis I disorders, personal- reliability of fi ndings is confounded by the study ity disorders are frequently more ego-syntonic in methods employed (Dreessen & Arntz, 1998 ) . nature. Because many of the underlying traits First, conclusions related to the deleterious between Axis I and Axis II disorders are similar, impact of personality disorders on Axis I treat- it may be diffi cult to treat ego-dystonic symptoms ment outcome often were based on retrospective that are related to an ego-syntonic trait. For Axis II diagnoses made by raters who were not example, the fear and avoidance based Cluster C blind to the treatment condition (Kringlen, 1965 ; Personality Disorders (i.e., Avoidant, Dependent, Lo, 1967 ; Mancuso, Townsend, & Mercante, and Obsessive-Compulsive personality disor- 1993 ; Minichiello, Baer, & Jenike, 1987 ; Turner, ders) may particularly complicate anxiety disor- 1987 ; Vaughan & Beech, 1985 ) . Second, many ders, which are also characterized by fear and studies which have concluded that personality avoidance. It may be that patients who identify disorders hinder treatment outcome are strictly with the fear as being consistent with their nature comparing posttreatment symptomology (van are less likely to seek treatment and have more den Hout, Brouwers, & Oomen, 2006 ) , although dif fi culty engaging in treatments that seem to the relative change from pre- to posttreatment challenge their nature. severity scores indicates that individuals with Despite these possible mechanisms of person- and without personality disorders bene fi t equally ality disorder interference in treatment, several from treatment (Dreessen & Arntz, 1998 ; van factors hinder our ability to make broad conclu- den Hout et al., 2006 ) . Third, in both self-report sions about the impact of personality disorders questionnaires and clinical interviews, personal- on the outcome of treatment for anxiety disor- ity assessments are sensitive to mood states ders. First, the anxiety disorders have not been (Hirsch fi eld et al., 1983 ; Pilkonis, Heape, Ruddy, equally represented in the extant research, with a & Serrao, 1991 ; Reich, Noyes, Coryell, & majority of the fi ndings relating to Panic Disorder O’Gorman, 1986 ) , so it may be that personality and OCD, and fewer data addressing GAD, Social assessments are distorted by transiently high lev- Phobia, and Posttraumatic Stress Disorder. els of anxiety (Stein, Hollander, & Skodol, Second, very few studies have examined person- 1993 ) . Finally, the method of assessment used to ality dimensionally. DSM-V fi eld trials for Axis make Axis II diagnoses contributes to the varied II disorders are testing dimensional approaches research fi ndings. Van den Hout et al. (2006 ) to personality disorders, re fl ecting a shift in the concluded that the presence of personality disor- way personality characteristics are understood. ders did not impact response to treatment when Important information regarding the impact of the Axis II diagnosis was made with the SCID-II Axis II disorders may be lost by using the dichot- but that it did attenuate treatment response when omous classifi cation method. Lastly, most the diagnosis was determined using an unstruc- fi ndings have not come from studies of comorbid tured interview. In light of these considerations, personality disorders speci fi cally but were sec- it is critical that the fi ndings related to treatment ondary analyses of existing data. Thus, the mech- outcomes of concomitant anxiety and Axis II anisms by which Axis II disorders impede disorders be interpreted in the context of the treatment of Axis I have not been fully explored. study methodologies. In conclusion, the extant research on co-occur- Considerations in interpreting fi ndings . The ring anxiety and Axis II disorders is inconsistent. fi ndings related to co-occurring Axis I and Axis While the research fi ndings are inconclusive, clini- II disorders in treatment outcome studies are cal experience suggests that the presence of an equivocal, and research methodologies may play Axis II disorder interferes with treatment outcome. 28 A.R. Mathew et al.

Because personality disorders are most detrimental the importance of therapeutic alliance, especially to relational functioning, it is intuitive that a disor- early in treatment. However, fi ndings on thera- dered personality would impact the therapeutic peutic alliance remain somewhat divided. Liber bond, a most critical aspect of psychotherapy. et al. ( 2010) reported that therapeutic alliance However, this clinical intuition has yet to inform did not predict anxiety reduction in children the theory related to the mechanism by which Axis who attended group or individual CBT. II disorders may impact the treatment of anxiety Numerous problems remain in studying thera- disorders. Thus, in addition to the special consid- peutic alliance, including measurement sensi- erations for research methods, it is important that tivity and lack of variability in therapeutic future studies are theoretically driven. alliance ratings (e.g., most ratings are high, likely due to demand characteristics). Furthermore, specifi c client characteristics and therapeutic Therapeutic Variables in techniques create diffi culties in forming thera- Complications of Anxiety Disorders peutic alliance. A client’s diffi culty forming social relation- In addition to factors of comorbidity discussed ships may be a consequential variable that inter- above, factors related to the therapist-client rela- feres with the forming of a therapeutic alliance. tionship may serve as complicating factors in the Moras and Strupp ( 1982 ) reported that clients treatment of anxiety disorders. Factors such as who form successful personal relationships often client motivation and therapeutic alliance have form positive therapeutic alliance regardless of been shown to impact treatment outcomes and theoretical orientation. Similarly, Kokotovic and serve as important prognostic indicators. Tracey ( 1990) reported that building therapeutic alliance was more diffi cult when therapists viewed Therapeutic alliance. Therapeutic alliance is their clients as having poor social relationships. It the bond between therapist and client that is intuitive that therapeutic alliance is even more engages the client in the therapeutic process. important in cases where clients struggle to build Therapeutic alliance is believed to be an essen- successful personal relationships, such as among tial factor in the effective treatment of anxiety those with social phobia. However, research (Bordin, 1979 ; Hayes, Hope, VanDyke, & involving social phobia and therapeutic alliance Heimberg, 2007 ) . However, the research on remains inconclusive. VanDyke ( 2002 ) reported therapeutic alliance and treatment outcomes is that strong therapeutic alliance measured after the in its early stages and its fi ndings remain incon- fi nal session related to low posttreatment symp- clusive. Hayes et al. ( 2007 ) found a signi fi cant tom severity after controlling for pretreatment relationship between session helpfulness and severity. Conversely, Woody and Adessky (2002 ) client-rated working alliance, but not observer- reported that therapeutic alliance did not rated working alliance. The researchers also signi fi cantly relate to group CBT treatment out- found that alliance was associated with the comes in clients with social phobia. Neither study level of engagement the client displayed during reported a relationship between early therapeutic therapy. Similarly, Chiu, McLeod, Har, and alliance and treatment outcomes, which may sug- Wood (2009 ) reported that poor early treatment gest that therapeutic alliance is a result of treat- therapeutic alliance predicted less improvement ment success. Further study is needed to elucidate in parent-reported anxiety reduction at mid- the complex relationship between client variables, treatment but not at posttreatment among chil- therapeutic alliance, and treatment outcome. dren receiving cognitive-behavioral therapy (CBT) for anxiety disorders. They also reported Client motivation. Problems with regard to moti- that improvement in therapeutic alliance over vation for treatment are common in individuals the course of therapy predicted better posttreat- with anxiety disorders. Grant et al. (2005 ) reported ment anxiety reduction. These fi ndings indicate that 80Ð95% of people with social phobia do not 2 Prognostic Indicators 29 seek treatment and that many people with social fl exible treatments to best address these prob- phobia only seek treatment after years of tribula- lems. Although manualized cognitive-behavioral tions. Clients lacking motivation often display therapies have yielded very strong treatment ambivalence in regards to anxiety treatment effects (Norton & Price, 2007 ) , the presence of (Buckner, 2009 ) . Clients are generally aware that complicating or negative prognostic variables excessive anxiety is distressing and interferes in may require adaptation of treatment models to their ability to partake in desirable activities. address the speci fi c case formulations. However, clients may also report hesitation to ini- Transdiagnostic, uni fi ed, or integrated cognitive- tiate services or prematurely terminate treatment behavioral treatments are presented as alterna- for fear of others thinking negatively of them tives to disorder-specifi c protocols that may better (Olfson et al., 2000 ) . Given the importance of cli- address complicating factors of comorbidity, ent participation in successfully reducing anxiety while treatments based on motivational interviewing symptoms, it becomes imperative for clinicians to models have begun to be used as stand-alone or address client ambivalence during therapy. adjunctive therapies for clients demonstrating Client motivation may be particularly salient motivational or relational complications. when considering exposure therapy, as the treatment may be considered aversive to many clients, Transdiagnostic and unifi ed treatments . The particularly when the approach is described effi cacy of cognitive-behavioral therapy for the before initiated. Indeed, Becker, Zayfert, and treatment of anxiety disorders has been well Anderson (2004 ) have reported that many CBT- established. Evidence-based treatments have oriented clinicians believe that the aversive nature been developed for many specifi c anxiety disor- of exposure therapy may increase client dropout, ders including panic disorder and agoraphobia despite evidence that clients in exposure-based (Craske & Barlow, 2001 ) , GAD (Dugas et al., therapy for PTSD are not more likely to drop out 2001 ) , OCD (McLean et al., 2001 ) , social phobia compared to clients in other forms of CBT (Heimberg & Becker, 2002 ) , and PTSD (Najavits, (Hembree et al., 2003 ) . However, therapeutic 2002) . However, these studies’ use of homoge- alliance can be damaged as a result of conducting neous samples (e.g., similar diagnoses, strict exposures at a rate in which clients are not ready exclusion criteria) limits the generalization of for or capable of handling. Furthermore, damage these treatment packages for the application to to therapeutic alliance may occur if anxiety complex factors such as comorbid anxiety, mood, symptoms do not abate during an in-session personality, or substance use disorders. Recently, exposure (Hayes et al., 2007 ) . It may be that cli- a number of researchers have suggested that a ents who partake in exposures and do not experi- non-diagnosis-specifi c approach to treatment ence a decrease in anxiety during the exposures may allow for greater individualization and treat- or between successive exposures doubt the bene fi t ment fl exibility by capitalizing on the common of continued treatment. A collaborative approach cognitive and behavioral processes that are shared is especially valuable when structuring exposure across a range of anxiety, mood, and other emo- sessions to help prevent nonadherence and rup- tional disorders (Barlow, Allen, & Choate, 2004 ; tures to the therapeutic alliance. Mansell, Harvey, Watkins, & Shafran, 2009 ; McEvoy, Nathan, & Norton, 2009; Norton & Hope, 2005 ) . Mansell et al. (2009 ) speci fi cally Treatment Approaches to Address suggest that unifi ed or transdiagnostic approaches Anxiety Disorder Comorbidity to treatment may be preferable for clients who do and Complications not fi t a specifi c diagnostic category or for clients with complex or highly comorbid presentations. Given the range of client and therapeutic vari- Uni fi ed treatment packages begin with an indi- ables discussed above that may complicate the vidualized case formulation that focuses on the treatment of anxiety, it is important to develop functional links between the component pro- 30 A.R. Mathew et al. cesses of most cognitive-behavioral models of elements of cognitive-behavioral techniques anxiety: maladaptive cognitive appraisals, poor (e.g., ERP for OCD, prolonged exposure for emotional regulation, emotional avoidance, and PTSD) perform better than those that do not. maladaptive behavior associated with disordered Despite dif fi culties in implementation, Zahradnik emotion (Barlow et al., 2004; McEvoy et al., and Stewart ( 2009) identify preliminary results 2009 ; Shafran, McManus, & Lee, 2008 ) . The of integrated anxietyÐsubstance use treatment as importance of an individualized and evidence- very encouraging. based case formulation is particularly signi fi cant as the complexity of a given presentation Treatment addressing anxiety and comorbid Axis increases. Although the unifi ed approach to the II . Overall, the extant research suggests that stan- treatment of anxiety disorders is a relatively new dard brief treatments for Axis I conditions often idea, research has demonstrated empirical sup- fail when Axis II pathology is also present (Crits- port for the treatment of anxiety disorders utiliz- Christoph & Barber, 2002 ) . However, this does ing this framework (Erickson, 2003 ; Erickson, not mean that the presence of personality disor- Janeck, & Tallman, 2007 ; Garcia, 2004 ; Norton ders precludes effective treatment of anxiety. & Hope, 2005 ) . Instead, it may be that standard treatment for While there has not been a specifi c anxiety anxiety needs to be tailored to effectively address disorder treatment package designed to accom- the presence of a personality disorder. An exam- modate the array of complicating factors that can ple of this is a case study by Walker, Freeman, arise in the treatment of anxiety, it is believed that and Christensen (1994 ) in which restricted envi- a uni fi ed approach to treatment may represent the ronmental stimulation was used to enhance the most desirable treatment strategy. With a unifi ed exposure treatment of OCD in a patient with approach, clinicians are able to treat the entire schizotypal personality disorder. Although treat- clinical picture rather than prioritizing diagnoses ment was focused on the OCD, restricted envi- and sequentially treating each with diagnosis- ronmental stimulation was incorporated due to specifi c treatment protocols (Blanchard et al., the attentional problems found in patients with 2003 ; Brown et al., 1995 ; Norton, Hayes, & schizotypal personality disorder. In sum, clini- Hope, 2004 ) . cians should be alert to the presence of a comorbid personality disorder as a potential prognostic Integrative treatment for anxiety Ðsubstance use indicator. Therapeutic progress should be care- comorbidity. The unifi ed approach discussed fully monitored and the treatment strategy may above may represent an ideal framework for need to be reevaluated if progress is not made addressing the emotional dysregulation that within the period of brief therapy. As effective underlies multiple comorbid anxiety disorder treatment for Axis II conditions typically requires diagnoses as well as comorbid anxiety-depression. a longer period of time than treatment for Axis I However, treatments designed to address both conditions alone (Kopta, Howard, Lowry, & anxiety and substance use may be more dif fi cult Beutler, 1994) , it may be that a more intensive, to develop and implement. Zahradnik and longer course of treatment is required to address Stewart (2009 ) identify integrated and parallel Axis II comorbidity. interventions as more promising than sequential interventions in the treatment of anxietyÐ Treatment addressing anxiety and therapeutic substance use. Theories that anxiety and barriers. In order to decrease client ambivalence substance use reinforce one another over time with regard to therapy, motivational interviewing through mutual maintenance would suggest that (MI) represents one promising therapeutic tech- integrated treatments may represent the best nique. MI is a client-centered therapy that aug- treatment option, but this has yet to be empiri- ments intrinsic motivation to change by openly cally established. One clear trend is that anxietyÐ discussing and resolving ambivalence to change substance use treatments that incorporate (Miller & Rollnick, 2002 ) . Comparison studies 2 Prognostic Indicators 31 conclude that clients receiving MI prior to CBT narrowing the “scientist-practitioner gap” by have superior homework compliance than clients implementing empirically supported treatments receiving only CBT (Westra & Dozois, 2006 ) . in the fi eld. It is widely acknowledged that there Kertes, Westra, Angus, and Marcus (2010 ) is a need for more collaboration between clini- reported that clients receiving MI prior to CBT cian and researcher in the design and implemen- viewed their role in therapy as more active, while tation of psychotherapy outcome research clients receiving only CBT who viewed their role (Goldfried & Wolfe, 1998 ) . This collaboration in therapy as more passive. Simpson and col- could help inform the study of integrated treat- leagues (2008 ) noted some success in using MI ments that incorporate techniques from different as an adjunct to exposure and ritual prevention in therapeutic perspectives. The fi eld is also in dire the treatment of OCD, although the authors note need of treatment manuals that provide fl exibility that the intervention is likely to be successful and guide the clinician in handling problems that only for patients whose ambivalence keeps them may arise during the course of treatment (e.g., from participating fully in treatment, are able to ruptures in therapeutic alliance, homework access this ambivalence in session, and value noncompliance). something more than the status quo. Further An additional direction for future anxiety study is needed to elucidate the full function of research concerns the translation of nomothetic Motivational Interviewing in enhancing treat- fi ndings into idiographic treatment plans relevant ment for anxiety disorders. to practitioners. Barlow and Nock ( 2009 ) discuss It is also important for therapists to recognize that, although the individual serves as the princi- the value of addressing any therapeutic alliance ple unit of analysis in the science of psychology, ruptures that may occur in treatment. In a CBT most psychological studies are conducted by framework, therapeutic alliance is the foundation comparing aggregated data from groups of indi- upon which the technical aspects of the interven- viduals. Problems then result from generalizing a tion rest, so it is crucial for this alliance to be fos- nomothetic result to an idiographic situation. The tered. Safran and Muran (2000 ) suggest several authors urge researchers to emphasize idiographic direct and indirect ways of repairing a ruptured strategies that can be integrated into existing therapeutic alliance. Direct methods include pro- nomothetic research approaches in both clinical viding rationale, examining core interpersonal and basic science settings. While this is a practi- themes with clients, and clarifying any misunder- cal and effi cient approach, it can also directly standings. Indirect methods may involve chang- address the causal relationships between key ing the task or goal, reframing meaning of the treatment-related variables. task, displaying empathetic characterization, and Thus, to better understand the clinical picture, helping to provide a corrective emotional experi- it may be necessary for researchers to focus more ence. Overall, it is important for the therapist to on individual cases than group averages in treat- recognize any problems in therapeutic alliance ment response. In a recent poll of leaders of the early and actively intervene to prevent interfer- fi eld, one researcher noted, “it is the non-responders ence in the therapeutic process. that should generate the research questions” (Donald F. Klein, as quoted in Norton, Asmundson, Cox, & Norton, 2000, p. 94). In this Conclusions and Future Directions way, future research may best be guided by attending to those who do not respond to standard In conclusion, as the anxiety literature moves CBT protocols and attempt to better adapt and beyond fi rst generation ef fi cacy studies, it tailor treatment to these individuals. Idiographic becomes increasingly important to examine prog- approaches could then build on nomothetic nostic indicators in the effective treatment of fi ndings to further advance our knowledge of anxiety. One promising area of the research lit- effective interventions for the complications and erature is translational research that addresses variants of anxiety disorders. 32 A.R. Mathew et al.

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Lara J. Farrell, Allison M. Waters, Ella L. Milliner, and Thomas H. Ollendick

Anxiety disorders are the most common mental Pine, Cohen, Gurley, Brooks, & Ma, 1998 ) and health problems in youth, affecting 8–27% of predict the development of other psychopathol- youth (Costello, Egger, & Angold, 2005 ) . These ogy later in life (Last, Perrin, Herson, & Kazdin, disorders represent serious mental health prob- 1996; Woodward & Fergusson, 2001 ) including lems for children and adolescents and lead to depression (Brady & Kendall, 1992 ; Cole et al., daily distress and impairment, peer and social 1998; Pine et al., 1998 ; Seligman & Ollendick, relation problems (Chansky & Kendall, 1997 ; 1998) , externalizing disorders, and substance Langley, Bergman, McCracken, & Piacentini, use disorders (Bittner et al., 2007 , Costello 2004 ; Piacentini, Peris, Bergman, Chang, & et al., 2003 , Last et al., 1996 ) . Jaffer, 2007 ; Strauss, Forehand, Smith, & The seriousness of child internalizing prob- Frame, 1986 ) , and signi fi cant dif fi culties in lems such as anxiety disorders and the develop- academic achievement (Kessler, Foster, ment of subsequent depression is highlighted by Saunders, & Stand, 1995 ; King & Ollendick, the World Health Organiation (WHO) prediction 1989 ) . Additionally, anxious youth often have that by 2030, internalizing problems will be sec- poor self-esteem, more physical problems, and ond only to HIV/AIDS in burden of disease greater family confl ict and distress than their (developed and developing countries combined; peers (Ezpeleta, Keeler, Alaatin, Costello, & Mathers & Loncar, 2006 ) . While treatment Angold, 2001 ; Harter, Conway, & Merikangas, research for child anxiety has received a surge in 2003 ; Strauss, Frame, & Forehand, 1987 ) . If interest over the past two decades, providing evi- untreated, childhood anxiety disorders tend to dence for favorable treatment outcomes, there be chronic and unremitting in their course remains considerable room for improvement with (Aschenbrand, Kendall, Webb, Safford, & less than 50% of children and youth evidencing Flannery-Schroeder, 2003 ; Keller, et al., 1992 ; full recovery following our best psychosocial treatments (e.g., Silverman, Pina, & Viswesvaran, 2008 ) . Improving early identi fi cation, access to L. J. Farrell , Ph.D. (*) • E. L. Milliner , D.Psych (Clin) treatment, and understanding the predictors and School of Applied Psychology, Griffith Health Institute, moderators of treatment response is the current Griffith University , Gold Coast , QLD , Australia challenge for anxiety disorder researchers in e-mail: l.farrell@grif fi th.edu.au order to improve the prognosis of children and A. M. Waters , Ph.D. youth most vulnerable to anxiety disorders. This School of Applied Psychology, Griffith Health Institute , Grif fi th University , Mt Gravatt , QLD , Australia chapter provides a review of the current state of treatment research for child anxiety disorders T. H. Ollendick , Ph.D. Child Study Centre , Virginia Tech University , and will discuss what is currently known about Blacksburg , VA , USA predictors and moderators of treatment outcome.

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 37 DOI 10.1007/978-1-4614-6458-7_3, © Springer Science+Business Media New York 2013 38 L.J. Farrell et al.

The review provides a comprehensive analysis existing literature into predictors and modera- across child anxiety disorder research by focus- tors of treatment response is minimal, yet slowly ing on (1) child anxiety generally, including growing with the publication of a number of treatment outcome across generalized anxiety large-scale multicenter RCT for various anxiety disorder, separation anxiety disorder (SAD), and disorders in children and youth (see POTS, 2004 ; social phobia (SoP); (2) latest research in child- Walkup et al., 2008 ) . speci fi c phobia treatment; and (3) current evidence for pediatric obsessive–compulsive disorder (OCD). These three diagnostic catego- Childhood Anxiety Disorders ries require a separate focus of review given that each requires a speci fi c and somewhat unique Current Status of Treatment Outcome approach to treatment and given that each has a separate and independent treatment outcome The vast majority of treatment research for literature. childhood anxiety disorders has focused on cogni- Kraemer and colleagues (Kraemer, Wilson, tive–behavioral therapy (CBT) or variants of CBT Fairburn, & Agras, 2002 ) , as well as March and (see Silverman et al., 2008 for review). Commonly Curry ( 1998 ) , specify that predictors of treat- used child CBT programs teach children to recog- ment response are variables that exist prior to nize emotional and physiological signs of anxiety treatment and are related to treatment outcome. and to employ somatic and cognitive strategies for A predictor variable is said to have a main effect managing these symptoms, in addition to encour- on outcome, meaning that its impact is not aging children to gradually expose themselves to specifi c to a particular treatment condition increasingly feared stimuli ( Spence, 1994 ; Kendall (Garcia et al., 2010 ) . Predictors of treatment out- et al., 2005 ) . In the seminal work by Kendall (1994 ) come therefore inform us “for whom” and under and Kendall et al. ( 1997) on the effi cacy of CBT for “what conditions” treatments work. For example, childhood anxiety disorders, 64% of anxious chil- a given treatment might work better for girls than dren receiving individual child-focused CBT no boys or for younger children than older children. longer met criteria for an anxiety disorder by post- Of importance, predictor variables differ from treatment compared to just 5% in the wait-list con- moderator variables. A moderator variable, not trol, results that were maintained at 12-month unlike a predictor variable, is associated with follow-up. Using a group CBT format (GCBT), treatment outcome; however, a moderator vari- Silverman et al. (1999 ) found that 64% of children able also predicts differential response to two or with anxiety disorders were diagnosis-free by post- more treatments. As such, a moderator variable treatment assessment compared with only 13% of must interact with treatment assignment to spec- wait-list children with effects that were maintained ify for whom a specifi c treatment works. For at 12-month follow-up. Since then, others have example, a reinforcement-based program might shown that anxious children improve signi fi cantly work best for younger children whereas a cogni- with CBT whether delivered in a group or individ- tive-based procedure might work best for older ual format (e.g., Manassis et al., 2002 ; Flannery- children. This distinction is an important one Schroeder & Kendall, 2000 ) . Consequently, because not all predictor variables are modera- individual or group CBT has been deemed to meet tors of treatment outcome. The examination of criteria as an ef fi cacious treatment for childhood predictors and moderators of treatment response anxiety disorders (Silverman et al., 2008 ) . presents a challenge in treatment research litera- Based on extensive evidence regarding the role ture, due to the large sample sizes needed to con- of parent factors in the etiology and maintenance duct appropriate statistical analyses and, of anxiety disorders (Craske & Waters, 2005 ) , furthermore, the need for RCT designs using at other work has examined the ef fi cacy of CBT least two active treatment conditions in order to when parents of anxious children are involved in establish moderator variables. As a result, the treatment. Multiple studies have reported superior 3 Prognostic Indicators 39 treatment outcomes from CBT interventions highlights that direct involvement of very young including parent anxiety management training anxious children may not be necessary in treat- compared with CBT alone (e.g., Barrett, Dadds, ment and could lead to signi fi cant time and & Rapee, 1996 ; Cobham, Dadds, & Spence, 1998 ; resource savings. Bogels & Siqueland, 2006 ; Rapee, 2000, 2003 ; Signi fi cant inroads have similarly been made Rapee, Abbott, & Lyneham, 2006 ; Spence, in disseminating CBT to a greater number of Holmes, March, & Lipp, 2006 ; Wood, Piacentini, children with anxiety disorders. This has included Southham-Gerow, Chu, & Sigman, 2006 ) . parent-implemented bibliotherapy supplemented However, long-term superiority of CBT including with written materials (Rapee et al., 2006 ) , and parent training has been inconsistently observed technological advancements including use of the (e.g., Barrett, Duffy, Dadds, & Rapee, 2001 ; Internet, DVD, and email/phone supplemented Cobham, Dadds, Spence, & McDermott, 2010 ) , bibliotherapy implemented by parents of anxious and other studies have not demonstrated greater children (Khanna & Kendall, 2010 ; Lyneham & effects for a parental component (Nauta, Scholing, Rapee, 2006 ; Spence et al., 2006 ) . Bibliotherapy- Emmelkamp, & Minderaa, 2001, 2003 ; Spence, based CBT relying on written materials was Donovan, & Brechman-Toussaint, 2000 ) . The tra- found not to be as effective as clinic-based CBT ditional assumption that parenting casually (Rapee et al., 2006 ) ; however, studies employing in fl uences child anxiety was challenged in a study Internet delivery of CBT and email/phone sup- by Silverman, William, Jaccard, and Pina ( 2009 ) . plemented bibliotherapy yielded treatment out- In this study, Silverman and colleagues (2009 ) come rates between 56 and 81%, paralleling suggested that the association between negative those of clinic-based CBT trials (Khanna & parenting behavior and child anxiety may in Kendall, 2010 ; Lyneham & Rapee, 2006 ; Spence fact refl ect the infl uence of child anxiety on par- et al., 2006 ) . These innovations in CBT dissemi- enting variables, as opposed to vice versa. Hence nation have high public health signi fi cance given they argue that as child anxiety improves, nega- the high prevalence of childhood anxiety disor- tive parenting similarly improves, providing one ders and their capacity to reach anxious children possible explanation why parental involvement in rural and remote regions. versus noninvolvement is often deemed similarly As can be seen, considerable advancement has effi cacious (e.g., Silverman et al., 2008 ) . been made over the past two decades establishing Interestingly, however, younger children (7–10 the effi cacy and accessibility of CBT for child- years) compared to older children (11–14 years) hood anxiety disorders. While approximately appear to respond better to CBT when supple- 60% of children are diagnosis-free following mented with parent anxiety management (Barrett, treatment (James, Soler, & Weatherall, 2006 ) , not 1998 ) . Indeed, recent work has shown that CBT all children respond to CBT, with numerous fac- including parental involvement was effective in tors contributing to relapse, dropout, or nonre- reducing clinical anxiety in 69% of anxious chil- sponse to treatment. This has spurred new efforts dren as young as 4–7 years of age which resem- to improve outcomes from CBT for childhood bles clinical outcomes with older children anxiety disorders, including the combination of (Hirshfeld-Becker et al., 2010 ) . Related studies CBT with pharmacotherapy agents, such as selec- have shown that between 59 and 80% of anxious tive serotonin reuptake inhibitors (SSRIs; e.g., children between 4 and 7 years of age were diag- sertraline). In a recent large multisite US study of nosis-free following CBT interventions delivered clinically anxious children, Walkup and col- solely with parents; rates that were comparable to leagues (2008 ) were the fi rst to evaluate a com- those obtained from more traditional child– bined (CBT) and pharmacological treatment parent conditions (e.g., Mendlowitz et al., 1999 ; (SSRI) for childhood anxiety disorders including Cartwright-Hatton, McNally, & White, 2005 ; GAD, separation anxiety disorder, and social Thienemann, Moore, & Tompkins, 2006 ; Waters, phobia. The authors concluded that combined Ford, Wharton, & Cobham, 2009 ) . This work CBT and SSRI (sertraline) produced superior 40 L.J. Farrell et al. outcomes to CBT alone, SSRI alone, or placebo. variables also diminished when comparing chil- These fi ndings suggest that, for anxious children, dren who received group treatment, relative to adding SSRI medication to quality CBT offers those whom received individual CBT. Based on the most favorable outcomes, relative to each this chapter, the fi ndings suggest that parental treatment alone. Further research examining pre- symptoms of psychopathology are more problem- dictors and moderators of treatment response is atic in treating younger children and in individual needed in order to develop prescribed treatment delivery of CBT (Berman et al., 2000 ) . options for individual children. Crawford and Manassis (2001 ) speci fi cally examined the impact of a wide range of familial variables on child outcomes in their treatment Predictors of Treatment Response study of 61 children and youth aged 8–12 years. This study examined predictors of response Silverman et al. ( 2008 ) provide the most recent across clinician-rated improvement, mother-rated and comprehensive systematic review of the treat- improvement, and child self-reported improvement literature for child anxiety disorders, includ- ment. Child ratings of family dysfunction and ing 32 group design treatment studies spanning frustration were signi fi cant predictors of both cli- almost two decades since Kendall’s ( 1994 ) semi- nician and child-rated treatment response. nal CBT treatment trial. The authors of this chap- Further, mother and father reports of family dys- ter dedicate a section to the cumulative evidence function and maternal parenting stress predicted on predictors and moderators of treatment response mother-rated treatment response, while father arising from the published literature. Interestingly, reported somatization also predicted child-rated there is no current study in the child anxiety treat- treatment response. This study highlights that ment literature (excluding OCD-speci fi c research) family dysfunction plays an important role in that systematically examines moderators of treat- treatment response for children with anxiety dis- ment response; however, there are several studies orders. Victor, Bernat, Bernstein, and Layne that explore predictors of treatment success and ( 2007 ) report similar fi ndings in 61 treatment- failure. Based on this literature, almost all the evi- seeking children (aged 7–11 years), with higher dence for signifi cant predictors of treatment family cohesion associated with greater symptom response relate to familial factors, including mater- reduction in child anxiety. This study, however, nal and paternal psychopathology, parenting found no effect for parenting stress or parental approaches, and general family functioning. psychopathology. A number of studies have found that parental Since Silverman and colleagues’ ( 2008 ) sys- psychopathology plays a signifi cant role in tematic review, Liber and colleagues from the response to child anxiety disorder treatment. Netherlands ( 2008 ) have published an examina- Berman and colleagues (2000 ) examined prediction of parenting variables and parental anxiety tors of response in 106 youth who participated in and depression as predictors of treatment outcome one of two treatment studies published by in child anxiety CBT treatment. This study Silverman and colleagues (i.e., Silverman, included 124 outpatient treatment-seeking chil- Kurtines, Ginsburg, Weems, Lumpkin, et al., dren, aged 8–12 years, as well as 123 mothers 1999 ; Silverman, Kurtines, Ginsburg, Weems, and 108 fathers. In this study, paternal anxiety and Rabian, et al., 1999 ) . A number of signifi cant depression symptoms, paternal rejection, and familial predictor variables emerged, including maternal emotional warmth were signifi cantly parental symptoms of depression, fear, hostility, related to a less successful response to treatment. and paranoia. Interestingly, the importance of Interestingly, mother’s and father’s levels of anxiety, these parental predictors variables appeared to be depression, and rejection were not signi fi cantly related to child age, with variables being signifi cant different at baseline; however, only father’s expe- for child samples but not so for adolescents. rience of these variables impacted on child treat- Furthermore, the importance of parental predictor ment outcome, suggesting a pivotal role of 3 Prognostic Indicators 41 paternal psychopathology on children’s response ioral disorders (including attentional disorders to treatment. Maternal emotional warmth is a sur- and oppositional disorders). This study reviewed prising predictor and largely inconsistent with 43 child anxiety randomized controlled trials and other studies; however, the authors of this study found that only 14 of these trials systematically suggest that children’s ratings of maternal emo- examined the predictive or moderating role of tional warmth may actually re fl ect maternal over- comorbidity on treatment outcome. Ollendick involvement—an interesting hypothesis which and colleagues ( 2008 ) found that there were only requires further exploration. two trials in the published general anxiety litera- In regard to maternal anxiety as a predictor of ture (excluding studies from the OCD treatment child treatment response, Cooper, Gallop, literature, which are reviewed later in this chap- Willetts, and Creswell (2008 ) found support for ter) that reported signifi cant, albeit small, differ- the signifi cant role of maternal anxiety in predict- ences on treatment response depending on ing a less favorable treatment response in 55 chil- comorbidity. Berman et al. ( 2000 ) found that dren referred to the local community health children with comorbid depression in a sample of service. This study also provided evidence for a anxious children from two Silverman et al. trials specifi city effect of maternal anxiety—with (Silverman, Kurtines, Ginsburg, Weems, maternal social phobia related to a poorer Lumpkin, et al., 1999; Silverman, Kurtines, response, whereas maternal GAD did not have a Ginsburg, Weems, Rabian et al., 1999 ) were more signifi cant effect on child treatment response. likely to be in the treatment failure group. Rapee Likewise, Gar and Hudson (2009 ) found a ( 2003 ) examined the in fl uence of comorbidity signi fi cant effect of maternal anxiety on child across three groups of anxious youth—no comor- anxiety response to treatment in their study of 48 bidity, comorbid anxiety diagnosis, and comor- clinically anxious 6–14-year-old children. In this bid non-anxiety diagnosis—and found that study, maternal anxiety was a signi fi cant predic- children with comorbidity had higher parent- tor at posttreatment, with only 28% of children reported externalizing symptoms from posttreat- improved with anxious mothers, compared to ment to follow-up and attended fewer therapy 58% of children with non-anxious mothers. This sessions relative to the no comorbidity group. difference in response rate was not, however, The prevailing evidence therefore, based on signi fi cant at 12-month follow-up suggesting that Ollendick et al.’s (2008 ) comprehensive review maternal anxiety might be related to a slower of this issue, suggests that comorbidity has little treatment response in children with anxiety. impact on child anxiety treatment response Apart from familial and parenting variables, (excluding OCD), although large studies that sys- there is little support for other signi fi cant predictors tematically examine comorbidity as a moderator of response to child anxiety treatment. Kendall of treatment response are needed. and colleagues (Kendall, 1994; Kendall, Brady, And fi nally, Liber and colleagues ( 2010 ) inves- & Verduin, 2001 ; Treadwell, Flannery-Schroeder, tigated the associations between treatment adher- & Kendall, 1995 ) have examined child gender, ence, child–therapist alliance, and child clinical ethnicity, comorbidity, perceptions of therapeutic outcomes across individual and group treatment relationship, and therapist perceptions of parental of 52 anxious youth (aged 8–12 years). This study involvement as possible predictors of child found that neither treatment adherence nor thera- treatment response and found none of these peutic alliance predicted child outcomes; how- variables to be signifi cant predictors (Silverman ever, results did provide support that a strong et al., 2008 ) . In regard to the important issues alliance in individual therapy was associated with of comorbidity, Ollendick and colleagues better diagnostic outcomes relative to group CBT. ( 2008) have published a review paper exploring Contrary to initial results, using a more stringent speci fi cally the role of comorbidity on child measurement of outcome, child alliance was treatment outcomes across child anxiety disor- associated with greater reliable change—a fi nding ders, affective disorders, and disruptive behav- that is also inconsistent with fi ndings of Kendall 42 L.J. Farrell et al. and colleagues (see Kendall, 1994 ; Kendall et al., to CBT including a parental anxiety management 1997 ) . Further research is clearly necessary to module. Further research is clearly needed, examine the role of therapeutic process variables involving multiple group design RCTs to eluci- in predicting child outcomes. Research specifi cally date moderators of treatment response for child exploring the role of different therapeutic pro- anxiety disorders. cesses variables across individual and group therapy (e.g., child alliance versus group cohesion; Liber et al., 2010 ) would also progress our Speci fi c Phobias in Children understanding about the role of technical and pro- and Adolescents cess variables in improving treatment outcome across different modalities of treatment. Current Status of Treatment Outcome The cumulative research to date in the general child anxiety treatment literature suggests that Behavioral and cognitive–behavioral procedures family functioning, parental rearing approaches have also received strong empirical support in the (i.e., rejection, warmth, hostility), and parental treatment of childhood phobias (King, Muris, & psychopathology (i.e., depression and anxiety) Ollendick, 2005 ; Ollendick, Davis, & Sirbu, 2009 ) . are consistently important predictors of treatment Techniques such as in vivo exposure, participant response for children with anxiety disorders. modeling, and reinforced practice or contingency Interestingly, research is suggestive of a stronger management have been shown to be particularly in fl uence of father’s psychopathology on child effective with these youth. For those youth with a outcomes (e.g., Liber et al., 2008 ) , highlighting specifi c phobia diagnosis, three large randomized the need for more focused research on the role of controlled trials (Öst, Svensson, Hellström, & fathers in both the etiology and treatment of child Lindwall, 2001 ; Ollendick et al., 2009 ; Silverman anxiety and most certainly greater efforts to et al., 1999 ) and two smaller clinical trials have involve fathers in child anxiety treatments. been conducted (Flatt & King, 2010 ; Muris, Gender, ethnicity, and comorbidity (apart from Merckelbach, Holdrinet, & Sijsenaar, 1998 ) . depression, see Berman et al., 2000 ) appear to In the fi rst RCT, Silverman and colleagues not be important in relation to a child’s respon- ( 1999) compared the effectiveness of exposure- siveness to treatment, and further research explor- based cognitive self-control (SC) and exposure- ing the impact of therapeutic alliance and based contingency management (CM) treatments treatment adherence on child treatment response to an education support (ES) control condition. is necessary. In regard to moderating variables, to Eighty-one children and adolescents (aged 6–16 date, there are no studies that systematically years) from the United States (US) participated. explore this in the child anxiety treatment litera- Youth presented with a diverse range of phobias. ture; however, child age and parental psychopa- Treatments were manualized and involved ten thology are hypothesized to moderate response sessions (80 min each) during which children and with regard to parent involvement in CBT. their parents were fi rst seen separately by the Evidence for this comes from two studies, includ- same therapist and then seen conjointly at the end ing one RCT of individual CBT versus CBT plus of the sessions. Findings were mixed. Although family involvement (Barrett et al., 1996 ) , which the three treatment conditions showed compara- demonstrated that younger children responded ble improvements on child self-report and parent signi fi cantly better to CBT involving a family report measures at posttreatment, signifi cant dif- component relative to CBT alone, and that for ferences were observed between the conditions older children there were no differential effects. on two major clinically signifi cant treatment out- Secondly, Cobham et al. ( 1998 ) found that when come measures (e.g., diagnostic outcomes and anxious children had at least one parent with fear thermometer ratings). Eighty-eight percent clinical anxiety, children responded signifi cantly of participants in the SC condition were recov- less well at posttreatment to CBT alone relative ered (no longer met diagnostic criteria for a pho- 3 Prognostic Indicators 43 bia) at posttreatment, compared to 55% in the present condition; however, no signifi cant differ- CM condition and 56% in the ES condition. ences were observed between the two conditions. Additionally, 80% of participants in the SC and This outcome was not expected as it was hypoth- CM conditions reported either no or little fear on esized that the presence of the parents during their fear thermometer ratings (a measure of sub- treatment would facilitate change. Although jective distress toward their feared object or speculative, this unexpected outcome may have event) at posttreatment compared to 25% in ES been due to the fact that most of the parents were condition. Hence, Silverman et al. found consid- not actively involved in the treatment process; erable support for exposure-based therapies par- rather, for the most part, they were passive observers. ticularly SC in the treatment of youth phobias. Nonetheless, treatment gains in both groups were More recently, cognitive–behavioral proce- maintained at one-year follow-up. dures have been incorporated into an intensive In the largest randomized trial, Ollendick et al. one-session treatment (OST) package in the treat- ( 2009 ) assigned 196 children and adolescents ment of phobias in children and adults (Öst, (7–16 years) with various specifi c phobias to 1989 ) . OST involves a single, 3-hour session of OST (alone, without parent present), education massed exposure which includes aspects of psy- support treatment, or a wait-list control condition. choeducation and skills training, cognitive Participants were recruited from Sweden and the restructuring, graduated in vivo exposure, partici- USA. OST and education support treatment were pant modeling, and reinforced practice (Cowart & superior to the wait-list control condition. Ollendick, 2013 ) . In a small randomized clinical Furthermore, OST was found to be superior to trial, Muris et al. ( 1998 ) compared OST to EMDR education support treatment on clinician ratings and a computerized exposure control group in 26 of phobic severity, percentage of participants spider phobic children and adolescents from the diagnosis-free (55% OST vs. 23% EST) at post- Netherlands. OST was found to be superior to treatment, child ratings of anxiety during the the two other interventions on measures of behavioral avoidance test, and treatment satisfac- subjective distress and ratings of anxiety during tion as reported by youth and their parents. the behavioral avoidance test. Unfortunately Treatment effects were maintained at six-month Muris and colleagues did not report diagnostic follow-up. However, similar to Öst et al. (2001 ) recovery rates. and Silverman et al. (1999 ) , no differences were In a subsequent trial conducted in Sweden, observed on child self-report measures. Öst et al. ( 2001 ) evaluated the relative ef fi cacy of Finally, Flatt and King ( 2010 ) replicated the OST alone and OST with parent present to a Ollendick et al. (2009 ) study with a smaller sam- wait-list control condition. In the parent present ple of 43 Australian phobic youth aged 7–17 condition, the parent sat in on the session with the years. Children and adolescents were randomized child and was enlisted primarily as a support to OST (alone, without parent present or involve- fi gure to the child during the in vivo exposures. ment in the treatment), a psychoeducation pack- Sixty youth (7–17 years) with a diverse range of age or a wait-list control. Both active treatments phobias participated in the study. Both OST con- were superior to the wait-list control on the behav- ditions were found to be superior to the wait-list ioral avoidance test and percentage of participants control condition on the primary outcome mea- who were diagnosis-free at posttreatment. sures of subjective distress, behavioral avoidance, Unexpectedly, however, differences in treatment and independent assessor ratings of the severity effectiveness were not found between OST and of phobias at posttreatment. However, as with psychoeducation treatments at posttreatment and Silverman et al. (1999 ) , the three groups did not one-year follow-up. This unexpected fi nding might differ signi fi cantly on child self-report and parent be explained by the psychoeducation program report measures following treatment. Overall, used by Flatt and King ( 2010) . In addition to there was a trend for youth in the alone OST education and support, this condition also taught condition to fare better than youth in the parent participants about gradual exposure and actively 44 L.J. Farrell et al. encouraged them to practice exposure in real-life dictors of treatment success for the two active situations. Hence, exposure may have been the exposure-based interventions and found that chil- active ingredient in both interventions. dren in the treatment failure group had signi fi cantly Overall, the aforementioned studies provide higher rates of comorbid depressive diagnoses strong empirical support for cognitive and behav- and higher levels of self-report trait anxiety and ioral treatments for phobic youth. In particular, depression than those in the treatment success OST is an effective and rapid treatment for pho- group. Similarly, parents in the treatment failure bic youth, with four randomized trials in four dif- group also reported higher levels of depression, ferent countries supporting its use (Flatt & King, fear, and hostility for themselves than did parents 2010 ; Muris et al., 1998 ; Ollendick et al., 2009 ; in the treatment success group. Öst et al., 2001 ) . Interestingly, to date, no large- In contrast to Silverman et al. ( 1999 ) , the scale randomized trials have been conducted with other randomized control trials and smaller clini- less intensive exposure programs delivered in a cal trials for youth with specifi c phobias imple- more standard weekly format over a period of mented exposure-based treatments in one session time as is typical in most outpatient settings. Nor, of approximately 3 h duration (Muris et al., for that matter, have the more intensive programs 1998; Ollendick et al., 2009; Öst et al., 2001 ) . been compared to the less intensive ones. Muris and colleagues ( 1998 ) evaluated the rela- Moreover, the potential role of parents in the tive effi cacy of OST, EMDR, and a computer- treatment of phobic youth has not yet been sys- ized exposure control group in a small clinical tematically explored—however, such a trial is trial with spider phobic youth. OST was found to presently under way by Ollendick and colleagues be superior to the other two interventions on in the USA. measures of subjective distress and ratings anxiety during the behavioral avoidance test. Unfortunately, however, Muris and colleagues Predictors of Treatment Response did not report on diagnostic recovery rates or investigate predictors of treatment outcome in Unfortunately, there is limited information about their study. predictors of treatment response in youth with It will be recalled that Öst and colleagues specifi c phobias, and worse still, there is presently (2001 ) compared two variants of the intensive little to no evidence for moderators of treatment OST to a wait-list control condition. As expected, outcome with specifi c phobias (Seligman & the OST groups responded better than the simple Ollendick, 2011 ) . We examine the fi ndings for the passage of time in the wait-list group. Clinical major randomized control trials and smaller clini- improvement was de fi ned in various ways, but for cal trials reviewed earlier in this chapter, which our purposes here, we will use the criterion that showed the ef fi cacy of cognitive–behavioral pro- was similar to that used by Silverman and col- cedures in the treatment of well-characterized leagues (1999 ) : signi fi cant reductions in clinical youth with speci fi c phobias. In the fi rst major ran- severity on the structured diagnostic interview. domized controlled trial, Silverman and col- Predictor variables in this study included age, gender, leagues (1999 ) examined the utility of contingency comorbidity, and type of phobia (e.g., animal, management, self-control, and education support situational, environmental, and blood-injection- in the treatment of childhood anxiety, including injury type). Measures of psychopathology in the phobias. As will be recalled, this study showed parents were not obtained. Findings revealed that that exposure-based contingency management none of the predictor variables was related to treat- and exposure-based self-control treatments proved ment outcome as de fi ned by signi fi cant reductions more ef fi cacious than an education support condi- in clinical severity on the diagnostic interview. It tion on major treatment outcome variables (e.g., should be noted that on a secondary measure of fear ratings, diagnostic outcomes). As previously treatment outcome, improvements on a behav- reviewed, Berman, et al. (2000 ) explored the pre- ioral approach test, girls responded better than 3 Prognostic Indicators 45 boys as did youth with animal phobias compared and depression in the children themselves were to those with other types of phobias. associated with treatment failure. These results Ollendick et al. ( 2009) compared this intensive also remain to be replicated at this time. As is intervention to not only a wait-list control condi- evident, the study of predictors of treatment tion but also to an education support condition. As response for youth with specifi c phobias is expected, youth in the OST responded better than extremely sparse at this time and much awaits to those in either the education support or the wait- be done before we will have a clear picture of the list control condition: These salutatory effects youth for whom and under what conditions our were found both in terms of those who evinced treatments will be shown to be effective. reduced clinical severity ratings and those who were diagnosis-free. Predictor variables included age, gender, phobia type, and comorbidity of Obsessive–Compulsive Disorder diagnosis (see also Ollendick et al., 2010 ) . As in Children and Youth with Öst et al. (2001 ) these variables were not related differentially to treatment success or treat- Current Status of Treatment Outcome ment failure. Additional analyses are currently under way to explore parental psychopathology The OCD Expert Consensus Guidelines (King, and family functioning variables and their rela- Leonard, & March, 1998 ) for treatment of child- tions to treatment success. hood OCD recommend CBT alone as the fi rst-line Finally, Flatt and King ( 2010 ) replicated treatment for children and adolescents with mild Ollendick et al. (2009 ) and randomized youth to to moderate OCD and the combination of an SSRI OST, a psychoeducation package or a wait-list medication in addition to CBT for severe OCD. control. Both active treatments were superior to The current status of treatment research, includ- the wait-list control on the behavioral avoidance ing long-term outcome studies and meta-analytic test and percentage of participants who were reviews, provide support for these current guide- diagnosis-free at posttreatment. Predictor variables lines, with evidence to support the ef fi cacy for examined in this study included age, gender, and CBT, based on exposure plus response prevention phobia type. Consistent with Öst et al. (2001 ) and (ERP), either alone or in combination with a sero- Ollendick et al. ( 2009 ) , these variables did not tonin reuptake inhibiting (SRI) medication (see predict treatment outcome. Abramowitz, Whiteside, & Deacon, 2005 ; Barrett, Collectively, although the fi ndings with diag- Farrell, Pina, Peris, & Piacentini, 2008 ; Barrett, nosed children and adolescents are limited, these Healy-Farrell, Piacentini, & March, 2004 ) . studies show that sociodemographics of the child CBT for children and adolescents with OCD (e.g., age, gender, socioeconomic status, and eth- is typically based on March and colleagues’ nicity) and severity of the diagnosis as well as individual CBT protocol (“How I ran OCD off type of phobia are not related to treatment suc- My Land”; see March et al., 1994 ; March and cess or failure. In the two one-session treatments Mulle, 1998 ) and involves three treatments that explored comorbidity (Ollendick et al., 2009 ; components including (1) psychoeducation, Öst et al., 2001 ) , the presence of comorbidity was “externalizing OCD,” anxiety management, not related to treatment outcome; however, in the and cognitive therapy; (2) intensive therapist 10-week exposure-based program of Silverman assisted ERP and associated homework; and and colleagues (1999 ) , comorbidity with depres- (3) maintenance of gains, including problem- sion was related to outcome. Still, even in this solving and relapse prevention. ERP is the study, only a few of the youth were comorbid active ingredient in CBT for OCD and involves with depression and the fi ndings have not yet exposing patients to stimuli that triggers fear been replicated. Further, in this latter study, while simultaneously encouraging them to parental psychopathology characterized by anxiety, resist engaging in compulsive behaviors. Most depression and hostility, and heightened anxiety approaches to child treatments for OCD also 46 L.J. Farrell et al. involve a parent or family component; how- (CBT + SRI) has been examined in a systematic ever, the nature and intensity of this aspect of review by O’Kearney, von Sanden, and Hunt treatment varies greatly. Parental or family ( 2010 ) . O’Kearney and colleagues (2010 ) adjuncts to CBT often includes psychoeduca- identifi ed three studies (Asbahr et al., 2005 ; de tion, problem-solving skills, strategies to Hann et al., 1998 ; POTS, 2004 ) to date, which reduce parental involvement and accommoda- have examined the relative ef fi cacy of CBT ver- tion to the child’s OCD symptoms, along with sus medication alone and found no evidence to encouraging family support of home-based suggest that either CBT or medication alone were ERP, and developing contingency management superior over the other on symptom severity or schedules to support ERP gains. remission rates. Two studies were identifi ed by Barrett, Farrell, and colleagues (2008 ) pub- O’Kearney et al. (2010 ) to have examined the lished a systematic review of the current status of relative ef fi cacy of combined CBT and medica- evidence-based for psychosocial treatments of tion treatment over medication alone (Neziroglu pediatric OCD. Studies were evaluated for meth- et al., 2000 ; POTS, 2004) , and one study has odological rigor according to the classifi cation examined the relative ef fi cacy of combined treat- system of Nathan and Gorman (2002 ) and were ment versus CBT alone and medication alone in then assessed relative to the criteria for evidence- a placebo-controlled design (POTS, 2004 ) . These based treatments specifi ed by Chambless et al. studies were consistent in demonstrating that ( 1998 ) , Chambless et al. ( 1996 ) , and Chambless combined treatment (CBT + SRI) was superior to and Hollon (1996 ) . Findings indicate that indi- medication alone in reduction of OCD severity as vidual CBT with ERP for children and adoles- well as remission rates; however, combined treat- cents with OCD meets criteria for designation as ment did not differ signi fi cantly from CBT alone probably effi cacious based on the treatment litera- (O’Kearney et al., 2010 ) . In the POTS trial (2004 ) , ture to date. To meet criteria for designation as a there was an interesting and signifi cant site X well-established treatment (e.g., Chambless et al., treatment condition interaction, indicating that 1998 ; Chambless et al., 1996 ; and Chambless & while combined treatment was favorable over Hollon, 1996 ) , a treatment requires at least two CBT at one site, it was not superior to0 CBT “good” RCTs from different investigative teams alone at another, with both condition providing showing the treatment to be superior to pill pla- very large effect sizes. Results from two further cebo or alternate treatment or equivalent to an meta-analyses (Abramowitz, Whiteside, & already established treatment in studies with ade- Deacon, 2005; Watson & Rees, 2008 ) also pro- quate statistical power. Furthermore, outcomes vide consistent results, that is, that both treat- from the Pediatric OCD Treatment Study (POTS, ments alone (CBT, SRI) and in combination are 2004 ) provide evidence to support combination signi fi cantly superior to placebo, with large CBT treatment of individual CBT plus sertraline (SRI treatment effect sizes relative to medium treat- medication) as also meeting criteria for probably ment effect sizes for pharmacotherapy. Taken effi cacious . Family-based CBT, delivered as indi- together, the results of these systematic reviews vidual or group therapy, was deemed as possibly provide evidence for the effi cacy of CBT, either effi cacious based on the review by Barrett et al. alone or in combination with an SRI medication, ( 2008 ) ; however, with the publication of a more and support the recommendations outlined in the recent RCT examining family-based CBT for expert consensus guidelines. younger children with OCD (aged 5–8 years), this In regard to the magnitude of change associ- treatment would now meet criteria as probably ated with CBT on children’s OCD symptoms effi cacious also, given the favorable effects of and disorder, examination of effect sizes pro- CBT relative to relaxation training on remission vides a favorable picture. Barrett and colleagues rates (see Freeman et al., 2008 ) . ( 2008) in their systematic review provide esti- The comparative effectiveness of CBT versus mates of between-group effect sizes (CY-BOCS SRI medication alone and combination treatment ratings) ranging from 0.99 to 2.84 for type 1 3 Prognostic Indicators 47 studies (i.e., based on Nathan and Gorman’s there are few studies examining predictors of classifi cation system, 2002 ) and within-group treatment outcome, due to the large sample sizes effect sizes on the CY-BOCS from 1.57 to 4.32 needed for these analyses. Furthermore, there are (individual CBT) and 0.82 to 1.15 (group CBT) only two studies to date which examine modera- for type 2 and type 3 studies. While effect sizes tors of treatment response, given that these stud- for CBT are impressive, examination of the ies require designs with more than one treatment actual percentage of children experiencing remis- condition. From the limited research conducted sion from disorder following treatment is less to date, however, there is some consistency with favorable with rates ranging from 40 to 85% regard to variables that might de fi ne subgroups of across studies (Barrett, Healy-Farrell, & March, children and adolescents with more diffi cult-to- 2004 ; POTS, 2004 ; Storch et al., 2007 ; Waters, treat OCD. Barrett, & March, 2001 ) . In fact, results from the A recent review of the treatment literature largest multisite RCT (POTS, 2004 ) indicates published between 1985 and 2007 (Ginsburg, that as many as 60% of children receiving CBT Newman Kingery, Drake, & Grados, 2008 ) alone, 50% receiving combined CBT and sero- identifi ed 21 studies which examined predictor tonergic medication, and almost 80% receiving variables in pediatric samples of primary OCD. serotonergic medication alone fail to fully remit Of these studies, six evaluated CBT only, 13 eval- following treatments. Understanding predictors uated medication treatment only, and two studies and moderators of treatment response for child- reported on combined CBT and medication hood OCD represents an important focus for (Ginsburg et al., 2008 ) . In this chapter, Ginsburg psychological treatment research and will assist and colleagues (2008 ) identi fi ed nine predictor in (1) the re fi nement of our current best treat- variables that were examined in more than one ment approaches, (2) the development and evalu- study, including child gender, age, duration of ill- ation of innovative interventions, and (3) the ness/age at onset, baseline severity of OCD, type advancement of clinical guidelines for prescrib- of OCD symptoms, comorbid disorders/symp- ing the most appropriate treatment for a given toms, psychophysiological factors, neuropsycho- individual. logical factors, and family factors. The authors of this chapter concluded that gender, age, or duration of illness (age of onset) were not associated Predictors of Treatment Response with treatment response. Baseline severity of OCD symptoms and family dysfunction, how- Although the majority of children and adolescents ever, were associated with poorer response to with OCD do experience clinically signi fi cant CBT, and comorbid tics and externalizing disor- reduction in OCD symptoms following our best ders were associated with poorer outcome in treatments, the outcomes in terms of remission medication only studies. Garcia and colleagues rates provide less than optimal results, with at ( 2010) have recently published an examination of least 50% of children deemed as non-remitters predictors and moderators, based on the multisite (e.g., POTS, 2004 ) . These fi ndings suggest that POTS (2004 ) study, and examined 15 variables of one in two treatment-seeking children and youth interest across four categories, including demo- will continue to suffer clinically signifi cant OCD graphic variables, severity of illness markers, even after combined CBT and SRI treatment. comorbid disorders/symptoms, and family fac- There is therefore a pressing need to understand tors. This study found that higher baseline OCD the predictors and moderators of treatment symptom severity, OCD-related functional response in pediatric OCD, in order to determine impairment (as rated by parents), higher external- appropriate ways to augment or refi ne our current izing symptoms, and higher family accommoda- best treatments and provide more effective tion were all signifi cantly associated with a management for those with diffi cult-to- treat poorer treatment response across treatment OCD. In the pediatric OCD treatment literature conditions in the POTS trial—which included 48 L.J. Farrell et al.

CBT alone, sertraline alone, combined treatment, which was superior to sertraline alone, which was and placebo control. superior to the placebo condition (POTS, 2004 ) . In addition to these fi ndings, Storch and col- However, for the sample with comorbid tic disor- leagues ( 2008 ) have added to the predictor of out- ders, sertraline alone did not differ signifi cantly come literature, examining the impact of from the placebo condition, while combined treat- comorbidity on response to CBT treatment in a ment (CBT + sertraline) remained superior to treatment-seeking sample of 96 youth with a pri- CBT, and CBT remained superior to PBO. This mary diagnosis of OCD. In their study, Storch and fi nding, consistent with Ginsburg et al. ( 2008 ) , colleagues ( 2008 ) found that having one or more provides strong evidence that children with comorbid conditions was associated with a poorer comorbid OCD and tic disorders respond differ- response to CBT outcome and that the number of entially to medication alone versus cognitive– comorbid condition was negatively related to out- behavioral treatments, which they appear to come. Furthermore, Storch and colleagues ( 2008 ) respond to equally as well as children without found that the presence of comorbid externalizing comorbid tic disorders. March and colleagues disorders (i.e., attention defi cit/hyperactivity dis- (2007 ) recommend that children with OCD and order, oppositional defi ant disorder, and conduct comorbid tic disorder should begin treatment with disorder) was associated with a poorer treatment CBT alone or a combined treatment of CBT and response and that both externalizing disorders and SRI, given that medication alone does not provide depressive disorders were associated with lower any benefi t over a placebo pill for these children. treatment remission rates. The authors of this Garcia and colleagues (2010 ) identifi ed another study did not fi nd evidence to suggest that comor- moderator variable—family history of OCD. For bid anxiety disorders or comorbid tic disorders those without a family history, combined treat- were associated with a poorer response to CBT. ment (CBT + sertraline) was superior to placebo The collective fi ndings by Ginsburg and col- and sertraline alone, and CBT alone was superior leagues (2008 ) , Garcia et al. (2010 ) , and Storch to placebo. However, for those with a family his- et al. (2008 ) on the impact of comorbidity are also tory of OCD, there were no signifi cant differences consistent with a recent study by Farrell and col- in outcome across the treatment conditions. leagues ( 2012) , whom also found that higher fre- Inspection of the effect size, however, demon- quency of comorbid conditions was associated strated smaller effects for those with a family his- with poorer response to CBT in children and tory across all conditions. Further, for CBT youth with OCD, and that specifi cally, comorbid monotherapy, this reduction in effect size was child disruptive behavioral disorders was associ- marked and in fact was 6.5 times smaller than ated with a poorer response to treatment. those without a family history of OCD. Garcia Two studies have recently examined the impor- and colleagues (2010 ) examined whether differ- tant issue of moderators of treatment response in ences in degree of family accommodation was pediatric OCD; offering valuable information associated with this reduction in effect size and about which of the current best treatments avail- found that patients with and without family his- able (e.g., CBT alone or combined CBT + SRI) is tory of OCD did not differ in the amount of family best for specifi c subgroups of clients with OCD. accommodation. The authors conclude that a fam- March and colleagues (2007 ) reported on the ily history of OCD may attenuate CBT because impact of comorbid tic disorder on outcomes in this treatment generally requires more family sup- the POTS trial (2004 ) , examining treatment port and engagement (e.g., with assisting the child response for the 15% of the POTS sample (n = 17 in ERP homework), perhaps more so than medi- of 112) whom had a comorbid tic disorder. In cation compliance. For parents and family mem- patients without tic disorders, outcomes were con- bers with OCD, this degree of family involvement sistent with the entire intent-to-treat sample in therapy may actually serve to interfere with a (POTS, 2004 ) with combined treatment child’s treatment progress. The recommendation (CBT + sertraline) being superior to CBT alone, by Garcia and colleagues was that combined 3 Prognostic Indicators 49 treatment should be offered as fi rst-line treatment specifi c predictors and moderators of treatment in the instance of a family history of OCD, as response across the child anxiety disorders is fairly combined CBT and sertraline was found to be limited, therefore hindering the development of more robust than CBT alone (2.5-fold decrease in innovative and idiographic treatment approaches effect size) in the POTS trial. targeting the more dif fi cult-to-treat anxiety and Given that family accommodation (Garcia phobic presentations. This chapter has, however, et al., 2010 ; Merlo, Lehmkuhl, Geffken, & Storch, highlighted what is currently known about predict- 2009 ) , family dysfunction (Ginsburg et al., 2008 ) , ing treatment response for children and adoles- and family history of OCD (Garcia et al., 2010 ) cents with an anxiety disorder, and we emphasize have all been identifi ed as attenuating treatment here what appears to be the important prognostic response, treatments speci fi cally addressing fam- indicator’s that may be the focus of future research ily interactions and functioning are likely to enquiry and novel treatment developments. improve outcomes. Furthermore, the issue of For child anxiety disorders including social comorbidity of pediatric OCD warrants further phobia, generalized anxiety disorder and separa- consideration in terms of approaches to treatment. tion anxiety disorder, familial factors such as For children with tics disorders, CBT is an impor- parental psychopathology, family functioning, tant fi rst-line approach given that SRI medication and parental rearing approaches appear to be appears to be less effective for these children (e.g., important variables that in fl uence a child’s POTS, 2004 ) . For children with comorbid OCD response to CBT. More speci fi cally, maternal and externalizing disorders, it may be that we can and paternal anxiety, depression (particularly in improve outcomes for these children by develop- fathers), parental rejection and hostility, and ing and evaluating multicomponent treatments family functioning and cohesion are all impor- that fi rst address externalizing symptoms and the tant aspects of the family environment that impact of behavioral problems on the family, prior appear to play a role in a child prognosis. There to addressing OCD symptoms. is some evidence to suggest that familial variables may play a more pivotal role in the treatment of younger versus older youth and that Concluding Remarks and Future parental involvement in treatment might be more Directions important for younger versus older children; however, the research is not yet clear on these This chapter highlights three important issues issues due to the absence of any moderation based on the cumulative child anxiety disorder analyses. There is little evidence to suggest that treatment research of the past two decades—(1) speci fi c comorbidities play an in fl uencing role in there is currently considerable evidence to demon- child anxiety outcomes; however, child depres- strate that cognitive–behavioral treatments are sion appears to be the one exception that should ef fi cacious for the treatment of child anxiety, pho- be considered more carefully. There is currently bic, and obsessive–compulsive disorders, produc- very limited research by comparison into prog- ing large effects sizes, good long-term maintenance nostic indicators for child-specifi c phobias; how- of gains, and delivering clinically signi fi cant ever, research across the treatment trials improvements in functioning; (2) while outcomes conducted to date indicate that neither age, gen- are broadly favorable and suggest overall improve- der, nor type or severity of phobia effect response ment following treatment, there is considerable to treatment. Large-scale RCTs, however, are room for improvement, with approximately 1 in 2 under way into OST of speci fi c phobias by children continuing to suffer symptoms of clinical Ollendick and colleagues, which will provide signi fi cance following treatment, indicating more data for analyses of both predictors and modera- is needed in terms of understanding “who” are the tors of response in the near future which will nonresponders and “how” can we improve outcomes inform this limited fi eld of research. for them; and (3) our current understanding about 50 L.J. Farrell et al.

The status of research into predictors and come of age, providing evidence for effi cacy, moderators of treatment response for pediatric durability and, more recently, preliminary evidence OCD is the most progressed of the literatures on predictors and moderators of treatment reviewed in this chapter. The research to date, response. The implications of this research sug- albeit not large, has involved sophisticated gest a number of important implications for clin- analyses of predictors and moderators of treat- ical practice, including (1) when treating children ment response, based on the large multisite with anxiety disorders, clinicians should also POTS ( 2004) trial. These analyses, combined routinely assess for comorbid psychopathology, with outcomes from meta-analysis reviews and parental psychopathology, the quality of the par- individual treatment studies, have provided ent and child interaction, and the quality of the some emerging clarity and consistency about family environment and general functioning of prognostic factors for children and youth with the family, to inform a family-based idiographic OCD. Obsessive–compulsive symptom severity, functional analysis and problem formulation of functional impairment, family dysfunction, and the child’s anxiety; (2) clinicians should rou- high family accommodation are all consis- tinely involve parents in therapy for a child anxi- tently related to poorer treatment response. ety disorder and should carefully consider the Furthermore, unlike with other child anxiety type of involvement and intensity of parental disorders, comorbidity does seem to be impor- involvement, offering a fl exible idiographic for- tant in predicting and moderating treatment mulation-informed approach (e.g.,, where there response. Evidence suggests that externalizing is parental anxiety present, the clinician might disorders appear to generally reduce treatment provide a parental anxiety management module, success (Garcia et al., 2010 ; Storch et al., 2008 ) in addition to parental education and support for and comorbid tic disorders moderate outcome child anxiety, or when family functioning is poor to medication-alone treatment, with children and there is high parental rejection and criticism, responding poorer to SRI treatment with a the clinician may opt for a family therapy comorbid tic disorder (Ginsburg et al., 2008 ; approach to delivering child CBT, involving par- March et al., 2007 ) . Family history of OCD also ents in the therapy process thereby providing appears to moderate response to CBT alone, observational learning opportunities for parents with a considerable reduction in treatment in providing support and positive problem-solving effect size for CBT alone when there is a family approaches to assisting their child). Finally, this history of OCD. This cumulative research into chapter of the treatment research and predictors predictors and moderators of treatment response of treatment response highlights the need for (3) for pediatric OCD now provides evidence for routine ongoing assessment of a child’s prog- some specifi c treatment recommendations, ress and response to CBT throughout treatment, including (a) when OCD is comorbid with tics, so that clinician’s can augment CBT when there children should be prescribed CBT alone or in appears to be poor responsiveness, in order to combined with medication, over medication optimize treatment success. Examples of aug- alone; (b) children with a family history of menting CBT include the addition of more inten- OCD may respond better to CBT when com- sive parental involvement in CBT or parental bined with an SRI; (c) family accommodation anxiety management; alternatively augmenting and dysfunction should be routinely assessed in CBT with an SRI medication might be indicated the case of pediatric OCD and addressed in when there is only a partial response to CBT, or treatment; and (d) targeting comorbid external- when there is increased severity and impairment izing symptoms and disorders in treatment for of anxiety/phobia/OCD, or when anxiety is com- OCD might improve treatment success for those bined with complex comorbidity; and/or increas- children with comorbid disorders. ing the intensity of CBT by offering sessions at The treatment literature for child anxiety dis- home, twice weekly, or with combined telephone orders over the past two decades has most certainly support. 3 Prognostic Indicators 51

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Colleen M. Cummings , Kendra L. Read , Douglas M. Brodman , Kelly A. O’Neil , Marianne A. Villaboe , Martina K. Gere , and Philip C. Kendall

Across the lifespan, anxiety disorders are highly dif fi culties in peer relationships (Greco & Morris, prevalent. For adults, anxiety disorders are among 2005 ; Verduin & Kendall, 2008 ) , comorbidity the most common mental disorders, with 18.1 % with other mental health disorders (Kendall et al., meeting criteria for any anxiety disorder. The 2010 ; Masi, Mucci, Favilla, Romano, & Poli, 12-month prevalence rates of different anxiety 1999 ) , and poor academic achievement (Van disorders range from 0.8 % (agoraphobia without Amerigen, Manicini, & Farvolden, 2003 ) . Given panic disorder) to 8.7% (speci fi c phobia) in adult- the prevalence and interference caused by anxi- hood (Kessler, Chiu, Demler, & Walters, 2005 ) . ety disorders, the development, implementation, Adults with anxiety disorders are often at risk for and evaluation of evidence-based therapies is relationship impairment (Senaratne, Van warranted. Ameringen, Mancini, & Patterson, 2010 ) , physi- Treatments labeled variously as “behavioral,” cal health concerns (Sareen et al., 2006 ) , and “cognitive,” and “cognitive-behavioral” are the occupational disability (Mancebo et al., 2008 ) , as most widely studied psychological treatments for well as substance abuse (Kushner, Abrams, & anxiety disorders (e.g., Deacon & Abramowitz, Borchardt, 2000 ) and suicidality (Sareen et al., 2004 ) . Evidence supports cognitive-behavioral 2005 ) . Prevalence rates in youth range from 10 to therapy (CBT) as an ef fi cacious treatment for 20% (Chavira, Stein, Bailey, & Stein, 2004 ; both adults (for a review, see Deacon & Costello, Mustillo, Keeler, & Angold, 2004 ) and Abramowitz, 2004 ) and children (see Ollendick are associated with multiple impairments, including & King, 2011; Silverman, Pina, & Viswesvara, 2008) with anxiety disorders. This chapter will fi rst review the status of research surrounding empirically supported treatments (ESTs) for anx- C. M. Cummings (*) ¥ K. L. Read ¥ D. M. Brodman iety disorders in children and adults. Next, fac- K. A. O’Neil ¥ P. C. Kendall tors that potentially impact the delivery and/or Department of Psychology , Temple University , outcomes of ESTs for anxiety disorders will be Philadelphia , PA , USA e-mail: [email protected] discussed, including comorbidity, familial and cultural components, and therapeutic process M. A. Villaboe ¥ M. K. Gere Center for Child and Adolescent Mental Health, Eastern variables. Finally, future directions for research and Southern Norway , Oslo , Norway and practice will be offered.

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 57 DOI 10.1007/978-1-4614-6458-7_4, © Springer Science+Business Media New York 2013 58 C.M. Cummings et al.

and emotional avoidance (Borkovec, Newman, Empirically Supported Treatments Pincus, & Lytle, 2002) , CBT outcomes have been for Anxiety Disorders: Social Phobia/ improved (Newman, Castonguay, Borkovec, Separation Anxiety Disorder/ Fisher, & Nordberg, 2008 ) . The fi ndings from Generalized Anxiety Disorder/Speci fi c meta-analytic studies of psychological treat- Phobia ments for adults with SoP, GAD, and SP provide consistent positive support for CBT interventions Because treatment of social phobia (SoP), sepa- (see reviews by Beidel, Turner, & Alfano, 2003 ; ration anxiety disorder (SAD), generalized anxi- Butler, Chapman, Forman, & Beck, 2006 ; ety disorder (GAD), and specifi c phobia (SP) is Deacon & Abramowitz, 2004 ; Olatunji, Cisler, very similar, the ESTs for these disorders will be & Deacon, 2010 ) . reviewed together. Treatment for these disorders When working with youth, Albano and follows a cognitive-behavioral perspective of Kendall (2002 ) describe components of CBT for anxiety including physiological, cognitive, and anxiety disorders as including (1) psychoeduca- behavioral components. Therapy addresses each tion about anxiety disorders, (2) somatic manage- of these components with various strategies, ment for physical symptoms, (3) cognitive including somatic management techniques, cog- restructuring, (4) exposure tasks, and (5) relapse nitive restructuring, and behavioral exposure. prevention. One “empirically supported” CBT With adults, CBT treatments for SoP incorporate treatment for youth is the Coping Cat program cognitive restructuring, applied relaxation, expo- (Kendall & Hedtke 2006a, 2006b ) . The Coping sure to feared stimuli, and social skills training Cat consists of 16 sessions, separated into two (Jorstad-Stein & Heimberg, 2009 ; Rodebaugh, segments: skills training and skills practice (expo- Holaway, & Heimberg, 2004 ) . Similarly, for SP, sure tasks), and has been adapted for adolescents CBT typically focuses on exposure to the rele- (i.e., The C.A.T. Project ; Kendall, Choudhury, vant stimulus (e.g., an individual with a phobia Hudson, & Webb, 2002 ) . Several randomized of elevators rides elevators until the fear clinical trials (RCTs) have examined the effi cacy decreases), with consideration also given to the of the Coping Cat program , with sample sizes person’s cognitive processing of the event. ranging from 47 (Kendall, 1994 ) to 488 youth Exposure tasks can be in vivo, imaginal, and vir- ( Walkup et al., 2008 ). Overall, study fi ndings tual reality (Rothbaum, Hodges, Smith, Lee, & indicate signi fi cant reductions in anxiety among Price, 2000 ) , and some speci fi c phobias have children who participated in individual child been treated in as little as one extended session CBT (ICBT; Coping Cat program) and family (e.g., Ost, Alm, Brandberg, & Breitholtz, 2001 ) . CBT (FCBT; Howard, Chu, Krain, Marrs-Garcia, The one-session treatment (OST) has been & Kendall, 2000 ) compared to waitlist partici- defi ned as a “probably ef fi cacious” treatment for pants and to a family-based education/support/ adults with spider phobias, small animal pho- attention control (Kendall, 1994; Kendall et al., bias, and fl ying phobia. Research is needed on 1997; Kendall, Hudson, Gosch, Flannery- the mediators and moderators of OST (see review Schroeder, & Suveg, 2008 ) . Additionally, gains by Zlomke & Davis, 2008 ) , and individuals with were maintained at 1-year to 7.4-year follow-ups, more complex symptoms may require additional and a meaningful percentage of successfully sessions. Treatment of generalized anxiety disor- treated participants had reduced problems associ- der (GAD) may be complicated by the less clear- ated with substance use (Kendall, Safford, cut role of exposure tasks (Borkovec & Whisman, Flannery-Schroeder, & Webb, 2004; Kendall & 1996 ) , but CBT typically includes self-monitor- Southam-Gerow, 1996 ) . ing, relaxation training, cognitive restructuring, The largest RCT, the Child Anxiety and worry exposures (Olatunji, Cisler, & Deacon, Multimodal Study (CAMS), evaluated the 2010 ) . By also targeting interpersonal diffi culties effi cacy of CBT (the Coping Cat program for 4 Factors in Treating Anxiety 59

7Ð13-year-olds; C.A.T. Project for 13Ð17-year- Panic Disorder olds), sertraline (Zoloft), a combination of the two treatments (CBT + MED), and a pill placebo Cognitive-behavioral therapy has shown effi cacy among 488 youth (ages 7Ð17). This trial was in the treatment of adults with panic disorder conducted at six different clinics (medical (PD), both with and without agoraphobia (Gould, schools, hospitals, university clinics) across the Otto, & Pollack, 1995 ) . Deacon and Abramowitz United States. Response rates indicated very ( 2004) determined that these treatments typically favorable outcomes, with 80.7% of CBT + MED consist of (1) psychoeducation regarding the participants, 59.7% of CBT participants, 54.9% nature of anxiety and panic, (2) cognitive strate- of sertraline participants, and 23.7% of placebo gies to combat tendencies to misinterpret bodily participates found to be treatment responders sensations as catastrophic, (3) exposure to feared (rated as “very much” or “much improved”) at bodily sensations, and (4) coping skills to man- week 12 (Walkup et al., 2008 ) . Additionally, age physical symptoms. Cognitive-behavioral various adaptations of the Coping Cat program therapy for PD has been shown to be effi cacious have demonstrated effi cacy, such as the in reducing adults’ panic symptoms acutely (e.g., Australian Coping Koala (Barrett, Dadds, & Barlow, Gorman, Shear, & Woods, 2000 ; van Rapee, 1996 ; Heard, Dadds, & Rapee, 1991 ) , Balkon et al., 1997 ) and at long-term follow-up the Canadian Coping Bear (Manassis et al., (Bakker, van Balkon, Spinhoven, Blaauw, & van 2002 ; Mendlowitz & Scapillato, 1994 ) , and the Dyck, 1998 ; Craske, Brown, & Barlow, 1991 ) . Dutch Coping Cat translation (Nauta, Scholing, One form of CBT for PD is Panic Control Emmelkamp, & Minderaa, 2003 ) . Treatment (PCT; Barlow, 1988 ; Barlow et al., Group CBT (GCBT) has been implemented 2000) . Panic Control Treatment is an 11-session and compared to ICBT. Barrett (1998 ) examined treatment that includes correcting misinformation the effi cacy of a group CBT (GCBT) program for about panic, breathing retraining, cognitive restruc- youth with SAD, overanxious disorder, and SoP. turing, and interoceptive and in vivo exposure. Three conditions were compared: GCBT, GCBT Panic Control Treatment has shown effi cacy as an plus family management, and a waitlist control. individual (Aaronson et al., 2008 ) and group CBT At posttreatment, 64.8% of treated children no (Heldt et al., 2006 ; Penava, Otto, Maki, & Pollack, longer met criteria for an anxiety disorder, com- 1998 ) . Further, Ollendick (1995 ) and Hoffman and pared with 25.2% of waitlist children, and Mattis (2000 ) have adapted PCT for adolescents. improvements were maintained to 12-month fol- Hoffman and Mattis ( 2000 ) piloted PCT-A with low-up. Differences between the two treatment two adolescents, both of whom showed signi fi cant groups were nonsignifi cant at posttreatment and improvements after treatment. Pincus, May, 12-month follow-up (see also Flannery- Whitton, Mattis, and Barlow ( 2010 ) reported a Schroeder, Choudhury, & Kendall, 2005 ) . randomized trial of PCT-A: in comparison to a Similarly, Silverman et al. ( 1999 ) found 64% of self-monitoring control group, the PCT-A group participants in GCBT no longer met criteria for experienced signi fi cant reductions in severity of their primary anxiety diagnosis at posttreatment panic disorder, self-reported anxiety, anxiety sen- compared to only 13% of the waitlist control, and sitivity, and depression ratings. Gains were main- these gains were maintained to 3-month, 6-month, tained to 6-month follow-up. See Table 4.2 . and 12-month follow-up. Several research groups have conducted comparisons of GCBT to ICBT, often demonstrating equivalent effi cacy Obsessive-Compulsive Disorder (Flannery-Schroeder & Kendall, 2000 ; Manassis et al., 2002 ) , with maintenance of gains to 1-year For obsessive-compulsive disorder (OCD) in follow-up (Flannery-Schroeder et al., 2005 ) ; see adults and youth, CBT with exposure and Table 4.1 . response prevention (ERP) has been established 60 C.M. Cummings et al.

Table 4.1 Sample Studies of Cognitive Behavior Therapy for Speciﬁ c Phobia, Social Phobia, Separation Anxiety Disorder, and Generalized Anxiety Disorder

Authors Sample Characteristics Findings Rodebaugh, Holaway, Review of the available treatments for Treatment typically incorporates cognitive Heimberg (2004 ) social phobia restructuring, applied relaxation, exposure to feared stimuli, and social skills training

Rothbaum, Hodges, Smith, Adults ( N = 49; M age = 40.5) with SP Virtual reality exposure and standard Lee & Price (2000 ) ( ﬂ ying) were assigned to virtual reality exposure therapy both showed positive exposure, standard exposure, and WLC treatment gains and were superior to WLC

Ost, Alm, Brandberg, Adults ( N = 46; M age = 41.3) with SP Treatment was superior to WLC, with no & Breitholtz ( 2002 ) (claustrophobia) were randomly signi ﬁ cant differences between the 3 assigned to 1-session exposure, treatment groups 5-sessions of exposure, 5-sessions of cognitive therapy, or WLC

Borkovec, Newman, Pincus, Adults ( N = 69; M age = 37.1) with GAD The majority of participants had signi ﬁ cant & Lytle ( 2002 ) were assigned to either applied improvements in anxiety and depression, relaxation and self-control desensitiza- with no differences between the groups. tion, cognitive therapy, or a combination Remaining interpersonal dif ﬁ culties at of the 2 posttreatment were negatively associated with treatment improvement

Newman, Castonguay, Adults ( N = 15; M age = 37.9) with GAD CBT + interpersonal processing therapy led Borkovec, Fisher, & were assigned to CBT + interpersonal to decreased GAD symptoms maintained to Nordberg ( 2008 ) processing therapy and 3 were assigned one year follow-up. Effect sizes were higher to CBT + supportive listening than previous studies of CBT for GAD Kendall ( 1994 ) Children (N = 47; age 9Ð13) with OAD, Children in ICBT experienced signi ﬁ cant Kendall & Southam-Gerow SAD, or AVD were assigned to ICBT or improvements in anxiety symptoms, and (1996 ) WLC gains were maintained at 1-year and 2 to 5-year follow-ups Kendall et al. ( 1996 ) Children (N = 94; age 9Ð13) with OAD, The majority of children in ICBT showed Kendall, Safford, Flannery- SAD, or AVD were assigned to ICBT or clinically signi ﬁ cant gains compared to Schroeder, & Webb (2004 ) WLC WLC. Gains were maintained to 7.4-year follow-up

Kendall, Hudson et al., Children (N = 161; M age =10.27) with Treatment gains were evident in all ( 2008 ) GAD, SAD, or SoP were assigned to conditions, with ICBT and FCBT superior either ICBT, FCBT, or a family-based to the control condition. Gains were education/support/attention control maintained to 1-year follow-up

Walkup et al. ( 2008 ) Children (N = 488; Mage = 10.7) with CBT + sertraline was superior to both CBT GAD, SAD, or SoP were assigned to and sertraline. CBT and sertraline were either CBT, sertraline, CBT + sertraline, equivalent and all therapies were superior to or placebo drug placebo Barrett (1998 ) Children (N = 60; age 7Ð14) with SAD, More children in treatment conditions were OAD, or SoP were assigned to GCBT, diagnosis-free at post-treatment and 1-year GCBT + family management, and WLC follow-up than WLC, with marginal bene fi ts of GCBT + family management above GCBT Flannery-Schroeder & Children (N = 24; age 8Ð14) with GAD, Children in the ICBT and GCBT conditions Kendall ( 2000 ) SAD, or SoP were randomly assigned to experienced signi fi cant reductions in anxiety Flannery-Schroeder, ICBT, GCBT, or WLC while the WLC did not. Gains were Choudhury, & Kendall ( 2005 ) maintained at 1-year follow-up Manassis et al. (2002 ) Children (N = 78; age 8Ð12) with Anxiety signi fi cantly decreased regardless primary diagnoses of SAD, GAD, SoP, of treatment group. Children with SoP had SP, and panic disorder were randomly higher gains in ICBT than GCBT assigned to either GCBT or ICBT Note: CBT = cognitive-behavior therapy; SP = specifi c phobia; SoP = social phobia; GAD = generalized anxiety disorder;

Mage = mean age; WLC = waitlist control; ICBT = individual cognitive-behavior therapy; GCBT = group cognitive- behavior therapy; FCBT = family cognitive-behavior therapy; OAD = overanxious disorder; SAD = separation anxiety disorder; AVD = avoidance disorder 4 Factors in Treating Anxiety 61

Table 4.2 Sample Studies of Cognitive Behavior Therapy for Panic Disorder Authors Sample Characteristics Findings Van Balkon et al. Meta-analysis of adult studies Pharmacotherapy, exposure in vivo, (1997 ) comparing the impact of pharmaco- pharmacotherapy + exposure, and psychological pain therapies, CBT, and combination management combined with exposure were all treatments for PD effective treatments Bakker, van Balkon, Meta-analysis of adult studies All treatments (psychopharmacological treatments, Spinhoven, Blaauw, comparing long-term ef ﬁ cacy of psychological panic management, exposure in vivo, & van Dyck (1998 ) different treatments for PD antidepressants combined with exposure, and psychological pain management with exposure) showed gains maintained to follow-up

Barlow, Gorman, Adults ( N = 314; Mage = 36.1) with After 6 months of maintenance, imipramine and CBT Shear, & Woods PD with or without mild agoraphobia were superior to placebo, with imipramine showing a (2000 ) were randomly assigned to either better quality of response and CBT showing more CBT, imipramine + medication durability. Combined treatment had limited bene ﬁ t over management, pill placebo + medication monotherapy management, and CBT + placebo

Aaronson et al. Adults ( N = 381; Mage = 38.8) with PD CBT was effective for both severe PD and less severe ( 2008 ) who participated in CBT PD

Heldt et al. (2006 ) Adults ( N = 36; M age = 34) with PD Signi ﬁ cant improvement in all areas of quality of life refractory to pharmacological was observed. Reductions in general and anticipatory treatment who participated in GCBT anxiety and agoraphobia avoidance were associated with quality of life improvements

Penava, Otto, Maki, Adults ( N = 37; M age = 35.8) with Subjects achieved treatment gains on all PD dimen- & Pollack (1998 ) PD participating in CBT sions, with the largest symptom reduction occurring in the fi rst third of the program Ollendick (1995 ) Adolescents (N = 4; age 13Ð17) with Panic attacks and agoraphobia avoidance were reduced. PD treated with CBT Self-ef fi cacy for coping with future attacks was increased Hoffman & Mattis Adolescents (N = 2; age 13) were Each adolescent experienced reductions in panic attack ( 2000 ) treated with Panic Control Treatment frequency, fear and avoidance, and self-reported adapted for adolescents in a case study anxiety format Pincus, May, Adolescents (N = 26; age 14Ð17) were Participants showed improvement in PD, self-reported Whitton, Mattis, & randomized to Panic Control anxiety, and depression in comparison to a control Barlow ( 2010 ) Treatment for adolescents and or group. Gains were maintained to 6-month follow-up self-monitoring control group Note: CBT = cognitive-behavior therapy; PD = panic disorder; GCBT = group cognitive-behavior therapy as an ef fi cacious treatment (e.g., Franklin, the feared consequences of not ritualizing will Abramowitz, Kozak, Levitt, & Foa, 2000 ; see not materialize (Barrett, Farrell, Pina, Peris, & review by Abramowitz, Taylor, & McKay, 2005 ) . Piacentini, 2008 ) . It is important to note that response rates may Exposure and response prevention is an empir- vary depending on symptom pro fi le and some ically supported treatment for OCD in youth subtypes, such as cleaning and checking compul- (Barrett et al., 2008 ; Storch et al., 2007 ) . The sions, have received more research attention than Pediatric OCD Treatment Study (POTS) was a others, such as multiple-ritual, exactness, and multisite trial for children aged 7Ð17. The 112 hoarding presentations (Ball, Baer, & Otto, 1996 ; participants were randomly assigned to receive CBT, Sookman, Abramowitz, Calamari, Wilhelm, & sertraline (SER), combined CBT and sertraline McKay, 2005 ) . A goal of exposure-based CBT is (COMB), or pill placebo (PBO) for 12 weeks. All to teach the individual that, with repeated expo- three active treatments signi fi cantly outperformed sure to the feared object or behavior, the obses- PBO, and COMB was superior to CBT and SER. sion-triggered anxiety will dissipate. As the Further, a signi fi cantly greater number of CBT individual reaches habituation, she/he learns that patients entered remission than SER patients. 62 C.M. Cummings et al.

Combined treatment showed a 53.6% remission session, and enhancing safety and future development rate, compared to 39.3% for CBT, 21.4% for SER, (Cohen, Mannarino, Perel, & Staron, 2007 ; see and 3.6% for PBO. However, the investigators also TF-CBT Web, 2005 ) . Trauma-focused CBT noted site differences for CBT and SER (POTS has demonstrated effi cacy in RCTs (e.g., Cohen, Team, 2004 ) . Predictors of attenuated response Deblinger, Mannarino, & Steer, 2004 ; Cohen, included higher OCD severity, higher levels of Mannarino, & Knudsen, 2005 ) . One study com- OCD-related functional impairment, higher levels pared TF-CBT to child-centered therapy among of comorbid externalizing symptoms, and higher 229 children (aged 8Ð14) who had been sexually levels of family accommodation. Family history abused. Trauma-focused CBT was superior on of OCD moderated the effect of treatment condi- almost all measures, although 21% of children tion: for participants with a positive family history treated with TF-CBT still met diagnostic criteria of OCD, there were no signi fi cant differences in for PTSD (Cohen et al., 2004 ) . A pilot study ran- outcomes across the treatment groups. domly assigned 24 female youth (aged 10Ð17) Additionally, treatment effect sizes were smaller with PTSD symptoms to either TF-CBT + pla- for those with a family history of OCD, and this cebo or TF-CBT + sertraline. Both groups reduction in effect sizes was particularly high for showed signi fi cant improvements on PTSD the CBT group (Garcia et al., 2010 ) . The presence symptoms, depression, anxiety, and behavior of a comorbid tic disorder moderated outcomes: problems. There were no signi fi cant differences among patients with a tic disorder, SER did not between the groups. The authors noted signi fi cant differ from PBO, whereas COMB remained supe- limitations including inadequate statistical power rior to CBT, and CBT remained superior to PBO due to a small sample size. Further, the investi- (March et al., 2007 ) see Table 4.3 . gators noted dif fi culty recruiting a representative sample willing to take sertraline (Cohen et al., 2007 ) ; see Table 4.4 . Post-traumatic Stress Disorder

Cognitive-behavioral programs for post-traumatic Implementation in Clinical Practice stress disorder (PTSD) typically involve exposures, cognitive restructuring, and anxiety-man- Several treatments for anxiety disorders across agement skills. Exposures consist of the lifespan have been established as ef fi cacious. confrontation with fearful memories of the At present, the focus is on transporting trauma and can be imaginal or in vivo (Cahill, ef fi cacious treatments into use in everyday prac- Foa, Hembree, Marshall, & Nacash, 2006 ; Foa tice (Kendall & Beidas, 2007 ; Weersing & et al., 1999 ) . Exposures are theorized to be Weisz, 2002 ) . Despite this recognition and effective by (1) reducing conditioned fear related efforts, CBT remains underutilized in responses associated with trauma cues and (2) the community (Becker, Zayfert, & Anderson, challenging cognitive distortions surrounding 2004; Gunter & Whittal, 2010; Shafran et al., perceived danger and threat (Foa, Steketee, & 2009) . Several potential complications in imple- Rothbaum, 1989 ) . In their review, Ponniah and menting CBT for anxiety will be discussed, Hollon (2009 ) describe trauma-focused CBT including comorbidities, cultural/family factors, (TF-CBT) as effi cacious for PTSD. and therapeutic process variables. For youth with PTSD, exposure-based CBT has established support (Ford & Cloitre, 2009 ; La Greca, 2008 ) . TF-CBT components are sum- Comorbidity marized by the acronym “PRACTICE,” including psychoeducation/parenting component, High rates of comorbidity have been well doc- relaxation, affect modulation, cognitive processing, umented in children (Costello, Mustillo, Erkanli, trauma narrative, in vivo exposure and mastery Keeler, & Angold, 2003; Hammerness et al., of trauma reminders, conjoint child-parent 2008 ; Kendall et al., 2010 ) and adults (van Balkon 4 Factors in Treating Anxiety 63

Table 4.3 Sample Studies Cognitive Behavior Therapy (CBT) for Obsessive Compulsive Disorder (OCD) Authors Sample Characteristics Findings Franklin, Examined adult treatment outcome Patients receiving ERP on an outpatient basis achieved Abramowitz, Kozak, data from comparing patients similar reductions in OCD symptoms to patients Levitt, receiving ERP on an outpatient basis participating in randomized clinical trials & Foa (2000 ) to those receiving ERP during clinical trials Ball, Baer, & Otto Meta-analysis of the prevalence of Patients with cleaning and checking compulsions made ( 1996 ) various OCD up 75% of the samples, while patients with multiple subtypes in adult samples compulsions, or compulsions not within those categories only made up 12% of the treatment literature reviewed Barrett et al., (2008 ) Meta-analysis of child treatment Exposure-based CBT for child and adolescent OCD is a studies for OCD probably ef fi cacious treatment. CBT (family-focused and group formats) is a possibly ef fi cacious treatment Storch et al. (2007 ) Children ( N = 40; age 7Ð17) with Both intensive and weekly CBT were ef fi cacious OCD randomized to either treatments, with intensive treatment showing some 14-weekly or intensive (daily) CBT immediate advantages sessions Storch et al. (2008 ) Children (N = 92; age 7Ð19) with Overall, treatment response did not appear to differ OCD who received either weekly or across OCD subtypes. Some differences were observed intensive family-based CBT (e.g. hoarding symptoms and sexual/religious symptoms) showed less favorable response to treatment. However, lower power limited these analyses POTS Team ( 2004 ) Children (N = 112; age 7Ð17) with Combined treatment was superior to CBT alone and OCD were randomly assigned to sertraline alone. All 3 were superior to placebo. Site either CBT, sertraline, and differences emerged which limit fi ndings combined treatment Garcia et al. (2010 ) Examined moderators and predictors Lower OCD severity, less functional impairment, greater March et al. (2007 ) among participants in the POTS trial insight, fewer comorbid externalizing symptoms, and lower levels of family accommodation predicted improved outcome. Family history of OCD and comorbid tic disorders moderated treatment outcome Note: CBT = cognitive-behavior therapy; OCD = obsessive compulsive disorder; ERP = exposure and response prevention; POTS = pediatric obsessive compulsive treatment study

Table 4.4 Sample Studies Cognitive Behavior Therapy (CBT) for Post-Traumatic Stress Disorder (PTSD) Authors Sample Characteristics Findings Ponniah & Hollon (2009 ) Reviews randomized controlled trials in the PTSD and ASD literature Cohen, Deblinger, Mannarino, Children ( N = 229; age 8Ð14) with Participants assigned to TF-CBT & Steer (2004 ) PTSD symptoms (89% met diagnostic demonstrated signi fi cant greater improve- Deblinger, Mannarino, Cohen, criteria) were randomly assigned to ments than child-centered therapy on a & Steer ( 2006 ) either TF-CBT or child-centered variety of measures. Gains were main- therapy tained to 6 and 12-month follow-ups Cohen, Mannarino, & Knudsen Children ( N = 82; age 8Ð12) who had TF-CBT showed signi fi cant greater (2005 ) been sexually abused were randomly improvements at 6-month and 12-month assigned to TF-CBT or non-directive follow-ups supportive therapy Cohen, Mannarino, Perel, & Children ( N = 24; age 8Ð15) with Both groups showed improvements, with Staron (2007 ) PTSD were randomly assigned to minimal evidence indicating sertraline had either TF-CBT + sertraline or added bene fi ts. The investigators noted TF-CBT + placebo some dif fi culty recruiting a sample willing to take sertraline Note : CBT = cognitive-behavior therapy; PTSD = post-traumatic stress disorder; ASD = acute stress disorder; TF-CBT = trauma-focused cognitive-behavior therapy 64 C.M. Cummings et al. et al., 2008 ) with anxiety disorders. Despite its predict therapy dropout or poor treatment response frequency, several questions regarding the impact (Davis, Barlow, & Smith, 2010 ) . of comorbidity remain. Is the presence of comorbidity a factor that infl uences treatment effects? Comorbid Depression. The co-occurrence of anxi- Is comorbidity a moderator that impacts the ety and depression has been frequently reported strength and/or direction of treatment effects? (Costello et al., 2003) . Both disorders have affec- Might comorbidity inform “for whom” and tive, cognitive, behavioral, and physiological com- “under what conditions” treatments work (Kendall ponents. Although anxiety and depression share & Comer, 2011 ; Kraemer, Wilson, Fairburn, & overlapping emotional features, they differ in Agras, 2002 ) ? Comorbidity may operate as a identifi ed key components (i.e., fear as a key com- patient characteristic that exists prior to interven- ponent for anxiety and hopelessness for depres- tion and that may help inform optimal treatment sion). Nevertheless, both depressed and anxious (Kraemer et al., 2002 ) . It has been suggested that individuals exhibit negative affectivity as a broad treatment outcome might be less successful when category of self-reported emotional distress treating individuals with comorbid disorders. The (Watson & Tellegen, 1985 ) . Some differentiation following will describe current research regard- between anxiety and depression is linked to the ing comorbidity among individuals with anxiety consideration of positive affectivity (positive emo- disorders, focusing on the co-occurring disorders tional states such as joy, enthusiasm, and energy). that have been studied: depression and external- High negative affectivity and low (not moderate or izing disorders. Intellectual disabilities will also high) positive affectivity is more linked to depres- be brie fl y discussed. sion than anxiety (Watson, Clark & Carey, 1988 ) , while physiological hyperarousal (PH) is common to anxiety (Clark & Watson, 1991 ; see also Brown, Comorbidity in Adults Chorpita, & Barlow, 1998 ) . In terms of treatment response, comorbid Personality psychopathology has been shown to mood disorders have been associated with greater negatively impact CBT treatment for adults with pre- and posttreatment symptom severity among anxiety disorders (Mennin & Heimberg, 2000 ) , but adults with anxiety, compared to comorbid addi- the impact of other comorbidities is less clear. tional anxiety disorders (Erwin, Heimberg, Juster, Studies comparing patients with a range of comor- & Mindlin, 2002 ) . It is important to note that bidities have shown that axis I comorbidity is asso- Erwin et al. ( 2002 ) did not fi nd differential treat- ciated with greater symptom severity, but did not ment rates for patients with comorbid depression result in differential rates of treatment improvement compared to those with comorbid anxiety in the for the anxiety disorders (Turner, Beidel, Wolff, CBT treatment of socially phobic adults. Spaulding, & Jacob, 1996 ; van Velzen, Emmelkamp, Additionally, patients with comorbid anxiety and & Scholing, 1997 ) . A meta-analysis on the topic depressive disorders may be more likely to concluded that comorbidity was generally unrelated exhibit higher severity of their principal anxiety to effect size at posttreatment and at follow-up disorder than patients without comorbidity (Davis (Olatunji, Cisler, & Tolin, 2010 ) . Similarly, Storch et al., 2010 ) , but it is not conclusive that comor- et al. (2010 ) found that although OCD severity at bidity has a detrimental impact on outcome (see baseline was higher among OCD patients with also Chap. 15 this volume). comorbidities (speci fi cally, GAD, major depressive disorder, SoP, and PD), pretreatment comorbidities had no impact on posttreatment symptom severity, Comorbidity in Youth treatment response, or treatment remission. In a naturalistic sample of adult anxiety patients (princi- Some research suggests that comorbid diagnoses pal diagnoses consisted of mostly anxiety disorders can complicate treatment for anxious youth but also some mood disorders), comorbidity did not (Berman, Weems, Silverman, & Kurtines, 2000 ; Storch, Larson et al., 2008 ; Storch, Merlo 4 Factors in Treating Anxiety 65 et al., 2008) and are associated with more severe order, conduct disorder) may require adjustments symptomatology (Kovacs & Devlin, 1998 ) . when implementing an empirically supported However, other studies have found that comor- treatment for anxiety, but the data can inform us bidity is not associated with differential treatment of the accuracy of this concern. Although ADHD outcome (Barrett, Duffy, Dadds, & Rapee, 2001 ; is more often comorbid with externalizing rather Kendall, Brady, & Verduin, 2001). As noted by than internalizing disorders, there are also size- Ollendick, Jarrett, Grills-Taquechel, Hovey, and able comorbid rates of ADHD with anxiety and Wolff (2008 ) , most RCTs for anxiety disorders in depression (~25%) in epidemiological studies youth have not found signifi cant differences on (Angold, Costello, & Erkanli, 1999 ) . To date posttreatment outcomes to be linked to comor- comorbid externalizing disorders, secondary to bidity. Some replicated fi ndings also demon- the principal anxiety disorder, do not moderate strated that the number and type of comorbid treatment outcomes, as evidenced by limited diagnoses do not signi fi cantly predict anxiety treat- effect on outcome of CBT treatment in youth ment outcomes (e.g., Beidel, Turner, & Morris, (Flannery-Schroeder, Suveg, Safford, Kendall, & 2000; Manassis et al., 2002 ; Ost, Svensson, Webb, 2004 ) . It seems that anxious youth with Hellstrom, & Lindwall, 2001 ; Smith et al., 2007 ) . comorbid externalizing problems sometimes A noteworthy complication for comorbidity and respond better to treatment than their non-comor- treatment outcome research is that anxious youth bid peers (Costin & Chambers, 2007 ; Kazdin & with comorbid diagnoses may be more likely to Whitley, 2006 ) . Regardless, savvy implementa- attend fewer therapy sessions (Rapee, 2003 ) . tion of treatments may be necessary, even during manual-based treatments, to address problematic Comorbid Depression . As with adults, the fre- features of comorbidity that impede progress (see quent comorbidity of depression among youth Hudson, Krain, & Kendall, 2001 ) . with anxiety disorders is well documented (see Seligman & Ollendick, 1998 ) . Some research with youth suggests that the magnitude of this Treatment That Targets Multiple comorbidity may vary depending if anxiety or Disorders depression is the principal disorder (e.g., Brady & Kendall, 1992 ) . In one report, exposure-based Should treatment be focused entirely on the pri- treatment had poorer outcomes in anxiety- mary anxiety disorder or should treatments also disordered youth with comorbid depression, be tailored to the comorbid issues? This topic has compared to anxious youth without comorbid been raised and debated, leading some to develop depression (Berman et al., 2000 ) . Despite such treatments that cut across diagnostic categories fi ndings, this study found no group differences (Wilamowska et al., 2010 ) . Cognitive-behavioral between responders and nonresponders in terms therapy focused on the primary disorder, as com- of total number of diagnoses, comorbidity with pared to CBT focused on the primary disorder externalizing disorders, and comorbidity with and the most severe comorbid condition, has been other anxiety disorders (Berman et al., 2000 ) . shown to be more benefi cial for both principal O’Neil and Kendall (2012 ) reported that although and comorbid disorders in PD patients (Craske a comorbid depressive diagnosis did not predict et al., 2007) . Such fi ndings suggest that for anxi- poorer outcomes, self-reported co-occurring ety, like panic, the greatest bene fi t to clients is to depressive symptoms were associated with poorer pour therapeutic energy into the most debilitating outcome for youth receiving anxiety treatment. domain of psychopathology (i.e., the principal Comorbid depressive symptoms seem to play a diagnosed disorder). Successful treatment of PD role and may warrant special consideration in the has also been associated with reductions of both treatment of anxiety-disordered youth. comorbid anxiety and depressive symptoms (Allen et al., 2010 ) . The development of inte- Comorbid Externalizing Disorders. Externalizing grated or “transdiagnostic” treatments is ongoing disorders (e.g., ADHD, oppositional defi ant dis- (for adults, e.g., Barlow, Allen, & Choate, 2004 ; 66 C.M. Cummings et al. for youth, e.g., Chu, Colognori, Weissman, & de-emphasis on meta-cognitive content that is Bannon, 2009 ) . Despite preliminary fi ndings for generally appropriate for youth of average intel- these interventions, additional research is needed ligence (Suveg, Comer, Furr, & Kendall, 2006 ) . to examine the ef fi cacy of these treatments in Learning dif fi culties may need to be taken into controlled and randomized trials. account, as it is not uncommon for youth with learning problems to experience elevated anxiety and self-consciousness in the classroom (Dekker, Intellectual Functioning Koot, van der Ende, & Verhulst, 2002 ) . For a and Implementation of Treatment child with limited intellectual functioning, treatment can be more parent oriented. When such Appropriately, RCTs for the treatment of anxiety- factors are taken into consideration, CBT can related disorders exclude individuals with psy- result in positive outcomes among children with chotic disorders, intellectual defi cits, or pervasive intellectual de fi cits ( Suveg et al., 2006 ) . developmental disorders. Nevertheless, such exclusions do prevent conclusions about treating such individuals, particularly given that intellectual Family and Cultural Factors in CBT functioning can be a factor when implementing for Anxiety Disorders CBT. In older adults this may be important, especially if there are age-related de fi cits. Doubleday, Family and cultural factors can play a role in the King, and Papageorgiou ( 2002 ) found no implementation of ESTs for anxiety disorders. signifi cant association between level of fl uid The following section considers how the family intelligence and benefi t from CBT in the treat- context and racial/ethnic or cultural background ment of anxiety, though higher fl uid intelligence may in fl uence treatment for both adults and chil- was associated with positive impact for patients dren with anxiety disorders. receiving supportive counseling. Conversely, poor performance on the Mini-Mental State Exam orientation domain in older adults with Family Factors GAD has been associated with poorer outcome 6 months after CBT (Caudle et al., 2007 ) . Low The family context, potentially important in CBT intellectual functioning (and problems with for anxiety disorders, is not limited to youth. For receptive and expressive communication) may be adult clients, the family context may include associated with patients that have trouble estab- spouses or romantic partners, as well as children, lishing a collaborative interaction with their ther- and their own parents. With regard to spousal apist (Jahoda et al., 2009 ) . Although factors relationships, there is mixed evidence as to related to intelligence are important to consider whether the quality of the spousal relationship in the context of treatment, mild or age-related predicts treatment outcome for adults with anxi- intellectual decline may not have substantial neg- ety disorders (e.g., Durham, Allan, & Hackett, ative impact on therapeutic alliance and outcome 1997; Marcaurelle, Belanger, & Marchand, in CBT for anxiety. 2003 ) . Nevertheless, some data indicate that spouse involvement in treatment can be bene fi cial Intellectual Functioning in Youth. When working (e.g., Barlow, O’Brien, & Last, 1984 ; Billette, with children with limited cognitive functioning, Guay, & Marchand, 2008 ) . therapists may need to modify manual-based For youth clients, the family context typically CBT protocols to ensure that treatment strategies includes parent(s) and may include siblings. are compatible with the child’s developmental Bottom-up research, studying the parents of chil- capacities. Individualized treatment may employ dren with anxiety disorders, indicates that such an increased focus on physical involvement (e.g., parents have elevated psychopathology (e.g., active games that illustrate session content) and a Hughes, Furr, Sood, Barmish, & Kendall, 2009 ) 4 Factors in Treating Anxiety 67 and less favorable parenting style (McLeod, Kendall et al., 2008 ; Nauta et al., 2003 ) . These Wood, & Weisz, 2007 ) . In particular, parental mixed fi ndings suggest that there may be client anxiety predicts poorer acute treatment outcome or family characteristics that predict for whom for youth who receive child-focused CBT parental involvement is bene fi cial. Cognitive- (Bodden et al., 2008 ; Cobham, Dadds, & Spence, behavioral therapy with increased parental 1998 ) , although it is not clear if parental anxiety involvement may be more bene fi cial for younger predicts long-term child outcomes (Cobham, children and females compared to older children Dadds, Spence, & McDermott, 2010 ) . Some and males (Barrett et al., 1996 ) , although in studies also suggest that a less warm, more reject- another study the benefi t of family CBT was ing, and over-involved parenting style may nega- greater for early adolescents than for younger tively impact treatment outcome for anxious children (Wood, McLeod, Piacentini, & Sigman, children (Creswell, Willetts, Murray, Singhal, & 2009) . Furthermore, Cobham et al. ( 1998 ) Cooper, 2008 ; Liber et al., 2008 ) . It has also been reported that an additional parent component shown that families of anxious youth are charac- (e.g., parental anxiety management) resulted in terized by poorer family functioning (e.g., better outcomes than child CBT only for youth Hughes, Hedtke, & Kendall, 2008 ) when com- with anxious parents. Similarly, Kendall et al. pared to families of non-disordered youth and (2008 ) found that FCBT outperformed ICBT that family dysfunction is associated with poorer when both parents had anxiety disorders. Taken treatment outcome for anxiety-disordered youth together, these fi ndings suggest that increased (Crawford & Manassis, 2001 ) . parental involvement in CBT for child anxiety Given the role that parental psychopathology, may be bene fi cial for youth with anxious parenting style, and family dysfunction may play parents. in treatment outcome, there is ongoing debate as to how parents should be involved in CBT for childhood anxiety disorders. In individual child- Cultural Factors focused CBT for anxious youth, parents are typically involved as consultants (e.g., provide The prevalence, symptom expression, treatment- information about symptoms and impairment) seeking behavior, and treatment outcome of anxi- and collaborators (e.g., bring youth to treatment, ety disorders in adults and youth can be infl uenced assist with exposures; Kendall, 2010 ) . Parents by cultural factors. Racial/ethnic minority adults may also be involved as co-clients, to the extent in the United States (Latinos, African Americans, that their own anxiety or behavior may be main- Caribbean Blacks, Asian Americans) have lower taining the child’s anxiety or interfering with reported rates of PD, SoP, and GAD than non- treatment (see also Barmish & Kendall, 2005 ; Latino Whites, whereas racial/ethnic differences Kendall, 2010 ) . In some work, parents may serve in prevalence rates for agoraphobia, SP, and OCD as co-therapists (see Renshaw, Steketee, & are less clear (Lewis-Fernandez et al., 2010 ) . Chambless, 2005 ) . Racial/ethnic minorities tend to seek mental Research examining the benefi t for child out- health care services at lower rates than Caucasians comes of including parents in treatment has (e.g., Snowden, 1999 ; Zhang, Snowden, & Sue, resulted in mixed fi ndings. There is support for 1998) and are more likely to seek help from a family-based CBT for childhood OCD, and primary care physician than a mental health care some studies suggest better child outcomes for provider (Snowden & Pingitore, 2002 ) . Factors SAD, SoP, and GAD with increased parental that may contribute to lower treatment-seeking involvement in CBT (Barrett et al., 1996 ; and higher attrition among minorities may include Cobham et al., 2010; Wood, Piacentini, the presence of stressors (e.g., SES), lack of trust Southam-Gerow, Chu, & Sigman, 2006 ) . Other in mental health professionals, lack of familiarity research fi ndings indicated no added benefi t of with treatment, and reliance on family, friends, or parental involvement (Bodden et al., 2008 ; faith-based sources for mental health needs. 68 C.M. Cummings et al.

Hunter and Schmidt ( 2010 ) , for example, have called for greater consideration of culture in described a sociocultural model of anxiety in research regarding ESTs for childhood psycho- African American adults in which an awareness logical disorders (e.g., Jackson, 2002 ) . of racism, stigma of mental illness, and salience of physical illness infl uence rates of anxiety disorders. Empirical investigations of the factors Therapeutic Process Variables that contribute to lower treatment-seeking and higher treatment attrition among racial/ethnic Appropriately, the bulk of treatment research for minority groups are needed. anxiety has focused on evaluating the effi cacy and For anxious youth, the available literature effectiveness of specifi c therapies and specifi c suggests some cultural differences in symptom strategies, both in children and adults. Indeed, the expression. There is evidence that Latino youth published reports have contributed greatly to our tend to report higher rates of somatic symp- knowledge of what works for anxiety disorders. toms compared to Caucasian youth (Canino, Exactly how these treatments bring about change 2004 ; Pina & Silverman, 2004) . Asian has become an area of recent, yet still understud- American youth tend to exhibit somatic symp- ied, focus (Chu & Kendall, 2004 ; Fjermestad, toms as early signs of anxiety (Gee, 2004 ) . Haugland, Heiervang, & Ost, 2009 ) . Theory and African American youth tend to score higher discussion suggest that process factors, common than Caucasian youth on measures of anxiety across many of the effective therapies, contribute sensitivity (Lambert, Cooley, Campbell, to outcomes for both children and adults. Although Benoit, & Stansbury, 2004) , although African these processes differ somewhat for children and American youth are less likely to be diagnosed adults, three process-relevant variables (alliance, with GAD (Kendall et al., 2010) . Additionally, client involvement, collaboration) have been similar to adult patterns, race and ethnicity viewed as important to treatment outcome across predict lower rates of treatment-seeking behav- many disorders (Chu & Kendall, 2004 ; Creed & ior and higher attrition rates among youth (Bui Kendall, 2005 ; Fjermestad et al., 2009 ) . & Takeuchi, 1992 ; Gonzalez, Weersing, Warnick, Scahill, & Woolston, 2011; Kendall & Sugarman, 1997 ; Sood & Kendall, 2006 ), Alliance although the variation in treatment-seeking patterns for different racial/ethnic groups indi- Many psychological therapies assign importance cates that generalization of one pattern for all to a variously labeled and described “therapeutic minority groups would be inaccurate. alliance.” This alliance has become a pantheoreti- A majority of the participants in RCTs exam- cal variable considered to be important for change ining the effi cacy of CBT for anxious youth have (Horvath, 2000 ; Martin, Garske, & Davis, 2000 ) . been Caucasian, limiting the examination of race De fi nitions of alliance converge around three and ethnicity as potential predictors of treatment themes: (1) the “work-together” nature of the outcome. However, available research suggests relationship, (2) the affective bond between client that CBT is an appropriate treatment option for and therapist, and (3) the patient and therapist’s youth from various racial/ethnic groups. ability to agree on treatment goals and tasks Treadwell, Flannery-Schroeder, and Kendall (Karver et al., 2008 ; Martin et al., 2000 ) . (1995 ) reported comparable outcomes for According to a meta-analysis of the adult lit- Caucasian and African American youth who erature, therapeutic alliance as a stable and received the Coping Cat program for their anxi- unmediated variable has a moderate relationship ety. Pina, Silverman, Weems, Kurtines, and ( r = 0.22) with therapeutic outcome (Martin Goldman ( 2003) found comparable outcomes for et al., 2000) . Similarly, a study examining CBT Caucasian and Latino youth who received expo- outcome for socially anxious adults indicated sure-based CBT for anxiety. Several researchers that greater alliance measured at the fi nal session 4 Factors in Treating Anxiety 69 was related to lower posttreatment symptomol- associated symptom reduction at early and mid- ogy. Here, alliance is indicated as a secondary points in treatment (Chiu, McLeod, Har, & Wood, but important in fl uence on treatment outcome 2009 ; Liber et al., 2010 ) . This change in alliance (van Dyke, 2002 ) . Additionally, socially anxious preceded change in symptomatology. A recent adult clients, with high self-reported levels of study by Marker, Comer, Abramova, and Kendall alliance, reported higher levels of therapeutic (2013 ) examining multiple reports of therapeutic helpfulness (Hayes, Hope, VanDyke, & alliance on treatment outcome not only found Heimberg, 2007 ) . This group evidenced greater that greater therapist- and mother-rated alliance changes in self-reported anxiety during expo- prospectively predicted improved treatment out- sures when observers rated their alliance at a comes, but they also identi fi ed a reciprocal rela- moderate level. tionship between therapist- and father-reported The relationship between outcome and thera- alliance and symptom reduction whereby alliance peutic alliance in children is, like that in adults, increases as anxiety decreases among children only moderate (Karver, Handelsman, Fields, & receiving CBT for anxiety. Bickman, 2006 ; Shirk & Karver, 2003 ) . Alliance has been associated with effective CBT for anxious children (e.g., Kendall, 2001; Southam- Involvement Gerow & Kendall, 1996 ) . However, the number of studies to assess and evaluate the therapeutic alli- Client involvement in therapy has been found to ance in children has been few. It is possible that signi fi cantly contribute to therapeutic outcomes therapeutic alliance among children is more for adults (e.g., Gomes-Swartz, 1978 ; O’Malley, dif fi cult to assess as they do not come to therapy/ Suh, & Strupp, 1983 ; Tryon & Kane, 1995 ) . The treatment of their own volition (and might even be relationship between involvement and outcome resistant to change; DiGiuseppe, Linscott, & holds for client-rated involvement (e.g., Jilton, 1996 ) . Youth, in general, may be particu- Holtzworth-Munroe, Jacobson, DeKlyen, & larly resistant or have limited insight, making the Whisman, 1989; O’Malley et al., 1983 ) , thera- forming of an alliance more diffi cult (Diamond, pist-rated involvement (e.g., Gomes-Swartz, Liddle, Hogue, & Dakof, 1999 ) . An additional 1978; O’Malley et al., 1983 ) , and involvement complication to considerations of the therapeutic assessed via an independent evaluator (e.g., alliance in child therapy is the presence of another Gomes-Swartz, 1978 ; Soldz, Budman, & Demby, relationship: with the child’s parent. This suggests 1992) . The relationship holds within individual that clinicians must also engage in and develop a therapies, for group therapy (Soldz et al., 1992 ) , positive relationship with the child’s primary in general clinical practice (versus a research caregiver (McLeod & Weisz, 2005 ) . Parental trial; Eugster & Wampold, 1996 ; Goren, 1991 ) , beliefs about therapy can infl uence child attitudes and with couples in marital therapy (Holtzworth- toward treatment (Chu & Kendall, 2004 ) . Munroe et al., 1989) . Not surprisingly, the degree Despite the potential complications, a thera- to which someone is involved in therapy has a peutic alliance with youth can facilitate their favorable association with the magnitude of the engagement in therapeutic activities, and a strong therapeutic outcome. Additionally, anxious relationship with their clinician can prompt patients have identi fi ed a preference for partici- involvement (Chu & Kendall, 2004 ; Kendall & pating in making treatment decisions, although Ollendick, 2004 ) . In a recent evaluation of alli- this effect was moderated by ethnicity, with some ance in manual-based treatment for anxiety disor- minorities showing more passive preferences for ders, Liber et al. ( 2010 ) found that a stronger involvement in decision-making (Patel & Bakken, observer-rated alliance was associated with 2010 ) . In other research, involvement has been greater reliable change in child-reported anxiety related to other variables, such as therapeutic alli- symptoms. A stronger observer-rated alliance was ance and therapy completion (e.g., Reandeau & also related to better treatment adherence and Wampold, 1991 ; Tryon & Kane, 1995 ) . Overall, 70 C.M. Cummings et al. research supports adult client involvement as a important factor in determining the quality of direct predictor of treatment outcome across a therapeutic alliance and in facilitating change variety of therapeutic settings. (Creed & Kendall, 2005 ; Tee & Kazantzis, 2011 ) . For children experiencing distressing anxiety, Therapist-client collaboration consists of a sense involvement in therapy may be particularly of teamwork, where the therapist encourages important given the previously mentioned com- feedback, and specifi c contributions to therapeu- plications this population brings to therapy and tic goals. In collaboration, therapist and client their characteristic avoidance and withdrawal share the therapeutic work, which progressively when feeling threatened. These behaviors are allows the client more leading control in the likely to impede the progress of therapy, and inception and testing of ideas and goals, boosting exploring methods of fostering improvement is their self-ef fi cacy and motivation for change (Tee an important research question. However, & Kazantzis, 2011 ) . Krupnik et al. ( 1996 ) found involvement in child psychotherapy has infre- that not only therapeutic alliance but also patient quently been studied in rigorous scienti fi c trials contribution to alliance, which may be consid- or within evaluations of the effi cacy of specifi c ered a piece of this collaborative effort, was treatments. Furthermore, where involvement is signifi cantly predictive of treatment outcome examined, the results are often inconsistent (e.g., among individuals with depression. Collaboration Chu & Kendall, 2004 ; Karver et al., 2008 ) . has often been emphasized as an important piece Despite complications, studies have examined of the therapeutic alliance (e.g., Bordin, 1979 ; child involvement as a factor in treatment out- Horvath, 2000 ) . Additional research is warranted come for various problems (e.g., disruptive class- to explore its particular contribution to treatment room behavior; Braswell, Kendall, Braith, Carey, outcome in the adult anxiety literature. & Vye, 1985 ) . In one project, independent observ- A collaborative process with children allows ers’ ratings of child involvement during the psy- the therapist to personalize the specifi cs of treat- choeducation phase of CBT (prior to exposure ment (i.e., exposure tasks) and the case conceptu- tasks) were associated with both improved diag- alization (Tee & Kazantzis, 2011 ) . Findings from nostic status and impairment outcomes (Chu & studies of child treatment outcome indicate that Kendall, 2004 ) . A recent meta-analysis indicated collaboration predicts a stronger child rating of that child involvement in treatment has a strong the therapeutic alliance (Creed & Kendall, 2005 ) , association with outcome (mean r = 0.7; Karver higher levels of treatment satisfaction in adoles- et al., 2006 ; twice that of alliance), although this cents (Church, 1994 ) , and more successful treat- association varies across the studies included in ment outcomes with anxious youth (Chu & the meta-analysis. Particular therapist behaviors Kendall, 2004 ) . have been shown to foster youth involvement, including exploring the child’s motivation for therapy or change, attending to the youth’s experi- Future Directions ence, and providing less structure in the initial session (Jungbluth & Shirk, 2009 ) . The associa- Our review discussed ESTs for anxiety disorders tion between child involvement in therapy and the across the lifespan. In an effort to continue to quality of the therapeutic alliance is not specifi c to advance these ESTs, we reviewed comorbidity, CBT (see Karver et al., 2008 ) . familial and cultural components, and process variables as factors that may in fl uence the implementation of these ESTs for anxiety disorders. Collaboration Based on this review, we offer several suggestions for future work. Often conceptualized as a necessary component The convention in anxiety treatment research of the therapeutic alliance, collaboration between is to examine improvement based on the diag- therapist and client has been identi fi ed as an nosed principal disorder. The presence of high 4 Factors in Treating Anxiety 71 rates of comorbidity, and related concerns about In addition to the areas discussed, there is con- the current diagnostic categories, suggests over- cern for translating empirically effi cacious treat- lapping features among anxiety disorders and ments into effective therapies for use in everyday even some mood disorders (Bahadurian, 2008 ; practice. Dissemination of manual-based cognitive- Brown & Barlow, 2009; Brown, Campbell, behavioral therapy for anxiety disorders remains Lehman, Grisham, & Mancill, 2001 ) . Such over- a critical next step. And, despite substantial evi- lap has implications for classifi cation and treat- dence documenting the ef fi cacy of cognitive- ment of anxiety disorders. For example, several behavioral therapy for anxiety disorders, reviews investigators are developing and evaluating trans- of the literature identify that a portion of children diagnostic emotion-focused CBT for the treat- maintain their anxiety symptoms after treatment ment of shared emotional disorders. Preliminary (Cartwright-Hatton, Roberts, Chitsabesan, evidence is encouraging (e.g., Wilamowska et al., Fothergill, & Harrington, 2004 ; Silverman et al., 2010 ) . The future of psychological intervention 2008) . We need to improve our ability to “per- research may lie within an empirically driven sonalize” CBT, tailoring the approach to meet consolidation of therapy strategies for treatment each child’s specifi c needs. In this way, we will of comorbid psychopathology. continue to advance empirically supported Family and cultural in fl uences suggest direc- treatments. tions for future research. 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Part II Complexities in Childhood and Adolescent Anxiety Disorders Treatment of Childhood Anxiety in Autism Spectrum Disorders 5

C. Enjey Lin, Jeffrey J. Wood, Eric A. Storch, and Karen M. Sze

found that up to 71% of the youth met criteria for Nature of Problem at least one psychiatric disorder and, of these, 42% met criteria for an anxiety disorder accord- Prevalence ing to the Diagnostic and Statistical Manual of Mental Disorders—4th Edition criteria (DSM- Considerable research indicates that youth IV-TR; American Psychiatric Association, 2000 ) diagnosed with autism spectrum disorders (ASD) based on a population-derived sample of children experience psychiatric symptoms meeting clinical and adolescents diagnosed with an ASD. diagnostic criteria for a range of disorders, including anxiety disorders (Gadow, Devincent, Pomeroy, & Azizian, 2005 ; Kim, Szatmari, Bryson, Symptomology and Diagnostic Issues Streiner, & Wilson, 2000 ; Sukhodolsky et al., 2008 ; White, Oswald, Ollendick, & Scahill, Youth with ASD have been reported to present 2009) . The presence of anxiety disorders in ASD frequently with simple phobias, generalized anx- has been widely documented, but the prevalence iety disorder, separation anxiety disorder, obses- rate varies across the literature (e.g., de Bruin, sive-compulsive disorder, and social anxiety. Ferdinand, Meester, de Nijs, & Verheij, 2007 ; There does not seem to be one anxiety disorder Leyfer et al., 2006 ) . For example, White et al. that is specifi cally associated with ASD. Rather, (2009 ) demonstrated in a comprehensive review heterogeneity exists in the rates in which the dif- that signi fi cantly impairing anxiety symptoms ferent types of anxiety disorders have been were present in 11Ð85% of youth diagnosed with reported. In one clinical sample of school-aged ASD. More speci fi cally, studies using robust children diagnosed with ASD, of those who met diagnostic criteria indicate that anxiety disorders diagnostic criteria for anxiety disorders, simple occur in at least 45% of youngsters with ASD phobia was the most widely endorsed (31%), (Leyfer et al., 2006 ; Simonoff et al., 2008 ; then social phobia (20%), separation anxiety dis- Sukhodolsky et al., 2008 ) . Simonoff et al. (2008 ) order (11%), and generalized anxiety disorder (10%; Sukhodolsky et al., 2008 ) . In another C. E. Lin , Ph.D. ¥ J. J. Wood , Ph.D. (*) ¥ K. M. Sze , Ph.D. study, social phobia was the most commonly Departments of Education and Psychiatry and diagnosed (30%) followed by generalized anxi- Biobehavioral Sciences, University of California , ety (13%; Simonoff et al., 2008 ) . Los Angeles , CA , USA e-mail: [email protected] Among youth with ASD, anxiety disorders occur at commensurate or higher frequency and E. A. Storch , Ph.D. Departments of Pediatrics, Psychiatry, and Psychology , severity levels than that observed in the general University of South Florida , Tampa , FL , USA community (e.g., Kim et al., 2000; Lecavalier,

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 83 DOI 10.1007/978-1-4614-6458-7_5, © Springer Science+Business Media New York 2013 84 C.E. Lin et al.

2006 ; Russell & Sofronoff, 2005 ; White et al., The extant research presents strong evidence 2009 ) . Gadow et al. (2005 ) found that 25% of that comorbid anxiety disorders have direct youth with ASD in their sample met diagnostic implications for the overall functioning and qual- criteria for generalized anxiety disorder relative ity of life of youth with ASD and their families to 20% of a typically developing outpatient com- (Matson & Nebel-Schwalm, 2007 ) . Youth with parison group. Social anxiety appears to occur at comorbid mood or anxiety were found to engage higher rates in youth with ASD than in the typi- in increased aggression and oppositional behav- cally developing population, with results from a iors and experience poorer social relationships number of studies indicating 20Ð57% of children compared to youngsters with ASD who did not and adolescents with high-functioning ASD have such comorbidities (Kim et al., 2000 ) . Other exhibit clinically relevant symptoms of social functional impairments such as poor social anxiety, as compared to 1Ð5% in typically devel- responsiveness and social skill de fi cits have been oping youth (Kuusikko et al., 2008; Muris, associated ( Bellini, 2004 ; Sukhodolsky et al., Steerneman, Merckelbach, Holdrinet, & 2008 ) . The relationship between the presence of Meesters, 1998 ) . Also, fi ndings are emerging anxiety and overall impairment in affected youth that youth with ASD who demonstrate higher underscores the importance of treatments to cognitive and functioning levels may be more relieve such symptoms. susceptible to developing anxiety disorders and experience greater symptom severity (Sukhodolsky et al., 2008; Weisbrot, Gadow, Potential Contributing Factors DeVincent, & Pomeroy, 2005 ) ; however, others have not observed such a trend (Kim et al., 2000 ; The most common hypotheses to explain the high Pearson et al., 2006 ) . occurrence of psychiatric comorbidity in ASD The high occurrence of comorbid anxiety dis- have been: (a) that there may be a common genetic orders in ASD has raised some concerns about linkage between ASD and other psychiatric the validity of diagnosis and assessment methods disorders, increasing the risk of each (e.g., Gadow, with this population. Wood and Gadow ( 2010 ) Roohi, DeVincent, Kirsch, & Hatchwell, 2009 ) , underscore that diagnostic methods need to be (b) that the stresses caused by having ASD (e.g., re fi ned to tease apart anxiety and core ASD social rejection, sensory over-responsiveness, symptoms in order to improve differential diag- confusion in light of communication challenges) nosis and obtain more accurate prevalence rates. overwhelm coping skills and induce emotional For example, they suggest taking into account the and behavioral disorders (e.g., Meyer, Mundy, emotional valence of symptoms when differenti- Van Hecke, & Durocher, 2006 ) , or (c) that core ating between obsessive-compulsive symptoms autism symptoms are sometimes “counted as” and ASD-related restricted interests and ritualis- aspects of a comorbid disorder that has pheno- tic behaviors. Positive affect is more likely to be typically similar features (Gillott, Furniss, & associated with restricted interests than with dis- Walter, 2001 ; Wood & Gadow, 2010 ) . turbing OCD-related obsessions. They also point A cognitive-behavioral model of psychopa- out that anxiety in ASD can be phenotypically thology in high-functioning youth with ASD pro- identical to the anxiety disorders in non-ASD vides a framework for understanding the groups, but it can also uniquely manifest stem- development and treatment of co-occurring anxi- ming from the interplay between ASD core ety. The interaction between behavioral, environ- symptoms and anxiety (e.g., anxiety stemming mental, and cognitive factors may explain the from a child prevented from engaging in autistic clinical presentation of youth in this population. routines). Accurate diagnosis will inform treat- The combination of their increased intellectual ment development and ensure appropriate access capabilities (capacity for insight) and ASD fea- to mental health services for children on the tures likely contribute to the development of mal- autism spectrum. adaptive schemas (e.g., low self-ef fi cacy; 5 CBT and Anxiety in ASD 85

Bandura, Adams, & Beyer, 1977 ) , limited coping Burton, & Cox, 2000 ) . Anxiety symptoms likely strategies, and shape anxiety symptomology. compound these defi cits given that even among Similar to typically developing children, typically developing children diagnosed with categorical psychosocial stressors such as parental separation anxiety disorder, decreased adaptive discord or peer victimization (Shytayermman, living skills was positively correlated with anxi- 2007 ) have been associated with increased emo- ety severity (Wood, 2006 ) . Youngsters with ASD tional stress in youth with ASD. Higher anxiety seem to lack the social self-suf fi ciency or “real- levels have been linked to the presence of such life skills” to lead independent lives, highlighting stressors, impaired behavioral fl exibility to minor the importance of incorporating these skills into life changes, and a decreased ability to manage intervention. resulting emotions (Evans, Canavera, Kleinpeter, The meditational role of cognition may Maccubbin, & Taga, 2005 ; Green et al., 2006 ; infl uence the development of maladaptive beliefs Tantam, 2000 ) . Biological factors such as an in ASD. Diffi culties with perspective taking, inhibited temperament style in ASD (Bellini, drawing inferences from contextual information, 2006 ) and a familial predisposition for psychiat- and executive functioning can contribute to ric conditions (Ghaziuddin, Ghaziuddin, & social-emotional issues in ASD; however, further Greden, 2002) also seem to contribute to these research exploring this area is necessary (Meyer risk factors. Impairments associated with core et al., 2006 ; Thede & Coolidge, 2007 ) . Similar ASD features likely limit the repertoire of coping to typically developing children with social- skills to effectively manage emotional distur- emotional disturbances (Dodge, 1993 ) , youth bance associated with adverse life experiences. with ASD displaying greater atypical social attri- High-functioning youth with ASD have a capac- bution processes and a hostile attribution bias ity for awareness of their social-communicative (tendency to attribute hostile intent in others) limitations (Meyer et al., 2006 ) . Children with were more likely to endorse anxiety and depres- Asperger Syndrome endorsed greater social wor- sion symptoms (Meyer et al., 2006 ) . ries relative to typically developing peers (Russell & Sofronoff, 2005 ) . Severity of generalized anxiety symptoms is more pronounced in Asperger Treatment Approaches disorder relative to high-functioning autism (Thede & Coolidge, 2007 ) . Contrary to the belief Cognitive-behavioral therapy (CBT) is an effec- that youth with ASD are satis fi ed being alone, tive form of treatment for typically developing affected children endorse greater social diffi culty, youth with childhood anxiety disorders ( Barrett, social distress, dissatisfactory interpersonal rela- Duffy, Dadds, & Rapee, 2001 ; Gosch, Flannery- tionships, and decreased social competency rela- Schroeder, Mauro, & Compton, 2006 ; Kendall, tive to a matched control group of children 1994; Walkup et al., 2008; Wood, 2006 ) , particu- diagnosed with learning disabilities (Burnette larly those incorporating family-based approaches et al., 2005 ) and typically developing peers (e.g., Wood, Piacentini, Southam-Gerow, Chu, & (Bauminger & Kasari, 2000 ) . Youth with ASD Sigman, 2006) . According to this treatment likely experience great distress and concern with approach, the theory of change primarily focuses interpersonal relationships. on cognitive and behavioral mechanisms for Adaptive functioning impairments can also symptom improvement. The main components of contribute to poor social-emotional functioning. CBT for children include psychoeducation; devel- Youth with high-functioning ASD demonstrated oping coping skills (e.g., awareness of anxiety adaptive functioning levels markedly below their feelings, cognitive restructuring); and applying cognitive potential (Klin, Saulnier, et al., 2007 ) skills in graduated in vivo exposures (e.g., Kendall, and only 50% of a clinical sample of individuals 1994 ) . An integral aspect to CBT is that children with ASD independently completed basic self- collaborate with clinical guidance to actively care needs such as grooming (Green, Gilchrist, engage in empirical and logical question-asking 86 C.E. Lin et al. and evaluation of anxiety-related situations through development of this intervention for children sequential and graduated experiences. Exposures and adolescents with ASD. Due to the complex are a core element as it provides mechanisms for clinical presentation of ASD and unique cognitive hierarchical counterconditioning, extinction and and emotional profi le of this group of youth, habituation, thereby altering children’s expecta- modi fi cations to the implementation of treatment tions of themselves and others (Gosch et al., have been evident across studies. The general 2006 ) . Kendall et al. (1997 ) showed that in typi- consensus in modifying traditional CBT high- cally developing youth cognitive intervention lights the importance of tailoring CBT to meet aspects of the treatment (e.g., challenging irratio- the clinical needs of children with ASD to maxi- nal beliefs) alone—when not paired with in vivo mize the uptake and active use of coping skills. exposure elements—was not effective in reduc- Some modifi cations to standard CBT methods ing children’s anxiety levels. for comorbid anxiety include the incorporation of Contemporary CBT methods promote the visual aids (e.g., cartoons and thought bubbles) to development of schemas that guide adaptive supplement discussion of clinical material with responses while suppressing maladaptive ones. the child, increased instruction on emotion recog- Generally, schemas are underlying mental frame- nition (self-awareness of anxiety symptoms), and works or memory representations that broadly clear and concrete presentation of ideas and encompass an individual’s network of attitudes, materials (breaking down abstract ideas, direct emotional associations, and episodic memories and explicit directions). Reaven et al. ( 2009 ) linked with a concept or situation. This notion of modi fi ed CBT to treat anxiety in children with a schema differs from those that may be more ASD in an unrandomized, open enrollment of a speci fi c to the patterns of thinking styles and 12-week group intervention that included indi- cognitive models associated with particular psy- vidual child, individual parent, and conjoint par- chological disorders such as depression (e.g., entÐchild components. The authors drew upon Beck, 1987 ) . One model of memory retrieval several existing CBT manuals to develop an orig- competition in CBT (Brewin, 2006 ) suggests that inal program to accommodate ASD. They incor- adaptive schemas may need to be encoded with porated visual and concrete approaches to teach positive information and rehearsed in relevant coping skills, emphasized drawing, photography, situations in order to successfully be retrieved and video modeling to enhance generalization of over coexisting maladaptive ones. The develop- skills and concepts. The results from their study ment of salient adaptive schema can be enhanced demonstrated an improvement in anxiety symp- by elaborated rehearsal of such adaptive responses toms in the active treatment group in comparison through deep semantic processing using active to the waitlist group. Trials of CBT conducted discussion, practice of skills within settings to with typically developing children and youth encode schema relevant to actual situations, and with anxiety disorders (e.g., Barrett, Dadds, & incorporating emotionally positive elements such Rapee, 1996 ) indicate that including parent train- as humor. ing in the intervention can lead to superior inter- Research on the effi cacy of CBT in reducing vention effects as compared to exclusively comorbid anxiety in youth with high-functioning child-focused treatments. Sofronoff et al. (2005) ASD and Asperger’s disorder has been promising found evidence that a CBT program for children and spans from case studies (Lehmkuhl, Storch, with ASD and anxiety that included a combined Bod fi sh, & Geffken, 2008 ; Reaven & Hepburn, child and parent treatment was more effective 2003 ; Sze & Wood, 2008 ) to group-design clinical than working with children alone. Also, CBT studies (e.g., Reaven et al., 2009 ; Sofronoff, programs for individuals with ASD and high anx- Attwood, & Hinton, 2005 ; Wood et al., 2009 ) . iety in the current literature vary widely with The established ef fi cacy of CBT for the treatment regard to the emphasis placed on in vivo exposure of childhood anxiety disorders in typically devel- relative to less active treatment elements (e.g., oping youth has served as a foundation for the role-playing). Only a few intervention studies 5 CBT and Anxiety in ASD 87 included in vivo exposures on a daily basis rently exist in the literature (Chalfant, Rapee, & (e.g., Wood et al., 2009 ) . Carroll, 2007 ; Sofronoff et al., 2005; Wood et al., Some researchers have remarked that 2009 ) . Additional RCTs are currently underway modifi cations to CBT, alone, may not fully (e.g., White et al., 2010 ) , including a multi-site address the expression of anxiety in ASD (Reaven investigation by the authors of this chapter in et al., 2009 ; White et al., 2009; Wood et al., early adolescents with ASD and comorbid anxi- 2009 ) . CBT interventions for anxiety in ASD are ety. All three of these studies had some method- based on treatment that was initially developed ological limitations, but overall, the results for typically developing children, potentially lim- demonstrate a reduction in anxiety symptoms iting the effi cacy of treatment. Some have ques- (with two of the more scienti fi cally methodologi- tioned whether CBT for anxiety in children with cally sound studies demonstrating that up to 71% ASD should be tailored speci fi cally for this group of the children in treatment no longer met (e.g., White et al., 2009 ) . Current evidence sug- diagnostic criteria at the completion of CBT gests that despite this concern, CBT interventions treatment) (Chalfant et al., 2007 ; Wood et al., have produced positive treatment gains in reme- 2009) . More importantly, these studies employed diating anxiety in ASD. The effectiveness of CBT methodological components (e.g., random assign- for children with ASD seems comparable to that ment to conditions) that were consistent with the observed in typically developing children with criteria necessary to establish empirically sup- anxiety (e.g., Chalfant, Rapee, & Carroll, 2007 ) ported interventions (Chambless & Hollon, suggesting that some manifestations of anxiety in 1998) . The RCTs will be described in more detail ASD may be similar to that in typically develop- below in order of the increasing degree to which ing youth given the positive response to treat- CBT was expanded. These exemplars will be ment. For example, up to 84% of children with used to demonstrate effi cacy for the respective ASD and co-occurring anxiety who received interventions and the specifi c adaptations that CBT with adjunctive family intervention were made to the traditional model of CBT. (Chalfant et al., 2007 ; Wood et al., 2009 ) no lon- In the fi rst example, Chalfant et al. ( 2007 ) ger met criteria for a primary anxiety disorder developed an adapted CBT model that was tai- which was consistent with that observed in ran- lored to accommodate the visual and concrete domized clinical trials (RCT) of CBT for typi- learning style of ASD. Forty-seven children aged cally developing children with anxiety (e.g., 8Ð13 years-old diagnosed with high-functioning Silverman et al., 1999; Storch et al., 2010 ) . The ASD were provided with group CBT and were basic elements of CBT are likely foundational randomly assigned to either immediate or wait- components in treating anxiety disorders, appli- list conditions. The CBT was adapted from a cable across populations. program intended to treat core anxiety symptoms The traditional model of CBT has been wid- in typically developing children. The sessions ened to develop interventions that are uniquely were 2 h in duration and intervention was tailored to youth with ASD. Enhancement of extended to 6 months (12 weekly sessions and CBT by expanding both treatment conceptualiza- three monthly booster sessions) to accommodate tion and methods to go beyond the immediate additional skill-building opportunities. Treatment implementational concerns (i.e., making the effects were assessed with a structured diagnos- treatment materials and skills accessible) has tic measure; child self-report measures; parent- given way to develop CBT that specifi cally tar- report measures; and a teacher-report. Results at gets ASD characteristics that could contribute to posttreatment revealed that about 71% of the the manifestation of anxiety in order to enhance children in the immediate treatment group no ef fi cacy of treatment. The degree to which CBT longer met criteria for a primary anxiety disorder has been expanded to meet the clinical needs of in comparison to 0% of the youth in the wait-list youth with ASD ranges on a continuum. Three group. Children in the CBT group demonstrated RCTs for the treatment of anxiety in ASD cur- a greater reduction in the number of anxiety 88 C.E. Lin et al. diagnoses from pre- to post-treatment and the providing little opportunity for direct practice or self-, parent-, and teacher-reports generally in vivo feedback from trained clinicians. showed that the CBT group reported signi fi cantly In the second example, Sofronoff et al. (2005) less internalizing thoughts about anxiety and conducted an RCT with 71 children, ages 10Ð12 self-esteem, reduced anxiety symptoms, and less years, diagnosed with Asperger’s Disorder who emotional diffi culties relative to the waitlist were randomly assigned to: (a) child-based inter- group. Some methodological concerns for this vention, (b) combined child and parent interven- study were that independent evaluators blind to tion, or (c) waitlist condition. CBT was provided treatment assignment was not employed to in 2-h sessions for 6 weeks in group therapy for- administer the post-treatment diagnostic inter- mat. The child condition consisted of therapy views and treatment fi delity was not examined. provided in group format to children, with no Modi fi cations to the CBT program were pri- parent training (parents were only informed of marily in the presentation of materials and weekly assigned home-based exposures). In the enhanced skill-building support through concur- childÐparent condition, children received therapy rent parent training. Specifi cally, Chalfant et al. in group format while parents also were trained (2007 ) sought to accommodate the visual and to be “co-therapists” in parallel to the child ses- concrete learning style of youth with ASD. Visual sions. These separate, concurrent parent sessions aids and structured worksheets were used exten- involved teaching parents intervention strategies sively for psychoeducation, anxiety symptom and distal coaching on implementing exposures. recognition, and skill-building of coping skills. Treatment effects were examined using an For example, the youngsters were provided with exploratory measure to assess for children’s self- worksheets to encircle their bodily feelings asso- generation of coping strategies and traditional ciated with anxiety from a list in order to alleviate parent-report measures. demands on verbal skills. Cognitive restructuring Across measures, a signi fi cant improvement activities (e.g., developing coping thoughts) were was observed in the CBT groups in comparison also simpli fi ed to accommodate language impair- to the waitlist condition, with greater improvements. Concrete and behaviorally based activities ment observed in the parentÐchild intervention were of focus through relaxation and exposure condition. Children in the CBT groups demon- activities. However, the exposure activities were strated an increased ability to generate coping completed at home as sessions focused on plan- strategies to a hypothetical scenario, and a ning exposure activities with the child and their signi fi cant reduction in the total number of anxi- family. No live coaching was provided to parents ety symptoms and social worries relative to the through in vivo exposures. Although parents waitlist group youth. However, this study lacked completed a daily diary entry to record the out- more rigorous diagnostic assessment, psycho- comes of the home-based exposures, no checks metrically sound measures, and methodology were in place to validate the completion or fi delity (e.g., did not employ independent evaluators). of home-based exposures. Interestingly, most of the signi fi cant changes in Parents were provided with a training program the measures were observed in follow-up (6 in parallel to their children’s group therapy. To weeks after treatment was completed), rather supplement the development and practice of the than posttreatment. The authors cited that the children’s coping skills (e.g., parents providing children may have needed additional time to exposure activities) the parent component was bene fi t from the coping strategies. comprised of anxiety education and teaching This treatment program went beyond modify- relaxation strategies, cognitive restructuring exer- ing materials to make them more understandable cises, graded exposure, parent management train- to the youth (simplifying materials or using visual ing for behavioral problems associated with aids). Sofronoff et al. attempted to make the anxiety, and relapse prevention. Conjoint parentÐ concepts more relatable and targeted a few core child sessions were not a part of this CBT model, ASD areas implicated in compounding anxiety 5 CBT and Anxiety in ASD 89 symptoms. First, the presentation of coping con- signifi cantly in the CBT group as compared to cepts and skills incorporated children’s special the waitlist group. However, child-reported anxiety interests. For example, capitalizing on a common did not differ signi fi cantly from pretreatment to special interest in science among children with follow-up. The authors described that a fl oor ASD, the youth in this intervention were given effect was expected, as baseline levels were low the role of a “scientist” or “astronaut” to practice and decreased with treatment. This study had and learn coping skills. Also, the metaphor of a several methodologically rigorous elements tool box (tools to fi x feelings, social tools, and including randomization and use of independent thinking tools) was used in presenting coping evaluators. strategies and emotion awareness. Second, social Wood et al. (2009 ) signi fi cantly enhanced the awareness about the behaviors of the children traditional CBT model by speci fi cally targeting and other people around them within anxiety pro- core ASD areas associated with the expression of voking situations was targeted. Last, the authors anxiety in addition to making the CBT relatable used cartoons and thought bubbles in relation to to this group of children. In conjunction with the children’s anxiety-related scenarios that were traditional coping skills training (developing cop- borrowed from an intervention strategy used by ing thoughts) and in vivo exposure elements con- you th with ASD to promote awareness and devel- certed efforts were made to treat both anxiety and opment of core social skills. associated ASD features. The core defi cits of In the third example, Wood et al. ( 2009 ) social-communication, perspective-taking skills, signifi cantly expanded upon traditional CBT by and the presence of idiosyncratic restricted inter- developing a comprehensive CBT model that ests and repetitive behaviors were actively tar- emphasized treatment elements to target both geted concurrently with anxiety symptoms. core ASD features associated with anxiety symp- Social skills closely tied to anxiety and likely to tomology. In this RCT, 40 children aged 7Ð11 interfere with the practice of more adaptive cop- years were randomized to either 16 weeks of ing skills were addressed. For example, social 90 min sessions of a family-based CBT program skills de fi cits have been associated social anxiety plus 2 school consultation sessions or a waitlist. in ASD (Bellini, 2006 ) ; therefore, Wood et al. Treatment effects were assessed with a struc- used social coaching techniques to teach func- tured diagnostic interview; independent rating of tional social skills to children and their parents. improvement in anxiety (Clinical Global Specifi c strategies included the identifi cation and Improvement Scale (CGI-I)); and parent and practice of age-appropriate social overtures (e.g., child report of anxiety symptoms. The results joining in games with peers), friendship (e.g., lis- showed large effect sizes for most outcome mea- tening to friends) and playdate hosting skills sures; remission of all anxiety disorders for more (e.g., playing fl exibly, giving complements), than 50% of the children in the immediate treat- reciprocal conversational skills, and perspective- ment group by posttreatment or follow-up; and a taking skills (e.g., understanding the thoughts of high rate of positive treatment response on the peers). Peer intervention techniques (training CGI-I (78.5% from intent-to-treat analyses). The peers to promote increased interactions with the children in the study had an average of 4.18 psy- target child) to develop positive peer relation- chiatric disorders at intake, yet despite a high ships within naturalistic such as park and school level of comorbidity, they demonstrated primary were also implemented. outcomes comparable to those of other studies Wood et al. integrated the use of special interests treating childhood anxiety in typically develop- into treatment. They specifi cally used special ing patients (e.g., Barrett et al., 1996; Wood interests as motivators for treatment and as a et al., 2006 ) . For treatment completers, 64% of medium for learning and practicing adaptive cop- the children in the treatment group did not meet ing skills. For example, a child’s interest in cartoon criteria for any anxiety disorder at posttreatment. characters was used as a reward for practicing Parent-reported anxiety symptoms also decreased coping skills and to develop thought bubbles 90 C.E. Lin et al. about anxious and coping thoughts through related Integrating the treatment and effi cacy consid- cartoons, which was drawn from the perspective erations from the available research highlights a that idiosyncratic interests and repetitive behaviors number of important aspects in treating anxiety in can be used to motivate children with ASD (Baker, youth with ASD using CBT. First, at the most Koegel, & Koegel, 1998) . Engagement in these basic level, CBT must be presented in a way that interests was gradually suppressed for increasing is understandable to youth with ASD to ensure the lengths of time through a contingency manage- uptake of concepts and skills. Presenting materi- ment plan to increase the likelihood that children als, concepts, and opportunities to practice both would benefi t from using functional and coping more adaptive coping thoughts and behaviors skills given that these behaviors can detrimentally need to be modifi ed to accommodate the learning interfere with functioning over time (Klin, profi les of children and adolescents with ASD. Danovitch, Merz, & Volkmar, 2007 ) . This largely has been accomplished through the Self-help skills necessary for daily, adaptive use of visual aids (cartoons, lists, diagrams), functioning was also an intervention enhance- increased structure in the sessions (developing ment. Poor adaptive skills associated with ASD predictable routines in the layout of the sessions), (Howlin, Goode, Hutton, & Rutter, 2004 ) and presenting concepts using clear, explicit, and sim- impaired self-help skills in typically developing ple language, and increased practice identifying children with anxiety disorders (Wood, 2006 ) and recognizing emotional and body feelings served as guiding posts to promote youth with related to anxiety. Second, CBT concepts and ASD and their parents to practice age-appropriate skills should be made relatable to children with self-help skills (e.g., showering independently). ASD to increase the likelihood of their active par- Wood et al. targeted comorbid externalizing ticipation in treatment and generalization of skills symptoms associated with anxiety in children in real world settings. This requires going beyond with ASD (Kim et al., 2000 ) by promoting chil- the simple modifi cation of materials by individu- dren’s perspective of these behaviors (through alizing treatment and incorporating elements of role-play and Socratic Questioning) and develop- these children’s interests to serve as a medium for ing a contingent reward plan for the gradual developing skills and capitalize on the motiva- increased display of appropriate behaviors and tional and reinforcing properties of special inter- use of emotional regulation strategies. ests in ASD. Additionally, it requires skill building Child motivation and active treatment par- through in vivo exposures in naturalistic settings ticipation was also an element of the expanded rather than through more distal role-play or lim- CBT. The authors concentrated their efforts in ited to a clinic setting. Practice and mastery in real parent participation, practice within natural set- world settings will make the skills relatable to tings to enhance generalization of skills, and children with ASD and develop adaptive schemas continuously used rewards (e.g., access to play- that are relevant to their lives and likely to be ing videogames) and other positive experiences employed by the children in actual situations. (humor, restricted interests) for the youth to Parent training components also ensure that the actively participate in treatment. Parent- and skills will be practiced by the children and make teacher-training components were included to the concepts and skills relevant to both the family ensure that coping skills were employed in and the child. Third, enhancement of CBT for daily settings. The program incorporated these youth with ASD also requires going a step further elements to maintain engagement and to pro- to address the complex integration between anxi- mote the recall of adaptive responses that were ety expression and core ASD features. It is clear informed through the long-established effi cacy from the research that anxiety can be manifested demonstrated by the literature on treatments in a unique way in ASD. Although anxiety can be targeting core ASD skill development (Hwang expressed in prototypical form similar to non- & Hughes, 2000 ; Koegel & Egel, 1979 ; Koegel, ASD cases of anxiety, anxiety seems to have a Koegel, & Brookman, 2003 ) . reciprocal, dynamic relationship with core ASD 5 CBT and Anxiety in ASD 91 features. Anxiety can exacerbate core ASD fea- presented with signifi cant anxiety towards sepa- tures and ASD characteristics can contribute to ration from his mother, endorsing fears that anxiety expression. Therefore, in the case of CBT either he or his mother would be harmed or “sto- for youth with ASD, additional components of len.” For example, Oliver exhibited excessive treating this unique intersection of anxiety and clinginess around his mother and engaged in co- ASD characteristics seems to be an integral aspect sleeping with his parents. With regard to OCD, of treatment for this group. In tandem with core his obsessions included repeated and unwanted CBT skills of cognitive restructuring and master- thoughts about the number six, the color red, ing coping skills, social-communicative skill contracting germs, and distressing images of a enhancement (e.g., conversation skills or playdate pony character from a cartoon he enjoyed watch- skills), mastery of age-appropriate adaptive skills, ing. He experienced times when mental images development of fl exibility in interests and the of the pony became intrusive and distressing. ability to suppress restricted interests when neces- Compulsions included repeated handwashing, sary are some behaviors that can be promoted and hoarding trash, and a set of ritualistic behaviors acquired alongside traditional CBT skills. he felt compelled to perform “just right” involv- Increased research in both the theoretical under- ing his stuffed animal. Consistent with ASD standing of ASD and anxiety and components symptoms, Oliver demonstrated impairments associated with effi cacious treatment will further with reciprocal social interactions (i.e., lack of guide the fi eld in ensuring that children with ASD shared enjoyment), communication (i.e., receive effective interventions. dif fi culty sustaining conversations), and stereotyped interests and behaviors (i.e., occasional hand fl apping). His special interests were related Case Study to vehicles, science, and cartoons intended for a younger audience. Oliver’s adaptive skills were Case description. Oliver was an 8-year-old boy who below age expectations. attended the second grade at a local public elementary school. He was fully included in the general Sessions 1Ð3: building coping and independence education classroom with support from a one-to- skills. The general focus was on establishing rap- one aide. Oliver was diagnosed with high-function- port, providing psychoeducation on the nature of ing autism at age 3. He was referred for psychosocial ASD and anxiety, collecting information on anxi- treatment by his psychiatrist due to impairing symp- ety symptoms, and providing an overview of the toms of anxiety. A modi fi ed and enhanced family- CBT program. Oliver and his mother were taught based CBT program (Wood & McLeod, 2008 ) was core cognitive restructuring skills (recognizing provided consisting of 16, 90-min sessions, one anxiety feelings, identifying anxious thoughts, follow-up booster session, and two school visits. developing coping thoughts, and the concept of Each session consisted of individual child, individ- gradually facing fears). Rapport building focused ual parent, and conjoint childÐparent portions. on identifying Oliver’s interests. A functional assessment of Oliver’s ASD features and anxiety Clinical pro fi le. Oliver met diagnostic criteria was conducted. His mother identi fi ed his current for three anxiety disorders: social anxiety, sepa- level of adaptive skills and selected age-appropri- ration anxiety, and obsessive-compulsive disor- ate target skills, focusing on private self-care der. He exhibited signi fi cant apprehension about tasks (self-grooming). She was taught key par- social interactions and negative social evalua- enting communication strategies (providing tion. As a result, he avoided partaking in age- choices, gradually fading assistance). Oliver’s appropriate activities (e.g., class participation). mother identi fi ed powerful rewards ranging from Distress in social situations further compounded daily to longer term incentives to use throughout his ASD-related social de fi cits, preventing him the program to increase his motivation for com- from developing friendships at school. Also, he pleting CBT assignments. 92 C.E. Lin et al.

Oliver was encouraged to indicate his prefer- to consider social coaching as a long-term strategy; ence for labeling anxiety (he preferred the term look for naturalistic opportunities to practice posi- “scared” and endorsed feeling “hot” when worried). tive social exchanges in the community (during Systematic Socratic questioning was employed school drop off and pick up); and provide him with to recognize bodily cues, challenge anxious positive feedback for practicing social and coping cognitions (“The pony might get me”), develop skills in real world situations. adaptive coping thoughts (“The pony is a silly Oliver was taught friendship skills of hosting cartoon, so it can’t harm me!”), and incremen- playdates with peers. His mother was taught tally face feared situations with the aid of car- skills to foster Oliver’s friendships and identify toon-based stories involving his special interests potential friends for playdates. Oliver was intro- relevant to anxiety-provoking scenarios. duced to and practiced the rules of a good host (provide compliments, stay with the friend, and Sessions 4Ð5: development of the hierarchy and play fl exibly by allowing the friend to choose the treatment plan. The focus was on providing an games). He was asked to select peers, make phone overview of exposure therapy, developing the calls to invite them, and host playdates as part of exposure hierarchy, and implementing an incen- his ongoing CBT homework. tive system. Oliver and his mother were presented Oliver’s mother was taught strategies for with a list of fearful situations based on his diag- increasing Oliver’s age-appropriate activities. nostic interview and information from the initial She was encouraged to raise Oliver’s interest in sessions. They provided ratings for each item on age-appropriate TV shows enjoyed by most chil- the hierarchy that included both anxiety and ASD- dren his age. His interest in idiosyncratic topics related symptoms (e.g., talking about his special and immature activities gradually diminished interests). Coaching was provided to his mother over time by rewarding him for increasing lengths to plan, negotiate, and complete exposures. of time in which he did not engage in these behaviors or engaged in more appropriate activities. He Sessions 6Ð15: comprehensive skill application in was gradually asked to refrain from watching real world settings. The focus was on conducting preschool cartoons or talking about them for 1 in vivo and home-based exposures and monitoring day. He was rewarded for watching or discussing the reward system. Concurrently, skills compro- more age-appropriate topics. mised by core ASD symptomology such as appro- The last phase of treatment involved a school priate social entry behaviors (e.g., joining games) observation, developing school-based exposures were targeted towards the middle of the treatment and home-school notes, and training relevant phase. Items rated as easier on his hierarchy were adults in the school setting. Social coaching was fi rst attempted; steadily including several items introduced to and implemented by his one-to-one from across anxiety domains. Cognitive restruc- aide during recess and lunch in the context of turing was practiced both in session and at home to naturally occurring peer exchanges. develop coping and parent communication skills. Home-based exposures served as extensions of in- Session 16: termination. Treatment progress was session exposures. Given his interest in science, he reviewed with both parent and child during which was encouraged to think about exposures as a way they planned future home-based exposures to to go about “busting myths.” Homework gradually practice coping skills, self-care, and ASD-related targeted multiple anxiety symptoms, self-care skill development. areas, and ASD-related de fi cits. Social coaching intervention was provided to Session 17: follow-up. The purpose was to main- the parent and child. First, role-playing of typical tain Oliver’s treatment gains and prevent symp- social exchanges between Oliver and his peers was tom relapse through progress review and practiced in the session and at home (e.g., asking to problem-solving to address new areas of anxiety join in a game). Then, his mother was encouraged in a collaborative manner. 5 CBT and Anxiety in ASD 93

Treatment outcome. Oliver no longer met diag- their obsessive behaviors. Journal of the Association for nostic criteria for any of the three anxiety diagno- Persons with Severe Handicaps, 23 , 300Ð308. Bandura, A., Adams, N. E., & Beyer, J. (1977). Cognitive ses. For example, obsessions related to cartoon processes mediating behavioral change. Journal of characters remitted and he did not engage in Personality and Social Psychology, 35 (3), 125Ð139. compulsive hoarding. He made gains in friend- Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). ships, as evidenced by an increased number of Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, playdates in which he had the opportunity to play 64 (2), 333Ð342. the role of host and guest. Overall, his anxiety Barrett, P. M., Duffy, A. L., Dadds, M. R., & Rapee, R. M. and related ASD symptoms improved to the (2001). Cognitive-behavioral treatment of anxiety dis- extent to which they became manageable, increas- orders in children: Long-term (6-year) follow-up. Journal of Consulting and Clinical Psychology, 69 (1), ing his quality of life and functioning. 135Ð141. Bauminger, N., & Kasari, C. (2000). Loneliness and friendship in high-functioning children with autism. Conclusion and Future Directions Child Development, 71 (2), 447Ð456. Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy, 1 (1), 5Ð37. Anxiety at clinical levels is a phenomenon that Bellini, S. (2004). Social skill defi cits and anxiety in high- occurs at high rates in youth with ASD and requires functioning adolescents with autism spectrum disor- treatment. It is becoming increasingly evident that ders. Focus on Autism and Other Developmental Disorders, 19, 78Ð86. in order to accommodate the complexity of anxiety Bellini, S. (2006). The development of social anxiety in expression in ASD, CBT must be tailored to com- adolescents with autism spectrum disorders. Focus plement and meet the needs of youth in this popula- on Autism and Other Developmental Disabilities, 21 , tion. Traditional CBT has provided solid foundations 138Ð145. Brewin, C. R. (2006). Understanding cognitive behaviour for the effective treatment of anxiety in typically therapy: A retrieval competition account. Behaviour developing children and those with ASD. Similar to Research and Therapy, 44 , 765Ð784. the growing consideration in the fi eld for more Burnette, C. P., Mundy, P. C., Meyer, J. A., Sutton, S. K., refi ned diagnostic methods to identify comorbid Vaughan, A. E., & Charak, D. (2005). Weak central coherence and its relations to theory of mind and anxi- anxiety diagnoses, the development of CBT pro- ety in autism. Journal of Autism and Developmental grams for anxiety in ASD is continuing to evolve Disorders, 35 (1), 63Ð73. with the growing fund of knowledge in the fi eld. Chalfant, A. M., Rapee, R., & Carroll, L. (2007). Children and adolescents with ASDs are susceptible Treating anxiety disorders in children with high functioning autism spectrum disorders: A controlled to anxiety disorders and require and deserve appro- trial. Journal of Autism and Developmental Disorders, priate treatment to promote their psychological 37, 1842Ð1857. well-being. The advancement of enhanced CBT Chambless, D. L., & Hollon, S. D. (1998). De fi ning interventions should be guided by research on the empirically supported therapies. Journal of Consulting and Clinical Psychology, 66 , 7Ð18. development of anxiety in both typically develop- de Bruin, E. I., Ferdinand, R. F., Meester, S., de Nijs, P. F., ing children and youth with ASD, paired with & Verheij, F. (2007). High rates of psychiatric co-mor- fi ndings from both psychosocial and behavioral bidity in PDD-NOS. Journal of Autism and treatments for youth on the autism spectrum. In this Developmental Disorders, 37 , 877Ð886. Dodge, K. A. (1993). Social-cognitive mechanisms in the way, CBT can have a lasting and meaningful impact development of conduct disorder and depression. on youth with ASD and concurrent anxiety. Annual Review of Psychology, 44 , 559Ð584. Evans, D. W., Canavera, K., Kleinpeter, F. L., Maccubbin, E., & Taga, K. (2005). The fears, phobias and anxieties of children with autism spectrum disorders and down References syndrome: Comparisons with developmentally and chronologically age matched children. Child American Psychiatric Association. (2000). Diagnostic Psychiatry and Human Development, 36 (1), 3Ð26. and statistical manual of mental disorders (4th ed., Gadow, K. D., Devincent, C. J., Pomeroy, J., & Azizian, text revision). Washington, DC: Task Force. A. (2005). Comparison of DSM-IV symptoms in ele- Baker, M. J., Koegel, R. L., & Koegel, L. K. (1998). Increasing mentary school-age children with PDD versus clinic the social behavior of young children with autism using and community samples. Autism, 9 (4), 392Ð415. 94 C.E. Lin et al.

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and suicidal ideation. Issues in Comprehensive Pediatric Journal of Autism and Developmental Disorders, Nursing, 30 (3), 87Ð107. 37 (5), 847Ð854. Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Weems, C. F., Lumpkin, P. W., & Carmichael, D. H. Compton, S. N., Sherill, J. T., et al. (2008). Cognitive (1999). Treating anxiety disorders in children with behavioral therapy, sertraline, or a combination in group cognitive-behavioral therapy: A randomized childhood anxiety. The New England Journal of clinical trial. Journal of Consulting and Clinical Medicine, 359 , 2753Ð2766. Psychology, 67 (6), 995Ð1003. Weisbrot, D. M., Gadow, K. D., DeVincent, C. J., & Simonoff, E., Pickles, A., Charman, T., Chandler, S., Pomeroy, J. (2005). The presentation of anxiety in Loucas, T., & Baird, G. (2008). Psychiatric disorders children with pervasive developmental disorders. in children with autism spectrum disorders: Journal of Child and Adolescent Psychopharmacology, Prevalence, comorbidity, and associated factors in a 15 (3), 477Ð496. population-derived sample. Journal of the American White, S. W., Albano, A. M., Johnson, C. R., Kasari, C., Academy of Child and Adolescent Psychiatry, 47(8), Ollendick, T., Klin, A., et al. (2010). Development of a 921Ð929. cognitive-behavioral intervention program to treat Sofronoff, K., Attwood, T., Hinton, S. (2005). A ran- anxiety and social de ﬁ cits in teens with high-function- domised controlled trial of a CBT intervention for ing autism. Clinical Child and Family Psychology anxiety in children with Asperger syndrome. Journal Review, 13 (1), 77Ð90. of Child Psychology and Psychiatry, 46, 1152Ð1160. White, S. W., Oswald, D., Ollendick, T., & Scahill, L. Storch, E. A., Lehmkuhl, H. D., Ricketts, E., Geffken, G. (2009). Anxiety in children and adolescents with R., Marien, W., & Murphy, T. K. (2010). An open trial autism spectrum disorders. Clinical Psychology of intensive family based cognitive-behavioral therapy Review, 29 (3), 216Ð229. in youth with obsessive-compulsive disorder who are Wood, J. J. (2006). Parental intrusiveness and children’s medication partial responders or nonresponders. separation anxiety in a clinical sample. Child Journal of Clinical Child and Adolescent Psychology, Psychiatry and Human Development, 37 (1), 73Ð87. 39 (2), 260Ð268. Wood, J. J., Drahota, A., Sze, K., Van Dyke, M., Decker, Sukhodolsky, D. G., Scahill, L., Gadow, K. D., Arnold, L. K., Fujii, C., et al. (2009). Brief report: Effects of cog- E., Aman, M. G., McDougle, C. J., et al. (2008). nitive behavioral therapy on parent-reported autism Parent-rated anxiety symptoms in children with perva- symptoms in school-age children with high-function- sive developmental disorders: Frequency and associa- ing autism. Journal of Autism and Developmental tion with core autism symptoms and cognitive Disorders, 39 , 1609Ð1612. functioning. Journal of Abnormal Child Psychology, Wood, J. J., & Gadow, K. D. (2010). Exploring the nature 36 (1), 117Ð128. and function of anxiety in youth with autism spectrum Sze, K. M., & Wood, J. J. (2008). Enhancing CBT for the disorders. Clinical Psychology: Science and Practice, treatment of autism spectrum disorders and concurrent 17 (4), 281Ð292. anxiety: A case study. Behavioural and Cognitive Wood, J. J., Piacentini, J. C., Southam-Gerow, M., Chu, B. Psychotherapy, 36 , 403Ð409. C., & Sigman, M. (2006). Family cognitive behavioral Tantam, D. (2000). Psychological disorder in adolescents therapy for child anxiety disorders. Journal of the and adults with Asperger syndrome. Autism, 4 (1), American Academy of Child and Adolescent 47Ð62. Psychiatry, 45 (3), 314Ð321. Thede, L. L., & Coolidge, F. L. (2007). Psychological and Wood, J. J., & McLeod, B. M. (2008). Child anxiety neurobehavioral comparisons of children with disorders: A treatment manual for practitioners. Asperger’s disorder versus high-functioning autism. New York: Norton. Treatment of Comorbid Anxiety and Disruptive Behavior in Youth 6

Omar Rahman, Chelsea M. Ale, Michael L. Sulkowski, and Eric A. Storch

Psychiatric comorbidity commonly occurs with ally impairing (Stringaris et al., 2009 ) , and are childhood anxiety disorders (Geller, Biederman, associated with lower treatment response rates in Grif fi n, Jones, & Lefkowitz, 1996 ; Verduin & youth who receive evi dence-based anxiety treat- Kendall, 2003 ) and contributes to functional ments (Storch et al., 2008 ) . Additionally, anxiety impairments beyond the infl uence of anxiety and DBD symptoms tend to become even more (Storch, Lewin, Geffken, Morgan, & Murphy, impairing across the life span if they are not suc- 2010 ; Sukhodolsky et al., 2005 ) . The presence of cessfully treated in childhood (Kendall, Safford, comorbid anxiety and disruptive behavior disor- Flannery-Schroeder, & Webb, 2004; Offord & ders (DBD, e.g., conduct problems, oppositional/ Bennett, 1994 ) . Because of the importance of de fi ant behavior, impulsivity, hyperactivity) may increasing and improving treatment for youth be particularly problematic for children and fam- with comorbid anxiety and DBD, this chapter ilies (Stringaris, Cohen, Pine, & Leibenluft, reviews research on the phenomenology of 2009 ) . Comorbid disruptive behavior disorders comorbid childhood anxiety and DBD symptoms (DBD) are relatively common (Loeber, Green, as well as the extant treatment approaches. Lahey, Frick, & McBurnett, 2000 ) , are function- Additionally, in an attempt to illustrate the application of interventions to treat comorbid anxiety and DBD symptoms, a case example is provided. O. Rahman , Ph.D. (*) Childhood anxiety is associated with disrup- Department of Pediatrics , University of South Florida , tions in academic, social, and family functioning Box 7523 , 880 6th Street, South , St. Petersburg , FL 33701 , USA (Ginsburg, Siqueland, Masia-Warner, & Hedtke, e-mail: [email protected] 2004 ; Langley, Bergman, McCracken, & C. M. Ale , Ph.D. Piacentini, 2004; Langley, Lewin, Bergman, Lee, Department of Psychiatry and Psychology, Mayo Clinic , & Piacentini, 2010 ; Woodward & Fergusson, 200 1st Street , SW Rochester , MN 55905 , USA 2001 ) , the development of psychopathology in M. L. Sulkowski , Ph.D. adulthood (e.g., anxiety, depression, substance Department of Disability and Psychoeducational Studies, abuse) (Aschenbrand, Kendall, Webb, Safford, & University of Arizona , Box 210069 , 1430 East 2nd Flannery-Schroeder, 2003 ; Kendall et al., 2004 ; Street, Tucson , AZ 85721-0069 , USA Woodward & Fergusson, 2001 ) , and an increased E. A. Storch , Ph.D. risk for comorbid psychiatric disorders (Geller Department of Pediatrics , University of South Florida , Box 7523 , 880 6th Street, South , St. Petersburg , et al., 2000 ; Kendall et al., 2004 ; Langley et al., FL 33701 , USA 2010 ; Verduin & Kendall, 2003 ) . Although there often is variation in which the disorders are Department of Psychiatry and Behavioral Neurosciences , University of South Florida , Box 7523 , 880 6th Street, classifi ed as DBD, we defi ne DBD to include South , St. Petersburg , FL 33701 , USA oppositional de fi ant disorder (ODD), conduct

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 97 DOI 10.1007/978-1-4614-6458-7_6, © Springer Science+Business Media New York 2013 98 O. Rahman et al. disorder (CD), and attention-de fi cit/hyperactivity presence of DBD symptoms was associated with disorder (ADHD). Furthermore, although categor- greater family accommodation of symptoms and ically distinct, some overlapping phenomenologi- less symptom resistance. Similarly, a study by cal features exist between anxiety and DBD. Drabick, Gadow, and Loney (2008 ) found that Studies comparing phenomenological charac- children with comorbid GAD and ODD displayed teristics of youth with comorbid anxiety and dis- greater confl ict with family members and had ruptive behavior symptoms to youth with anxiety more co-occurring symptoms than children with symptoms alone are limited. One study found either single diagnosis. Thus, comorbid anxiety that 44% of children with pediatric obsessiveÐ and DBD symptoms have a negative impact on compulsive disorder (OCD) display comorbid child and family functioning beyond the in fl uence disruptive behavior symptoms and a similar per- of either type of condition. centage (43%) displayed comorbid ADHD symp- Other combinations of anxiety and DBD also toms (Geller et al., 2000 ) . Among non-OCD are problematic. For example, children with ADHD anxiety, estimates are similar: 28% of youth with and CD are at risk for developing anxiety and expe- GAD, 34% with separation anxiety disorder riencing signifi cant impairments in their psychoso- (SAD), and 15% with social phobia (SP) dis- cial functioning (Loeber, Farrington, played disruptive behavior symptoms (Verduin & Stouthamer-Loeber, & Van Kammen, 1998 ) . These Kendall, 2003 ) . In a meta-analytic review, youth often have dif fi culty adjusting to social envi- Boylan, Vaillancourt, Boyle, and Szatmari ( 2007 ) ronments, which can cause distress as they age and found an average odds ratio estimate of having value social relationships (Guevremont & Dumas, ODD with a comorbid anxiety disorder between 1994) . Similarly, children with comorbid OCD and 5.4 (community samples) and 8.9 (clinic-referred ADHD diagnoses display signi fi cant dif fi culties in samples). Approximately 25Ð32% of youth with social functioning, school problems, and an ele- ADHD also display comorbid anxiety (MTA vated risk for depression (Sukhodolsky et al., 2005 ) . Cooperative Group, 1999 ; Spencer, 2006 ) . Overall, research suggests that the presence of dis- Moreover, an interaction may exist between age ruptive behavior contributes to the development of and the development of anxiety in youth with additional psychopathology and exacerbates the DBD. For example, Biederman et al. (2006 ) impact of other disorders on children’s functioning found a 7% increase in the prevalence of co- (Loeber et al., 2000 ; Storch et al., 2010 ). occurring anxiety disorders from age 11 years to mid-adolescence in a sample of youth with ADHD. Although additional research is needed Conceptualizing the Problem to establish the role of development in the expression of anxiety and disruptive behaviors, the Several hypotheses have been put forth to explain increasing demands of adolescence may affect the co-occurrence of disruptive behavior and anxi- the development of both disorders (Guevremont ety in youth (Jarrett & Ollendick, 2008 ; Lilienfeld, & Dumas, 1994 ) . 2003 ) . First, disruptive behavior may serve an oper- Although few studies have investigated this ant function. For example, children may engage in phenomenon, the presence of comorbid anxiety reactive disruptive behavior that serves to reduce and DBD may result in greater psychosocial exposure to anxiety triggers. In this regard, Bubier impairment than is produced by either type of and Drabick (2009 ) suggest that reactive aggression disorder alone. A study by Storch et al. ( 2010 ) is an impulsive behavior that is learned over time found that youth with comorbid DBD and OCD and eventually becomes a typical pattern of respond- had greater OCD-related symptom severity, ing. This behavior is often elicited when a child is in OCD-related impairment, overall anxiety levels, an anxiety-provoking or threatening situation, does and other symptoms of internalizing psychopa- not see a possibility of an easy escape, and experi- thology relative to youth with OCD but no ences emotions that are diffi cult to control. Children signifi cant DBD symptoms. Additionally, the with high levels of anxiety often are sensitive to 6 Anxiety and Disruptive Behavior 99 experiencing dysphoric emotions, which may stimuli. Although the behavior may be topo- cause them to be irritable, highly reactive, disrup- graphically similar, understanding the function is tive, and potentially aggressive (Walker et al., imperative in determining appropriate treatment 1991 ) . Additionally, recent evidence suggests that and in modifying parentÐchild interactions. parental accommodation of anxiety symptoms Behavioral parent training has been studied may contribute to co-occurring disruptive behav- extensively for the treatment of DBD symptoms ior (Flessner et al., 2011 ; Storch et al., 2007 , 2010 ) . in preschool-aged children through adolescents Parents of children with both OCD and disruptive (e.g., Barkley, 1997 ; Eyberg & Bussing, 2010 ; behavior may respond differently to their child’s McMahon & Forehand, 2003 ) . Many empirically “fearful” behaviors as compared to a “behavior based behavioral parent training protocols exist problem,” which can lead to inconsistent, ineffec- that include a variety of treatment components tive parenting and increased disruptive behaviors (e.g., positive attending, using time-out, giving (Lehmkuhl et al., 2009 ) . effective commands). Based on operant condition- Second, although there is limited evidence for ing principles (e.g., Skinner, 1953 ) , parents essen- this phenomenon, disruptive behavior may pre- tially are taught to change their interactions with cede anxiety in some cases. For example, co- the child and their responses to the child’s behav- occurring impairments in academic, family, and ior using differential reinforcement of prosocial social functioning in youth with disruptive behav- behaviors (see Herschell, Calzada, Eyberg, & ior disorders may contribute to the development McNiel, 2002; McMahon & Forehand, 2003 ; of anxiety. In this regard, children with ADHD Patterson, 1971 ; Patterson, Reid, Jones, & Conger, may experience increased anxiety related to aca- 1975 ) . Component analyses of behavioral parent demic struggles, problematic interactions with training suggest that the inclusion of positive inter- others, or negative consequences resulting from actions with the child, the use of a time-out from their disruptive behavior (e.g., losing privileges). positive reinforcement procedure, opportunities to Finally, other studies have found no temporal practice new parenting skills with the child during relation between anxiety and disruptive behav- therapy sessions, and consistent parental respond- iors (e.g., Baldwin & Dadds, 2008 ) . Anxiety and ing predicted moderate to large treatment effects DBD symptoms may co-occur due to shared on externalizing behavior (mean effect sizes = 0.36Ð polygenetic traits, neurological dysregulation, 0.69). There is some evidence that treating DBD and the infl uence of various family factors (e.g., symptoms also results in improvements in anxiety inconsistent caregiving) (Baumgaertel, Blaskey, symptoms (Chase & Eyberg, 2008 ) or other inter- & Antia, 2008 ; Jarrett & Ollendick, 2008 ) . nalizing symptoms (i.e., anxiety and/or depression; mean effect size = 0.40) (Kaminski, Valle, Filene, & Boyle, 2008 ) . Factors Contributing to Treatment CognitiveÐbehavioral therapy (CBT) is the Complexity fi rst-line treatment for pediatric anxiety disorders and is associated with robust effects. For instance, Given the complex and multi-determined rela- Silverman, Pina, and Viswesvaran (2008 ) reported tions of anxiety and DBD, clinicians should con- an average effect size for CBT for an anxiety dis- duct a functional assessment to examine the order in youth as 0.99. Effect sizes for CBT for antecedents and consequences of each behavior OCD are even higher. For example, Watson and to identify which function the behaviors serve Rees (2008 ) reported an average effect size of (see Haynes and O’Brien ( 2000 ) for a compre- 1.45 for the ef fi cacy of CBT to treat pediatric hensive review of functional assessment). Parents OCD. Furthermore, 50Ð80% of youth with anxi- may not know how to respond to children who ety achieve symptom remission when CBT is display concomitant anxiety and disruptive combined with selective serotonin reuptake behavior. For example, children may scream to inhibitor (SSRI) medication (Pediatric Obsessive get their parents’ attention or to avoid feared Compulsive Disorder Treatment Study Team 100 O. Rahman et al.

2004 ; Walkup et al., 2008 ) . In CBT, the treatment improves simply by treating the child’s primary typically involves having a patient approach fear- anxiety disorder (Flannery-Schroeder, Suveg, evoking stimuli to extinguish his or her anxious Safford, Kendall, & Webb, 2004 ) . However, response through repeated exposure (Gillan & Rapee (2003 ) found that children with anxiety Rachman, 1974 ; March, Frances, Carpenter, & and DBD symptoms displayed worse DBD symp- Kahn, 1997 ; Silverman et al., 2008 ) . This is toms 12 months after treatment compared to accomplished in several steps. First, a patient- baseline. specifi c hierarchy of fears is developed with the There are several reasons why children with help of the therapist. Second, the patient is comorbid DBD and anxiety may not respond to encouraged to approach the fear-provoking stim- treatment. First, children with comorbid DBD uli (referred to as an exposure task) starting with symptoms may display defi ance related to engag- less feared stimuli to ensure success and reinforce ing in exposure tasks, completing homework approach behavior. The exposure task is then assignments, or taking medication (Storch et al., repeated until the stimulus no longer triggers 2007) . Some children may even become aggres- anxiety or triggers minimal anxiety. Third, expo- sive when therapists and parents attempt to sure tasks are repeatedly conducted with increas- expose them to anxiety-provoking stimuli. This ingly more anxiety-provoking stimuli as the can then in fl uence parents or therapists to reduce patient progresses in therapy. If a patient typi- the magnitude of exposure tasks or may even cally responds to anxiety with a compulsion or make them reluctant to expose the child to anxi- ritual (as in the case of OCD), he or she is asked ety-provoking situations altogether. Thus, disrup- to refrain from doing the ritual or avoidance tive behavior may decrease the level and frequency behavior which allows escape from the anxiety- of behavioral exposures, which negatively provoking stimuli and interferes with the auto- impacts a patient’s treatment response. nomic habituation essential for extinguishing the Second, hyperactivity, impulsivity, and inat- fear response. The cognitive component of CBT tention can interfere with engagement in therapy. involves teaching the patient to recognize irratio- Managing these behaviors during sessions can nal thoughts and challenge or externalize them interfere with a therapist’s ability to focus on (Kendall, 1992 ; March & Mulle, 1998 ) . therapeutic goals. In addition, youth with these Although most anxious children respond comorbid symptoms may struggle to persist in favorably to CBT, comorbid anxiety and DBD therapeutic tasks or complete homework between are associated with lowered treatment response. sessions. In addition, these disruptive symptoms Storch et al. ( 2008) found youth with comorbid may interfere with the performance of other tasks OCD and DBD symptoms to display lower CBT (such as school homework or chores), which can treatment response rates (46% remission) com- cause them to take longer to complete and subse- pared to youth with single OCD diagnoses or quently leave less time to engage in therapeutic comorbid anxiety disorder diagnoses (92% remis- tasks and homework. Thus, similar to how symp- sion). Similarly, children with comorbid anxiety toms of ADHD interfere with academic engage- and DBD symptoms displayed lower response ment at school, therapists may fi nd that children rates to behavioral therapy and stimulant medica- with comorbid ADHD and anxiety also struggle tion than did children with ADHD alone in the to engage in therapy. Multimodal Treatment Study of Children with Third, as suggested by Storch, Björgvinsson, ADHD (March et al., 2000 ) . Further, attenuated Riemann, Lewin, Morales, & Murphy (2010 ), treatment outcomes have been observed for youth comorbid DBD symptoms can affect behavioral with comorbid DBD and OCD symptoms in treatment of anxiety because of potential “second- pharmacotherapy trials (Geller et al., 2003 ; Masi ary gains that make youth less motivated to reduce et al., 2005 ) and in combined medication and symptoms” (p.173). Building on the coercive par- psychotherapy trials (Wever & Rey, 1997 ) . Other entÐchild interactions of DBD (Patterson, 1982 ) , studies of anxiety have found that comorbid DBD both parents and children are reinforced in some 6 Anxiety and Disruptive Behavior 101 ways when parents acquiesce to the child’s and small child groups met separately for 1 h per disruptive behaviors. The child does not have to week. In addition to standard CBT for anxiety engage in the task, and the parents do not have to components, the comorbid anxiety and aggres- manage disruptive behavior. Thus, they are both sion treatment incorporated anger management rewarded by continued avoidance of feared stimuli skills for the child (e.g., self-management, self- (i.e., family accommodation) and escape from re fl ection, and self-monitoring skills, including feared stimuli when the child becomes disruptive. self-talk; social problem-solving skills; behavior Over time, the child may seek attention (e.g., parents management; goal setting; and interpersonal rubbing back to calm down) and privileges (e.g., group processes) and “education about aggres- delayed bedtime) that have been associated with sion and a greater emphasis on behavior anxiety (i.e., secondary gains). These complex func- management techniques” for the parents (p. 1114). tional relations may make it more dif fi cult to extin- Results revealed that both interventions guish anxiety and likely affect family engagement signifi cantly reduced anxiety and aggressive in treatment and adherence to CBT homework. behavior and that comorbidity did not affect Additionally, as a fi nal feature that contributes treatment outcomes. Additionally, both treatment to treatment complexity, research suggests that groups reported improvements in parenting prac- poor emotion regulation skills associated with the tices and may have inadvertently involved the presence of ADHD may make children hypersen- use of contingency management skills to engage sitive to anxiety (Kendall & Choudhury, 2003 ; children in treatment. Although the relatively Sukhodolsky et al., 2005 ) . Therefore, the interaction small sample size precludes de fi nitive fi ndings, of DBD symptoms and anxiety may be particularly this study provides preliminary support for a tai- challenging to manage in treatment as inattentive, lored treatment approach for anxiety with comor- oppositional, and de fi ant behavior directly impact bid aggression. mechanisms of change associated with anxiety Several case studies offer preliminary support treatment. Each one of the aforementioned factors for the combined use of CBT for anxiety and complicate treatment, and in combination, they can behavioral parent training for DBD symptoms. interfere with children’s habituation to anxiety, One case study of a 10-year-old girl with OCD learning of adaptive ways to manage anxiety, and disruptive behaviors incorporated four ses- improvements in family functioning, and general- sions of parent training prior to implementing ization of skills outside of CBT sessions. CBT for OCD in order to address DBD symptoms and facilitate CBT (Lehmkuhl et al., 2009 ) . After implementing behavioral parent training Treatment skills, CBT was implemented to treat the child’s OCD symptoms, which resulted in reductions in Psychosocial Approaches. Although there is a both OCD and DBD symptoms. Another case need for tailored interventions to target anxiety study of a 6-year-old child with OCD and ODD and DBD symptoms, few studies have examined involved working with the child’s parents to dif- the effects of combined treatment on anxiety and ferentiate between the functions of his problem- DBD symptoms. In one such study, Levy, Hunt, atic behaviors and implement behavioral parent and Heriot ( 2007 ) compared the effectiveness of training skills and CBT interventions (Ale & group-delivered CBT for anxiety and group- Krackow, 2011 ) . Over the course of 23 sessions, delivered CBT tailored for children with anxiety they implemented positive attention, planned and signi fi cant aggressive behaviors (i.e., scoring ignoring, time-out from positive reinforcement, in the 90th percentile on both the Aggressive and exposure tasks for a fear of accidentally swal- Behaviors and Externalizing scales of the Child lowing and choking on buttons. Following treat- Behavior Checklist). Both treatment arms con- ment, the child exhibited mild OCD symptoms sisted of nine sessions delivered over the course and no longer met criteria for ODD. These cases of 11 weeks, during which small parent groups demonstrate the effects of working with parents 102 O. Rahman et al. to incorporate a structured reward system to ticularly useful with younger children, with motivate compliance, differential reinforcement children largely motivated by external rewards, (i.e., provide attention for desired behaviors and and with those who engage in disruptive behavior ignore minor misbehavior and engagement in to escape anxiety-provoking situations. rituals) (Francis, 1988 ), and time-out from positive Alternatively, if functional analysis reveals that reinforcement for aggressive behaviors. Further, DBD symptoms primarily occur in the context of parent contingency management components can anxiety, it may be more effective to treat anxiety decrease aggressive behavior while increasing aggressively with CBT in lieu of the disruptive engagement in exposure therapy. Thus, family behavior, with the expectation that disruptive involvement is important in the treatment of chil- behaviors will decrease along with reductions in dren with disruptive behavior, and these case anxiety. However, this strategy may not be effec- studies highlight the importance of including tive in cases where the disruptive behavior inter- caregivers in anxiety treatment to address behav- feres with treatment implementation and ior problems and decrease family accommodation. compliance. In this case, continued assessment Results of the previous studies suggest that throughout treatment may indicate a need to incor- treatment to address anxiety and DBD (either con- porate speci fi c behavioral techniques designed to currently or sequentially) may reduce both DBD increase engagement in treatment. In addition, for symptoms and anxiety symptoms. With the excep- older adolescents, the use of motivational inter- tion of OCD, literature examining combined treat- viewing (see Erickson, Gerstle, & Feldstein, 2005 ment for anxiety and DBD symptoms is limited. for review) may increase treatment engagement as This may be due to the mixed fi ndings which sug- well as reduce resistance. gest that DBD symptoms may respond to standard For children with primary DBD symptoms CBT for anxiety (Flannery-Schroeder et al., 2004 ; and comorbid anxiety or for families who cannot Rapee, 2003 ) . Moreover, it may be that OCD with engage in exposure tasks due to severely disrup- comorbid DBD exhibits different clinical presen- tive behavior, therapists should address disrup- tations and challenges than comorbid anxiety. tive behaviors fi rst using parent training and contingency management techniques. Parent Treatment Strategies. Based on our clinical expe- training interventions focused on increasing com- rience and on the evidence available, we suggest pliance and decreasing aggressive behaviors several strategies for treating comorbid anxiety should fi rst be introduced. As discussed above, and disruptive behavior. Initially, the clinician key parent training skills include developmen- should gain a functional case conceptualization tally appropriate praising and rewarding desired to better understand the relation of anxiety and behaviors, ignoring minor misbehaviors, and DBD symptoms (i.e., which diagnosis is pri- implementing time-out or loss of privileges for mary? how do the behaviors impact one another? potentially dangerous misbehaviors. In our expe- what environmental variables maintain each rience, addressing parenting skills can provide a behavior?). If the therapist notices that the disor- stable foundation for children with comorbid ders are co-primary and are interacting with each DBD and anxiety. Children with primary DBD other and negatively affecting the family interac- require parents and clinicians to have high-level tions, a concurrent approach to treatment will contingency management skills while conduct- likely yield the strongest results. Therapists ing exposure tasks; thus, shaping parent skills should work with parents to incorporate rewards prior to addressing anxiety may be dually (and possibly mild punishment) to encourage bene fi cial. Additionally, preliminary evidence engagement in treatment and to reduce disruptive suggests that children’s anxiety may be reduced behavior. There should also be an effort to limit with the treatment of DBD symptoms (Chase & family accommodation and thus reduce negative Eyberg, 2008 ) . Furthermore, anxiety should be reinforcement associated with escaping anxiety- reassessed following behavioral parent training provoking situations. This approach may be par- and addressed with CBT as necessary. 6 Anxiety and Disruptive Behavior 103

Pharmacological Approaches. In addition to the communication was delayed and a speech and above strategies, pharmacotherapy also has been language pathologist diagnosed him with speech used to manage disruptive behavior in children apraxia when he was 2 years old. He has since with anxiety disorders. Haloperidol and chlorpro- been receiving regular speech therapy, with mazine are neuroleptic medications that have treat- signi fi cant bene fi t. Johnny met all other development indications; however, these medications are mental milestones within normal limits. Mrs. associated with the presence of many untoward Smith, Johnny’s adoptive mother, described his side effects (e.g., anticholinergic effects, extrapyra- temperament as “dif fi cult.” Johnny has dif fi culty midal reactions, weight gain), so their use has with social interactions and developing close declined with the advent of atypical antipsychotic friendships. After appropriately separating from medications that generally have safer side effect his parents in early childhood (i.e., displaying no profi les. Although no FDA-approved pharmaco- separation anxiety), Johnny started to display logical treatments exist for ODD or CD in typically separation anxiety at age 8. developing youth, risperidone and aripiprazole Johnny was brought to the clinic for evaluation (two atypical antipsychotic medications) have been when he was 9 years old and he was diagnosed approved for use with youth with comorbid autism with generalized anxiety disorder and separation spectrum disorders and disruptive and irritability anxiety disorder. In addition, he displayed disrup- symptoms ( Food and Drug Administration, 2006 ) . tive behavior including explosive outbursts, non- Additionally, these medications are often used off- compliance with adult requests, and physical label to treat disruptive behaviors in typically aggression toward his parents and teachers. developing youth with anxiety disorders (Kutcher Johnny had numerous sources of anxiety. et al., 2004 ) . In a multisite, double-blind placebo- Examples included worrying about whether he controlled maintenance trial that included 436 would like the menu at a restaurant, whether the children aged 5Ð17 years, Reyes, Buitelaar, Toren, temperature in various places would be appropri- Augustyns, and Eerdekens ( 2006 ) found that ate, if he would have a place to charge his elec- risperidone treatment was associated with tronics, etc. Johnny’s generalized anxiety reductions in disruptive behavior yet not “insecure/ symptoms made it diffi cult for the family to go to anxious” symptoms. Buspirone, an anxiolytic restaurants and other public places. Johnny also medication, also has been used off-label to treat had diffi culty separating from his mother, which comorbid anxiety and disruptive behavior. In an contributed to his reluctance to attend school. His open-label trial, Pfeffer, Jiang, and Domeshek parents described him as an “exact” child with a (1997 ) found that youth who were treated with bus- need to keep the same routine and order with pirone displayed reductions in anxiety and aggres- tasks. For example, he refused to dress for school sion. However, treatment was discontinued for until after breakfast and he required his parents to 25% of children due to increases in aggression or serve him food following a specifi c routine. Any mania associated with treatment. In light of these deviations from this routine, whether by Johnny fi ndings and limited research on pharmacothera- or others, contributed to outbursts of disruptive peutic approaches for youth with comorbid anxiety and aggressive behavior. At the time of the evalu- and disruptive behavior, caution is warranted when ation, Johnny’s parents accommodated his anxi- using medication to treat this population. ety to prevent his aggressive behavior. They modi fi ed family routines such as avoiding restaurants, parties, and family gatherings. Additionally, Case Study they provided him with constant supervision in social settings and Mrs. Smith attended school Background. Johnny Smith (pseudonym) was with Johnny to help manage his classroom behavior. adopted when he was 2 days old. He was born Johnny often spent a majority of the school day one month premature and made limited eye con- with his mother in a separate room away from tact with his parents as an infant. Johnny’s verbal his classmates. Despite these accommodations, 104 O. Rahman et al.

Johnny’s academic performance suffered because ing, using a coping strategy [e.g., listening to a he often refused to do schoolwork and homework. song], or expressing displeasure appropriately). Initially, concurrent with the behavior manage- Pharmacological Treatment. About a year before ment session, issues related to Johnny’s anxiety being evaluated by a psychologist, Johnny started also were addressed (e.g., we attempted to talk to taking escitalopram (5 mg), which resulted in Johnny about ways to handle his anxiety); how- immediate decrease in his anxiety and disruptive ever, his disruptive behavior interfered with these behavior. However, according to Mr. and Mrs. efforts and he became aggressive when the dis- Smith, initial treatment effects associated with cussion focused on his anxiety. escitalopram waned over time and his dose was Over several sessions, with the use of speci fi c increased (up to 20 mg). With dosage increase, rewards and consequences (usually related to loss Johnny’s rage attacks and separation anxiety symp- of electronics for a specifi ed time period), toms also increased and he started to pick his skin Johnny’s behavior improved and engagement in compulsively, particularly on his legs. Subsequently, therapy increased. However, Mr. and Mrs. Smith Johnny went through multiple medication trials continued to accommodate Johnny’s anxiety- that included oxcarbazepine, fl uvoxamine, bus- driven behavior, which worked to sustain nega- pirone, clomipramine, and aripiprazole. Mrs. Smith tive interactional patterns in the family. Thus, a reported that Johnny often initially responded well plan was developed to address Johnny’s anxiety to a medication change, but the therapeutic effects that involved providing rewards for engaging in gradually attenuated and he began to experience and practicing relevant anxiety-management untoward side effects (e.g., sedation, agitation, and techniques learned in therapy (e.g., not escaping memory problems). At the time he presented for the situation entirely or asking for help). At the behavior therapy, Johnny was taking aripiprazole same time, Mr. and Mrs. Smith were encouraged (15 mg), which was associated with modest reduc- to reduce their accommodation of Johnny’s anxi- tions in disruptive behavior but also with signifi cant ety-driven behavior gradually. For example, weight gain. instead of letting Johnny escape an anxiety- provoking situation immediately, they allowed Behavioral Treatment . Behavioral treatment for him to escape the situation after a few minutes. Johnny initially targeted his most disruptive and Exposure to feared stimuli was initiated on the impairing behaviors including physical aggression. sixth therapy session. After a hierarchy of fears In the fi rst session, Johnny refused to participate was constructed, Johnny’s fear of elevators was and became verbally and physically aggressive targeted fi rst using behavioral exposures. For (pushing his parents and throwing objects) when instance, he stood near the elevators, then he put his parents discussed his behavior problems with one foot inside, and so on. Each step was repeated the therapist. He grew increasingly upset and began until Johnny’s habituated to the situation and the turning over chairs and struck his parents. These anxiety was manageable. After doing exposures in instances were dealt with loss of privileges, time- session, Johnny and his parents repeated them for out, and, in one case, physical restraint. homework. Using a combination of speci fi c Because Johnny’s disruptive and anxiety- rewards and the implementation of strategies to related behaviors were equally problematic and reduce accommodation of Johnny’s anxiety-driven his disruptive behavior would likely prevent behaviors, Mr. and Mrs. Smith were able to get effective engagement in anxiety treatment (e.g., Johnny to continue participating in behavioral exposure therapy), the fi rst several therapy ses- exposures. Three weeks after initiating exposure sions focused on parent training and behavior therapy, Johnny was able to ride in elevators with contingency management. Behavior management an adult present. However, Mr. and Mrs. Smith training included both parent-directed techniques were encouraged to continue exposures until (such as prompts, rewards, and consequences) Johnny was able to ride in an elevator alone. It is and child-directed strategies (such as deep breath- worth noting that Johnny often expressed a fear 6 Anxiety and Disruptive Behavior 105 that the elevator would become stuck. His parents sures was reinforced by daily rewards. Any had previously responded to this fear by providing aggressive behavior during this process was him with reassurance, which had not been effec- addressed using consequences and rewards for tive in reducing his anxiety. Therefore, Mr. and demonstrating restraint. Mrs. Smith were encouraged to remain calm, neu- Johnny’s behavior and anxiety improved tral, and not indulge Johnny’s reassurance-seeking steadily during the course of treatment. He expe- behavior during exposures. rienced fewer confl icts with others as his behav- In addition to exposures, cognitive techniques ior improved and this contributed to improved were used to help Johnny cope with anxiety. adjustment at home and school. He also displayed These included having Johnny remember that less disruptive, defi ant, and aggressive behavior anxious feelings are transient and decrease in following reductions in his anxiety. Although intensity after several minutes. Johnny also was Johnny’s anxiety and behavior were signi fi cantly encouraged to affi rm that he was able to manage improved by the end of 15 weekly therapy ses- anxiety in the past and would likely be able do it sions, he still experienced occasional behavioral again in the future. However, it should be noted outbursts that were successfully maintained in that cognitive techniques were not used to reas- monthly maintenance sessions. sure the fear (e.g., “the elevator will not harm me”) because of their potential to undermine the exposure process and their limited success in the Conclusions and Future Directions home environment when provided by Mr. and Mrs. Smith. Childhood anxiety and DBD are commonly As therapy progressed, Johnny began to comorbid, associated with signi fi cant impair- develop more trust in his therapist, which allowed ment, and complicate treatment delivery and the therapist to begin challenging Johnny’s “just related outcomes. As discussed, the presence of right” symptoms using the exposure-based model. disruptive behavior can interfere with children’s These included his need for strict adherence to engagement in treatment for anxiety and anxiety routines, requirements for the food to be cooked can contribute to children’s resistance to engage a certain way, and clothes to feel right. Johnny in interventions to address disruptive behavior. was not able to express a feared consequence or a Thus, this chapter highlights treatment strategies cognitive component underlying the anxiety driv- for youth with comorbid anxiety and disruptive ing these symptoms. Rather, he experienced more behavior symptoms to introduce a treatment par- general distress and discomfort when his routines adigm for this diffi cult to treat population. Some were not performed or accommodated. Exposure specifi c strategies involved treating anxiety as a therapy for Johnny’s “just right” symptoms primary indication, increasing motivation to involved graduated exposure to each anxiety- engage in treatment, using contingency strategies provoking situation until Johnny was able to to manage disruptive behavior while treating withstand the situation with manageable anxiety. anxiety concurrently, and reducing disruptive Therapy concluded with addressing Johnny’s behavior before initiating with anxiety symptoms of separation anxiety and refusing to treatment. attend school without his mother. A combination The treatment strategies discussed in this of strategies was used to address these problems. chapter are based on available research on child- Speci fi cally, gradual exposures were used in hood anxiety and DBD (alone and when comor- which Johnny was separated from his mother ini- bid), a very limited number of clinical trials, case tially for short intervals that were steadily studies, and our own clinical experience. One key increased over a period of days. Johnny also was factor in the treatment of youth with comorbid encouraged to use coping thoughts to manage his anxiety and disruptive behavior is that the treat- anxiety when separated from his mother (e.g., “I ment approach directly follows the case concep- will see her after 30 minutes”). Engaging in expo- tualization. The specifi c strategy may depend on 106 O. 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Pediatric Obsessive Compulsive Disorder Treatment sive-compulsive disorder. Behaviour Research and Study Team. (2004). Cognitive behavior therapy, ser- Therapy, 48 , 1204Ð1210. traline, and their combination for children and adoles- Storch, E. A., Merlo, L., Larson, M., Geffken, G., cents with obsessive-compulsive disorder: The Lehmkuhl, H. D., Jacob, M. L., et al. (2008). Impact of pediatric OCD treatment study randomized controlled comorbidity on cognitive-behavioral therapy response trial. Journal of the American Medical Association, in pediatric obsessive-compulsive disorder. Journal of 292 , 1969Ð1976. the American Academy of Child and Adolescent Pfeffer, C. R., Jiang, H., & Domeshek, L. J. (1997). Psychiatry, 47 , 583Ð592. Buspirone treatment of psychiatrically hospitalized Stringaris, A., Cohen, P., Pine, D. S., & Leibenluft, E. prepubertal children with symptoms of anxiety and (2009). Adult outcomes of youth irritability: A 20-year moderately severe aggression. Journal of Child and prospective community-based study. American Adolescent Psychopharmacology, 7 , 145Ð155. Journal of Psychiatry, 166 , 1048Ð1054. Rapee, R. (2003). The inﬂ uence of comorbidity on treat- Sukhodolsky, D. G., Rosario-Campos, M. C., Scahill, L., ment outcome for children and adolescents with anxi- Katsovich, L., Pauls, D. L., Peterson, B. S., et al. ety disorders. Behaviour Research and Therapy, 41 , (2005). Adaptive, emotional, and family functioning 105Ð112. of children with obsessive-compulsive disorder and Reyes, M., Buitelaar, J., Toren, P., Augustyns, I., & comorbid attention de ﬁ cit hyperactivity disorder. Eerdekens, M. (2006). A randomized, double-blind, American Journal of Psychiatry, 162 , 1125Ð1132. placebo-controlled study of risperidone maintenance Verduin, T. L., & Kendall, P. C. (2003). Differential occur- treatment in children and adolescents with disruptive rence of comorbidity within childhood anxiety disor- behavior disorders. American Journal of Psychiatry, ders. Journal of Clinical Child and Adolescent 163 , 402Ð410. Psychology, 32 , 290Ð295. Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Walker, J. L., Lahey, B. B., Russo, M. F., Frick, P. J., Evidence-based psychosocial treatments for phobic Christ, M. A. G., McBurnett, K., et al. (1991). Anxiety, and anxiety disorders in children and adolescents. inhibition, and conduct disorder in children I: Relations Journal of Clinical Child and Adolescent Psychology, to social impairment. Journal of the American 37 , 105Ð130. Academy of Child and Adolescent Psychiatry, 30 , Skinner, B. F. (1953). Science and human behavior . New 187Ð191. York: Free Press. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Spencer, T. J. (2006). ADHD and comorbidity in child- Compton, S. N., Sherrill, J. T., et al. (2008). Cognitive hood. Journal of Clinical Psychiatry, 67 , 27Ð31. behavioral therapy, sertraline, or a combination in Storch, E. A., Björgvinsson, T., Riemann, B., Lewin, A. childhood anxiety. New England Journal of Medicine, B., Morales, M. J., & Murphy, T. K. (2010). Factors 359 , 2753Ð2766. associated with poor response in cognitive-behavioral Watson, H. J., & Rees, C. S. (2008). Meta-analysis of ran- therapy for pediatric obsessive-compulsive disorder. domized, controlled treatment trials for pediatric Bulletin of the Menninger Clinic, 74 , 167Ð185. obsessive-compulsive disorder. Journal of Child Storch, E. A., Geffken, G. R., Merlo, L. J., Jacob, M. L., Psychology and Psychiatry, 49 , 489Ð498. Murphy, T. K., Goodman, W. K., et al. (2007). Family Wever, C., & Rey, J. M. (1997). Juvenile obsessive- accommodation in pediatric obsessive-compulsive compulsive disorder. Australian and New Zealand disorder. Journal of Clinical Child and Adolescent Journal of Psychiatry, 3 , 105Ð113. Psychology, 36 , 207Ð216. Woodward, L. J., & Fergusson, D. M. (2001). Life course Storch, E. A., Lewin, A. B., Geffken, G., Morgan, J. R., & outcomes of young people with anxiety disorders in Murphy, T. K. (2010). The role of comorbid disruptive adolescence. Journal of the American Academy of behavior in the clinical expression of pediatric obses- Child and Adolescent Psychiatry, 40 , 1086Ð1093. Diagnosis and Cognitive Behavioral Treatment of Anxiety Disorders 7 in Young Children

Klaus Minde

Anxiety disorders are the most common form of about the “problems of preschool children” or psychopathology in children and adolescents focused on symptoms such as general behavior, with reported rates of 5–15% in the general child sleep, or feeding problems (e.g., Richman & and adolescent population (Klein & Pine, 2002 ) . Lansdowne, 1988 ) . In fact, in a 1995 volume of This wide range of incidence may refl ect varia- the Child and Adolescent Psychiatric Clinics of tions in defi ning “a disorder” in children by dif- North America that dealt with the fi eld of psy- ferent authors but may also be related to the chiatry of infants and preschoolers, there is no varying peak onset times for individual anxiety chapter on anxiety disorders, depression, or dis- disorders. Thus social phobia is more commonly ruptive disorders (Minde, 1995 ) . seen during adolescence while the onset of sepa- A major reason for hesitating to “diagnose” ration anxiety disorder occurs more often during preschoolers as suffering from categorical disor- early childhood ( Wittchen, Stein, & Kessler, ders has been the belief that young children need 1999 ) . This explanation is supported by to be seen within the context of their families and Merikangas et al. (2010 ) who examined the life- that disorders in early childhood are best concep- time prevalence of a mental disorder in 101,123 tualized as relational psychopathologies, that is, US adolescents. The group documented that 8% consequences of dysfunction in the parent–child of their sample met the criteria for an anxiety dis- environment system (Cicchetti, 1987 ) . As a order at age 4, going up to 14% at age 5 and 17% result, diagnostic assessments were usually based at age 6. Ten years later, 38% of girls and 26% of on observations of children and their caregivers, boys had experienced one or more anxiety disor- frequently documented by videotaped standard- ders of which 8.3% were considered to be associ- ized interactional paradigms with detailed coding ated with severe impairment. The whole concept systems. This provided clinicians with relevant of giving preschool-aged children a psychiatric information and facilitated individually tailored diagnosis based on categorical disorders is rather treatment plans. Furthermore, by reviewing tapes new. While there has long been interest in the with caregivers and asking them for their obser- normal and abnormal early development of chil- vations and comments, the clinician learned how dren, academic investigators and clinicians talked parents interpreted their own and their child’s behaviors, and any potentially distorted perceptions of the parents could then be addressed. There was also the general assumption that prob- K. Minde , M.D. (*) lem behaviors in the early years did not necessar- Department of Psychiatry and Pediatrics , McGill University , Montreal , QC , Canada ily predict later psychopathology and that children e-mail: [email protected] “outgrow” these behaviors.

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 109 DOI 10.1007/978-1-4614-6458-7_7, © Springer Science+Business Media New York 2013 110 K. Minde

Thus, the idea of distinct forms of psychopa- aspects of a diagnosis. When DSM-IV was pub- thology in the fi rst years of life has not been easy lished 10 years ago, our knowledge about diag- to accept for some clinicians. However, there is nosing infants and preschoolers was far less now ample evidence that supports the presence of developed than it is today. Hence, the criteria for categorical psychiatric disorders in early child- speci fi c psychiatric conditions consisted of only hood and in this chapter both categorical and a few cautionary remarks alerting the clinician to dimensional approaches to psychopathology will variations in the actual presentation of symptoms be discussed. Furthermore, some of the research denoting anxiety in young vs. older children. about the new understanding of anxiety disorders This has led some clinicians to ignore that, for in preschool children and some recently devel- example, 3 out of a possible 8 symptoms are oped and validated assessment tools will be required by DSM-IV-TR to diagnose a 3-year-old described. Following that, the early clinical man- toddler to suffer from a separation anxiety disor- ifestations of these disorders will be discussed, der, and instead have based their diagnosis on based on data from developmental psychopathol- only 2 or even just one of the DSM-IV-TR ogy and neuroscience. The emphasis will be on required symptoms. This lack of fi delity to the the clinical similarities to and differences from required number of symptom partly refl ects the the anxiety disorders in older children and ado- reality that the cognitive development of most lescents. Finally, some treatment programs that toddlers does not yet allow them to demonstrate have been successful in helping young anxious at least 5 of the possible 8 criteria demanded for children will be described and the importance of this diagnosis such as excessively worrying about effective prevention strategies and early interven- possible harm befalling major attachment fi gures, tion programs for anxious children and their fam- having a history of nightmares, fear of getting ilies are discussed. lost or being kidnapped, or complaining of physical symptoms. Moreover, many anxious youngsters are not enrolled in out of home daycare The Diagnosis of Anxiety Disorders programs as their caregivers do not think them in Young Children appropriately ready for it—and hence they will not qualify for the item requiring “a persistent Traditionally, the diagnosis of psychiatric disor- reluctance or refusal to go to school.” Another ders in North America has been based on criteria example of diffi culties clinicians have had with de fi ned by the Diagnostic and Statistical Manual the DSM criteria for diagnosing young children of Mental Disorders (DSM) of which there have is PTSD, a condition described in a signi fi cant been fi ve versions so far, each refl ecting the then number of preschool children who have experi- current scienti fi c understanding of psychiatric enced abuse or been exposed to violence. This is disorders. The last version, called DSM-IV TR particularly relevant as there has long been con- ( American Psychiatric Association, 2000 ) , cern about the potentially long-term impact vio- describes a number of disorders “fi rst diagnosed lence or trauma have on children and an interest in infancy, childhood, or adolescence.” Among to determine whether there are developmentally them are mental retardation, attention de fi cit defi ned age limits that may function as a shield hyperactivity disorder, and separation anxiety against an actual memory of a trauma experi- disorder. Some of these diagnostic categories ask enced during the fi rst 5 years of life. This has led to “specify early onset” which implies that the to nine studies over the past 15 years where inves- onset occurs before age 6 years. However, none tigators have examined the clinical presentations of these diagnostic criteria allow qualifying state- of traumatized young children and compared ments about possible variations in, for example, them with the DSM-based diagnostic criteria of the symptomatology of separation anxiety in tod- PTSD. Four of these studies were by Scheeringa dlers and in adolescents. There are a number of and his colleagues and in a recent review of the reasons for failing to recognize the developmental nine studies Scheeringa (2009 ) con fi rmed that (a) 7 Anxiety in Young Children 111

PTSD can be reliably detected in children as who react negatively to novelty tend to show the young as 12 months; (b) it manifests most (but same reaction as toddlers (Fox, Henderson, not all) of the items mentioned in DSM-IV and Marshall, Nichols, & Ghera, 2005 ) . Likewise, that; (c) an alternative criteria algorithm appears toddlers labeled “behaviorally inhibited” by more developmentally sensitive than the DSM- Kagan, Snidmen, Arcus, and Reznik (1994 ) show IV-TR algorithm. Specifi cally, Scheeringa, a two-to-fourfold increased risk for anxiety dis- Zeanah, Myers, and Putnam ( 2003 ) modi fi ed the orders in later childhood. As anxious children are wording of some items and changed the C crite- frequently born to anxious parents (Gregory rion (numbing and avoidance items) by requiring et al., 2007 ) , these continuities likely re fl ect both only 1 rather than 3 items out of 7. This raised the genetic and environmental effects as well as rates of PTSD in clinic referred traumatized tod- gene–environmental interactions. Complicating dlers and children from 5 to 25%, equivalent to these fi ndings are studies reporting that up to rates found in older populations. 30% of anxious children face elevated risks for While modifi cations in this specifi c diagnostic depressive disorders during adolescence, espe- category has been helpful, it has also led to cially among girls (Caspi, Moffi tt, Newman, & research examining to what extent psychiatric Silva, 1996 ) . This suggests a heterotypic continu- disorders during the preschool age are stable ity. Infants with undifferentiated reactions to nov- despite otherwise rapid developmental change. elty become anxious toddlers and children who This work has been well summarized by Angold may mature into adults with anxiety and/or and Egger in a chapter (2004 ) and a special jour- depression. Yet, three important questions nal issue on preschool mental health (2007 ) . They remain: conclude that (a) preschool externalizing and 1. It is not possible to predict whether an anxious internalizing problems are both quite stable and child will remain anxious as an adult or will predict negative outcome years later; (b) it is not become an adult suffering from a major relevant to locate psychopathology “into the depressive disorder (MDD). child” vs. “in the child’s relationship,” but, to cite 2. Studies show that only a minority of “at-risk” Bronfenbrenner (1974 ) , “to understand how the children ultimately manifest persistent disor- characteristics of the child and its social context ders (Gregory et al., 2007 ) . This implies that work to produce psychopathology.” In the same treatment of at least some anxious children book, Egger and Angold (2004 ) present a will be successful because of the natural his- Preschool Age Psychiatric Assessment Instrument tory of the condition and not because the ther- (PAPA) which they had developed and used to apeutic modality was relevant for the assess 307 children aged 2–5 years, recruited from disorder. the Duke Children’s Primary Care Clinic. Based 3. Some of the present DSM-IV-de fi ned psychi- on parental reports, the authors could identify atric anxiety disorders provide special chal- eight specifi c diagnostic clusters (e.g., anxiety lenges because the symptomatology of some disorders) in these children which in turn were of them, e.g., Obsessive compulsive behavior, based on 25 modules (e.g., PTSD as a part of selective mutism, or PTSD, is more consistent types of the anxiety disorder cluster). The anxiety over time and children suffering from these disorder cluster included 9.5% of all children. In a conditions are often not even included in pub- later paper the authors showed that the PAPA had lished treatment outcome studies of anxiety good 2-months test–retest reliability (kappas disorders (Kendall, 1992 ) . between 0.50 and 0.75, Egger et al., 2006 ) . The assessment also includes detailed questions about the psychosocial environment of the child and his New Insights from Neuroscience family and requires several hours to complete. As far as anxiety disorders are concerned, Recent research in neuroscience provides addi- clinical studies based on the criteria of develop- tional explanations for the brain–behavior asso- mental psychopathology demonstrate that infants ciations suggested by the above mentioned 112 K. Minde clinical observations. For example, there is now tive failure to regulate threat-related information solid evidence that the amygdala is necessary for processing functions in children and adults alike. learning how to deal with threats by regulating While there is a great need to better under- attention allocation to stressful events (Davis & stand the potential causes of these perturbations Whalen, 2001 ) . However, there are many more and how they relate to specifi c types of anxiety ways in which brain circuitry may relate to disorders, there is agreement about the profound observed anxious behavior. As Pine (2007 ) states emotional and cognitive burdens these disorders in his review on this topic, there are different neu- place on the lives of affected individuals. There is ronal components engaged when a person is con- also agreement on the premise that these disor- fronted by innate threats or threats emanating ders move from an undifferentiated and plastic from outside sources or a separation. There is state of a fear circuitry early in life to a more rigid also a different circuitry engaged when we learn and resistant threat appraisal bias in later child- to minimize punishment versus learn which cues hood or adolescence. This suggests that treatment are associated with specifi c punishers. In addi- should start as early as possible for at-risk or tion, signifi cant developmental changes that affected children and should deal with modifying occur in an individual’s threshold for avoidance their regulatory abilities regarding both their may be partly related to contextual factors such emotional and cognitive responses to potentially as family support and education. Thus geneti- threatening life experiences. Moreover, any cally at-risk but clinically unaffected individuals effective treatment will need to involve caregiv- may become symptomatic only when they are ers as their potential role in modulating early repeatedly exposed to stress, leading to an reactions to threats in their young children is increasing appraisal bias, i.e., the individual will powerful and can lead to a signi fi cantly better perceive even lower stresses as increasingly quality of their lives. threatening (Bar-Haim, Lamy, Pergamin, It is of interest that the authors of two other Bakermans-Kranenburg, & van IJzendoorn, prominent psychiatric assessment tools have also 2007 ) . There is also research that documents that developed separate versions of their instruments distinct threats engage distinct brain circuitries for children aged 18–60 months ( Achenbach & which in turn leads to different behaviors (Blair, Rescorla, 2004 ) and for those aged 3–4 years Mitchell, & Blair, 2005 ) . This could also serve as (Goodman, 2001 ) . Achenbach’s CBCL identi fi es a template for understanding the presence of dis- seven syndromes in the 18–60 months age group tinct subtypes of anxiety disorders, such as OCD compared to eight syndromes in the older chil- and SAD. Finally, different threats may show dis- dren. Syndromes re fl ecting the same DSM- tinct associations with risk factors but not with oriented diagnosis are given a different name for actual disorders, i.e., they may primarily affect the preschool group, for example, Emotionally children who have anxious relatives (Pine, 2007 ) . Reactive instead of Affective Disorder. Other threat circuits appear to be additive, so that Goodman’s (1997 ) Strength and Dif fi culties at-risk/affected individuals show the highest level Questionnaire (SDQ) has fi ve items for each of of threat appraisal bias, with at-risk but unaf- its fi ve classes of behavior but uses somewhat dif- fected people scoring lower although still higher ferent wording to adapt them for each age group when compared with non-at-risk/unaffected and syndrome. While the published validation of individuals. the SDQ is restricted to children older than 5 It is clear even from this superfi cial review that years, the validity for 3 and 4 year olds has also there are an increasing number of investigators been established (Goodman, 2011, Personal com- who attempt to integrate clinical and neuroscience munication). However, neither questionnaire perspectives on anxiety disorders. Their work attempts to diagnose specifi c subtypes of anxiety shows that anxiety disorders are primarily the result disorders and the authors consider their instru- of developmental perturbations that lead to a rela- ments primarily as screening tools and advise that high scoring children should have a more 7 Anxiety in Young Children 113 detailed clinical assessment although Goodman societies whose children fell in the suggested and Goodman (2011 ) have reported that in clinical range based on much lower or higher 5–16-year-old British children the SDQ scores scores than was suggested by the respective predict the actual prevalence of clinician rated omnicultural mean. Achenbach calls this approach child mental health disorders within 1–2% the “bottom-up” strategy and sees it as one way to ( R2 = 0.89–0.95). learn more about cultural values in speci fi c cultures and their impact on psychopathology. It appears reasonable to make use of Achenbach’s Cultural Impact on Anxiety Disorders empirical data when considering the long-term association between similarly “abnormal” behav- Another issue complicating the assessment of iors in preschoolers of immigrant families from, psychiatric conditions in young children is the e.g., Vietnam and South America and their valid- impact culture has on child development and psy- ity in predicting later psychiatric disorders within chopathology. While there is general agreement the North American context. that cultural traditions shape behavior and the Finally, it is important to point out that neither clinical presentation of psychopathology, few the PAPA, nor the suggested modi fi ed diagnostic studies have addressed this issue. This seems even criteria of DSM-IV-TR nor screening instruments more important today as there is increasing evi- developed by Achenbach and Goodman claim to dence that epigenetic forces powerfully modulate be relevant for classifying children younger than the clinical expression of genetically determined 24 months because of the developmental plastic- medical and psychiatric conditions. Since care- ity of this period of life. However, a number of givers transmit cultural narratives that will impact clinicians working with infants and their caregiv- on possible gene expressions of psychopathology ers felt that a different approach to diagnosing in their children, it would be helpful to have infants would overcome this challenge and devel- assessment tools that are sensitive to cultural values. oped the DC: 0–3 classi fi cation system in 1994, There is currently no instrument available that followed by an updated version DC: 0-3R (2005 ) . addresses this issue speci fi cally in preschoolers. This classi fi cation was created especially for However, Achenbach (2010 ) recently presented the diagnosis of infants and toddlers, avoiding the data that may provide the structure for such an pitfalls inherent in DSM-IV. Unfortunately, the endeavor. In contrast to DSM-IV-TR which repre- system uses criteria that are primarily operation- sents a top-down approach to psychopathology alized on clinical experience because of a miss- where criteria have been formulated on the basis ing research base. This led to some new diagnostic of the opinions of experts, Achenbach used data categories such as regulatory disorders and par- from evaluations of 47,987 children by their care- ent–child relationship disorders which have been takers from 24 societies, using the CBCL and helpful to some clinicians but do not re fl ect valid computed an “omnicultural mean score” for each precursors for distinct later clinical entities. syndrome. This then allowed him to rank the total scores of the 24 individual countries or societies and divide them into those whose mean score was Treatment one or more standard deviation above or below the omnicultural mean score with a third group As has been documented in the previous sections, containing ratings of societies within one SD of data from neuroscience, developmental psycho- the omnicultural mean. That permitted him to pathology, and culturally relevant situational fac- assess to what extent, e.g., gender or SES differ- tors suggest that treating anxiety disorders in ences determined the ratings of cases above the young children would be useful. All these lines 96th percentile, suggesting clinical dif fi culties in of investigation demonstrate the relative mallea- respective groups of societies. It also facilitated bility of anxious behaviors in early childhood and the presentation of comparative data on groups of stress that potentially rapid remediation can be 114 K. Minde expected. There is also evidence that it is possible acknowledged. For example, there are as yet no to obtain an accurate and valid early diagnosis of follow up reports on the outcome of preschool-aged a range of conditions such as SAD, OCD, speci fi c anxious children since authors studying the phobias, general anxiety disorder (GAD), and long-term outcome of child samples had not PTSD. While parental counseling and play ther- included subjects below the age of 8 years apy have been the primary clinical interventions (Kendall, Safford, Flannery-Schroeder, & Webb, for young children despite limited supporting 2004 ) . This is especially regrettable as Saavedra, empirical data, the effi cacy of CBT in helping Silverman, Morgan-Lopez, and Kurtines (2010 ) older children with anxiety disorder and prelimi- in a recent report indicated that a CBT-based pro- nary data in younger children, e.g., Freeman et al. gram of 10–12 weeks for 106 children aged 6–16 (2008 ) has raised the question whether treatments years (M = 9.64 years) at the time of intake had using cognitive behavioral strategies can be help- bene fi cial effects 9–13 years later when the chil- ful in this population. It has long been taken for dren were between 16 and 26 years old (M = 19.4 granted that preschool-aged children function at years). The children had a wide range of initial a concrete, egocentric, prelogical, or preopera- diagnoses, such as agora and social phobias as tional cognitive level whereas CBT is based on a well as specifi c phobias, and separation and rationalist paradigm that expects the child to use GADs. Many had a comorbid second anxiety dis- a concrete operational way of thinking. order but also ADHD, and all were randomized Speci fi cally, CBT requires patients to have a cer- into either a group- or individual-based cognitive tain linguistic ability, self-re fl ection, perspective behavioral treatment group. The authors were taking abilities, and an understanding of causality able to locate 82 of the 106 initial sample (77%) in order to recognize cognitive threat biases. and 67 fi nally participated in the follow-up study. According to Piaget, these qualities develop only A surprisingly high number of adolescents and after age 8 (Grave & Blissett, 2004 ) which would adults did not meet criteria for any DSM-IV anxi- therefore exclude CBT as a valid treatment option ety disorder (86.5%) and for DSM-IV major for such young children. depression (91%) anymore. There was no differ- However, these assumptions warrant revision. ence in the outcome between the individually and Some recent studies suggest that Piaget may have group treated children. Unfortunately, the authors underestimated the cognitive competence of pre- do not provide separate data for the children who operational children, since it appears that by were less than 8 years old when they were diag- using familiar contextual information they can nosed and treated, making it impossible to see indeed understand causality and engage in hypo- whether they responded differently from the rest thetical thinking (Meadows, 1993 ) . According to of the sample. The study does suggest, however, Robinson and Beck ( 2000 ) , preschoolers can also that even young school-aged anxious children engage in hypothetical thinking of the future but can bene fi t from CBT. not the past. Moreover, they prefer therapeutic In the last 2 years three papers have been pub- strategies that are active, concrete, and outward lished that focus specifi cally on treatment out- focused (Harter, 1988 ) . In practice, this means come in preschool samples (Minde, Roy, that young children can fi ght distorted cognitions Bezonsky, & Hashemi, 2010 ; Monga, Young, & quite readily if they are given an age appropriate Owens, 2009 ; and Scheeringa, Weems, Cohen, narrative that is forward looking as has been so Amaya-Jackson, & Guthrie, 2011 ) . As this may successfully demonstrated by March and Mulle mark the beginning of evidence-based research (1998 ) in their treatment of OCD where children into the possibilities of treating young anxious are encouraged to “run OCD off my land.” Yet children using CBT, they will be discussed in standard textbooks and researchers continue to more detail. Scheeringa et al. suggested speci fi c ignore these fi ndings and the clinical ef fi cacy of modi fi cations of the DSM-IV criteria de fi ning cognitive behavioral treatment approaches for PTSD (Scheeringa et al., 2003 ) , and recently preschool-aged children is still to be properly published the fi rst randomly designed CBT-based 7 Anxiety in Young Children 115 treatment study of young children with PTSD ing to their therapists. The changes of behaviors who were recruited through three battered women’s between pre- and posttreatment assessments had programs in the New Orleans metropolitan area a large effect size for PTSD (1.01; p < 0.0001) (Scheeringa et al., 2011 ) . Their sample consisted and substantial ones for MDD, SAD, and ODD of 75 children aged 36–83 months (M = 63.5 (from 0.72 to 0.92, p < 0.0005). Moreover, at a months). 64 children were randomized, 40 of 6-month follow-up evaluation, PTSD symptoms them received “immediate treatment,” and 24 as well as MDD-, SAD-, and ODD-associated were placed on the waiting list (WL). At base- dif fi culties were very signi fi cantly improved relative line, 18 had a suf fi cient number of symptoms to to baseline values (p < 0.0005). Not surprisingly, satisfy the regular DSM-IV diagnostic criteria there was no change in their rate of ADHD. (24.0%) and 54 (72%) satisfi ed the modifi ed These are very impressive results, especially PTSD criteria. Overall diagnoses were derived since they were based on work with a rather dis- from fi ve modules of the PAPA described by advantaged population. The mothers’ relatively Egger et al. (2006 ) . In addition to the two ver- low level of education, together with the interrup- sions of PTSD, they included the PAPA version tion of the study by Hurricane Katrina, may of MDD, SAD, oppositional de fi ant disorder explain why out of the 40 immediately treated (ODD), and ADHD. Treatment consisted of 12 and 24 waitlisted families who were treated after highly structured individual sessions, using tech- the initial cohort had terminated the study, only niques adapted from a manual used with sexually 26 children completed all 12 treatment sessions abused preschool children (Cohen & Mannarino, and not more than 19 were available for the 1996 ) . The primary maternal caretakers were in 6-month follow-up session. the room with the children at all times, and all A group program study with a patient popula- sessions included signifi cant time for psycho- tion of 5–7-year-old children attending a univer- education of the mothers. The therapists also sity-based anxiety clinic was reported by Monga rated the cognitive understanding the children et al. (2009 ) . In this pilot study, 32 children were had of speci fi c concepts associated with PTSD enrolled in a 12-week manualized CBT group and the aims of the treatment. They reported that program and a subset of 11 children were placed at session 1, none of the 8 children aged 3 under- on a waitlist for an average of 3.5 months as a stood the concept of posttraumatic stress disorder control. Groups consisted of 5–8 children and from verbal discussion but 62.5% understood it parents were mostly seen separately during the from cartoons. However, more than half of the 4 times of the group meetings. The children had year olds (7 of 13), understood it from verbal dis- various anxiety disorders, including social anxi- cussion and all of them from cartoons at session ety disorder, GAD, and selective mutism. This is 1. Almost all the 5- and 6-year-old children of interest as social anxiety disorder is consid- understood the concept using either way of pre- ered rare in preschoolers and selectively mute sentation. By session 8 almost all children of the children usually require more than 12 sessions of total sample could differentiate moderate from treatment. Yet 43.8% of the children did not meet worst anxiety provoking stimuli (92.6%) and criteria for any Axis-I anxiety disorder at the end self-ratings of their anxiety level could be of the group treatment program. It is not clear obtained during sessions 6–10. Overall, the chil- from the data presented whether the children with dren were judged to understand and complete SM were actually able to talk to nonfamily mem- 83.5% of the possible 1,793 items rated in the bers after the treatment or whether changes were 388 treatment sessions performed during the related only to their level of anxiety. The primary study. The 3 year olds had diffi culties in grada- novelty of this paper is that Monga et al. devel- tions of emotion states but were successful at oped a treatment manual for this age group which doing exposure exercises. They were also suc- was not just a modi fi cation of other programs but cessful in doing homework assignments although used stories and games intrinsically appealing to they had diffi culties verbalizing their understand- this age group. The manual was tested on the 116 K. Minde initially treated subgroup and thought to be and their parents. Before the assessment, the appropriate for the children. In addition, mothers parents and the child’s teacher were requested to were taught relaxation exercises and desensitiza- fi ll in the Strengths and Dif fi culties Questionnaire tion strategies in the hope that they would then (SDQ) (Goodman, 1997 ) and fi ll in a standard teach these techniques to their children. It is pos- form asking for a set of family and developmen- sible to imagine that some children may prefer a tal data. group treatment format to individual sessions as The initial assessment included all family seeing others with similar diffi culties would members and led to a diagnosis based on DSM- decrease their emotional isolation. On the other IV-TR criteria, SDQ ratings, interview fi ndings, hand, few practitioners have the resources to deal and a consensus rating on the Children’s Global with the organizational challenges associated Assessment Scale (CGAS) score (Shaffer et al., with running groups for anxious preschool-aged 1983) by the primary investigator, social worker, children and their parents. and psychiatric resident. Nineteen percent of the Finally, Minde et al. (2010 ) published out- children had only one anxiety disorder (SAD, come data on 37 children aged 37–89 months GAD, OCD, or phobias), 43% had more than 1 (average 71 months) who had attended a univer- anxiety disorder, 27% showed various comorbid- sity-based child psychiatry anxiety specialty ities (ADHD, ADD, and ODD), and 11% had an clinic and were treated with CBT. They were the associated delay in their language development. youngest subgroup of 250 children who were The treatment offered to the children included a consecutively referred to this clinic by their modifi ed CBT model, consisting of exposure respective physicians during a 4-year period. The only or exposure and response prevention, and clinic accepted only children younger than 12 learning how to “talk back to the brain,” as well years and the sample presented all the children as psycho-education for the parents. In the treat- who were younger than 8 years at the time of ment, special emphasis was placed on concrete referral except those with a primary diagnosis of ways to overcome fears and emotional vulnera- selective mutism because this condition is inap- bilities, using games, drawings, or stories to keep propriate for a short-term CBT-based treatment the children interested. One or both of their par- program. All children were English speaking and ents came in for the last 20 min of each session, attended some type of daycare or preschool pro- allowing the parents to report on the progress gram at least on a part time basis. The majority made during the past week and help in planning came from middle class families. All had been the subsequent “home work.” If no improvement symptomatic for more than 6 months with 20 was observed after 4–5 weeks, Fluoxetine was being considered clinically anxious for more than added, using the liquid form of 4–6 mg/day. Ten 1 year. Eleven had been seen by community- children (27%) required this additional help. based psychologists or counselors in the past and There was one follow-up session 4–6 weeks after their parents had received advice about appropri- the last regular appointment when SDQ and ate management techniques, but that had not been CGAS scores were again obtained. No family successful. The waiting period between the initial discontinued the treatment of their children phone call to the clinic and the fi rst scheduled prematurely. appointment with the director of the clinic and Results revealed that almost 50% of available his team was between 10 and 12 weeks, further parents quali fi ed for one or more psychiatric extending the period between onset of the symp- diagnoses, in 60% consisting of anxiety and/or toms and the treatment. While the team partici- depression. SDQ ratings by parents and teachers pating in the initial assessment usually consisted as well as CGAS ratings showed statistically of medical students, psychiatric residents, master signi fi cant improvements after an average of 8.3 level students in art and drama therapy, a social treatment sessions. The treatment effect was not worker, and a child therapist, the primary author associated with the age of the children. provided all treatment sessions to the children Interestingly, of nine potentially high risk back- 7 Anxiety in Young Children 117 ground variables, only the presence of a past tional relief that provided in most cases. Another parental psychiatric diagnosis signi fi cantly problem of this study is that all children and their predicted a positive treatment outcome (r = 0.64), families were treated by the primary author who as if the personal experience of living with men- was also responsible for obtaining the follow-up tal health problems had made these parents into information and scoring the CGAS ratings. especially committed partners in the therapeutic However, the rapid turnover of team members process. Treatment had no effect on symptoms of such as the psychiatric residents and the groups ADHD, confi rming fi ndings of Scheeringa and of other students made it practically impossible his group (Scheeringa et al., 2011 ) . Parent ratings to create a group of seasoned clinical practitio- on the SDQ also revealed a signifi cant decrease ners for these young children. This makes it in the burden of caring for their children after the essential to replicate this study on larger samples treatment. The 10 children (27%) who had of children of more diverse backgrounds, and received medication in conjunction with CBT using more than one experienced therapist. showed signifi cantly higher baseline sum SDQ scores by both parents and teachers and signifi cantly lower CGAS ratings by the psychia- Two Cases trist. The medicated children also received signi fi cantly more treatment sessions. Case 1 In summary, this study shows that offering CBT- Sara was 42 months old when she was referred by based interventions within the context of a regular her paediatrician because of severe anxiety com- outpatient clinic is well accepted by families of bined/associated with controlling and wilful preschool-aged children and can be helpful in behaviors for more than 2 years. She had an older decreasing the anxiety of the children and improve sister aged 10. Her parents, both in their 40s, the overall quality of life for their families follow- were from Italian immigrant families; their ing relatively few sessions. The study also con fi rms respective parents were factory or restaurant that many young anxious children already show workers who had little time for them as children. comorbid conditions such as an ODD or an addi- Sara’s mother, who was also worried about her tional anxiety disorder. As many of their parents own mother, had not worked outside the house appeared to have suffered from anxiety now or in since the birth of her fi rst child. Sara’s anxieties the past, they were ready to become solid partners had shown themselves in various ways since in the clinical work when invited to do so. birth. She had always been afraid to be separated The purely clinical venue of the study also from her mother and, even when with her, had explains some of the study’s shortcomings. For never been able to visit anyone except her mater- example, there was no control group of untreated nal grandmother. While she reached her mile- or differently treated children and we also did not stones at a normal age, she had always been an use a fully manualized treatment format as we extremely sensitive child, e.g., during her fi rst 2 felt that this would not allow us the necessary years, she would at times vomit when she was fl exibility in establishing a therapeutic alliance exposed to loud noises; she would hide in the with these young children. Our decision to add a basement when her sister invited another child psychopharmacological component for children for a play date; and had never had a birthday party not responding to cognitive strategies presents because she could not tolerate sharing her mom’s another methodological challenge although attention with anybody else. She ate only very authors studying older children have reported this few foods and would just sit at the table with her to be the best strategy for dealing with serious eyes closed and eat nothing if a different food manifestations of anxiety (Walkup et al., 2008 ) was offered. She had also never been able to fall within a clinical setting. In fact, many parents asleep alone. In fact, she slept on her mother’s were reluctant to accept medication for their chil- abdomen for the fi rst 18 months of her life. At the dren although they were grateful for the addi- time of the intake she would fall asleep around 118 K. Minde

8.30 PM with father being in bed with her. She paediatrician because she had developed obses- woke up three or four times a night always sive behavior patterns during the preceding 8 demanding one of her parents to be with her. She months. For example, she had very elaborate would also lie down on the sidewalk and cry bedtime rituals where she required her bed sheets when her father attempted to bring her to a park to be precisely positioned across her chest. She just across the street. could not tolerate to have her toes covered by her Mother’s pregnancy with Sara was uneventful. blanket and would scream if her parents did not However, she had lost two babies during previous do it right. In her daycare, she would line up the pregnancies because of an undiagnosed clotting shoes of all the attending children before joining disorder and was extremely worried that she them in play. She was also very particular that no would lose Sara as well and therefore spent piece of clothing was ever exchanged with her almost 6 months in bed. twin sister. She also would not permit anyone to The parents scored Sara in the abnormal range touch any of her new toys or pieces of clothing. on the emotional and conduct disorder and However, she slept and ate well, enjoyed her day- ADHD axes of the SDQ (Goodman, 2001 ) but care and was a popular child overall. felt that she had good pro-social abilities. Marian’s mother comes from a family without During our assessment interview, Sara hid psychiatric dif ﬁ culties and works at a medical behind her mother and would not look at me. I department in a local hospital. Because of her left her alone for about 1 h but then addressed her experiences at work and personal acquaintance with a puppet in my hand, saying that the puppet with an autistic youngster she became very wor- thinks that Sara does not enjoy her worrying ried about Marian’s symptoms. In addition, about so many things but does not know how to Marian’s father, an IT specialist, washed his stop it. She responded by nodding. I then men- hands more than ten times per day. He also tioned that I would try to help her chase these demanded that the house was spotless and parked scary thoughts away and mom and dad would do his car at least 15 m away from the next car at the so as well. We met 12 times during the subse- local shopping mall to prevent potential scratches quent 7 months where we played with farm ani- from other drivers. He defended these peculiari- mals that were scared but overcame their fears ties forcefully. Marian, during the initial inter- and were proud of themselves. The parents were view, came across as a curious youngster who asked to institute very gradual changes in her showed her love for her family by insisting that daily routine. For example, father moved from her parents also each got a cookie when I offered lying down with her at night to sitting on the bed, one to her. However, she was not interested in then to a chair besides the bed, etc. changing any of her habits as she felt well Sara started drawing more positive pictures accepted by everybody. Marian’s birth weight and after six sessions agreed to try a daycare pro- had been 3 lbs 19 oz and both twins had remained gram once per week for 3 h. While she did not eat in the hospital for 3 weeks after birth. Both slept and drink anything at the daycare and did not use through the night by 3 months and reached their the toilet, she allowed her mother to leave her milestones at the expected ages, but were diag- there after 4 weeks. We all had ice cream during nosed to have prematurely closed sutures of their our last session and she sent me a Christmas card skull, requiring a corrective operation at 13 6 months later with a photo of herself smiling. months. Both parents also rated Marian within Twelve months later, she slept and ate well, had the normal range of all 5 axes of the SDQ. two friends and was looking forward to enter a We discussed to what extent Marian’s rituals regular kindergarten program. were truly necessary and scheduled another appointment 4 weeks later. At that time, all her Case 2 rituals had disappeared and Marian had men- Marian, aged 44 months, the second born of a tioned to her parents that these habits were “not nonidentical pair of twins, was referred by her important anymore.” 7 Anxiety in Young Children 119

These cases document that anxieties and control group and no regularly scheduled follow-up obsessional behavior patterns, as shown by assessments of all children. Marian, can be part of normal development dur- Nevertheless, there have been increasing ing the preschool period. However, the clinical efforts and some interesting results reported for features in Sara’s case had a far more pervasive interventions provided to selected groups of chil- fl avor, signi fi cantly impacted her overall social dren under the age of 3 years. For example, development and impaired her relationship with Wallace and Rogers ( 2010 ) recently summarized her family and peer group. Her profound need to the implications of intervening in infancy for control others is commonly seen in anxious chil- children with autism spectrum disorder (ASD) dren and best understood as the child’s attempts and those born with developmental delays and to gain control over his or her anxieties. very prematurely. These groups can be reliably Psychological treatment requires a true partner- diagnosed at 18 months and interventions can ship between therapist, child, and family and is start early. The mean effect size (SE) of the 12 most effective when the therapist respects the type 1 and 2 studies, i.e., reporting on randomly child’s challenges and gently assures him or her prospectively designed trials, blind assessments, that one can change and talk back to the brain adequate samples and treatment manuals, encom- when it tries to convince us about unnecessary passing families who had children with ASD, fears and worries. was 0.56. The 19 studies examining interventions for premature infants had a mean effect size of 0.44 and the four studies with infants at risk for Prevention intellectual disability had a mean SE of 1.26. These very signi fi cant changes con fi rm the poten- The fi nal part of this chapter deals with the pos- tial plasticity of early abnormal child behaviors. sibility to create early prevention and interven- An additional interesting aspect of these studies tion programs for anxious children and their is that the most ef fi cacious interventions for these families. One can argue that any clinical inter- three groups of children used a combination of vention involving young children with well- four speci fi c intervention procedures. These documented anxiety problems could be were: (1) active parent involvement in the inter- interpreted as representing a “secondary” type vention, including ongoing parent coaching that prevention since it may modify the natural course focused on parental responsivity and sensitivity of the illness. Thus in the report by Minde et al. to child cues and on teaching families to increas- (2010 ) , mentioned previously, the great majority ingly provide the infant interventions, (2) indi- of patients had displayed clinically meaningful vidualizing each infant’s developmental pro fi le anxiety symptoms for more than one year and and address it accordingly, (3) focusing on a their parents or other direct family members had broad rather than narrow range of learning tar- often shown a lifelong history of battling anxious gets, and (4) begin interventions as soon as the thoughts and behaviors. In fact, many parents did risk is detected and do so intensively and system- not want their children to suffer for 30 or more atically for an extended time. Some of these years from anxiety as they had done and they saw intervention procedures are the same that have our clinic as an opportunity to prevent this fateful been found effective by clinical investigators in intergenerational continuity. Moreover, only 2 of their work with anxious preschoolers. Thus all our initial cohort of 37 children have come back stressed the crucial role parents play in facilitat- for additional help during the subsequent 3–7 ing and supporting their children’s growing cog- years, and their “relapse” required no more than nitive and emotional understanding of their two booster sessions to regain control. However behavior. They also support early treatment and gratifying, this does not provide any proof for the the need to address broad learning targets. It is longer term prevention of anxiety problems in not clear whether strictly manualized treatment our sample as there was no randomly selected programs, especially when employed with groups 120 K. Minde of children and parents, meet the anxious child’s intervention and monitoring group showed a individual needs and how long such interventions reduction of their temperamental inhibition have to be to assure the best possible outcome. scores between age of 3 and 6 years, suggesting There are two interesting published group that the children’s shy predisposition had intervention programs that focus directly on pre- remained equal in both groups, but had not led to vention of anxiety disorders in young children. anxiety in those whose mothers had attended the One of them, designed by Rapee, Kennedy, treatment group. Ingram, Edwards, and Sweeney (2010 ) , is based These follow-up results are very encouraging on the observation by Kagan (1994) that young because they are associated with a brief parent- children who show a temperamental profi le dom- based intervention 3 years earlier and are well inated by behavioral inhibition in infancy tend to documented by validated instruments. This inter- remain shy and anxious over time and frequently vention, however, benefi tted a specifi c subgroup develop an anxiety disorder in later childhood. of young children that can be identifi ed early in This relative stability of anxious symptomatol- life, much as children with ASD or other devel- ogy was chosen by the authors as a worthwhile opmental disorders, and needs to be replicated target for an early intervention. They sent special with other populations. screening packets to more than 5,600 families of More evidence that community-based group 3-year-old children attending 95 preschools in intervention programs targeting parents work Sydney, Australia and received 1,720 responses. comes from another recent Australian study A total of 146 children from this group were where Havighurst, Wilson, Harley, Prior, and selected because they scored high on withdrawal Kehoe ( 2010) reported on a program called on a temperament questionnaire (approximately “Tuning in to Kids” that aims to improve emotion 1.15 standard deviations above the mean). The socialization practices in preschool children. children also passed a laboratory assessment to They randomized 216 parents of a target child elicit shy and inhibited behaviors and subse- aged 46–68 months and offered them 6 weekly quently were randomly allocated to either a par- 2 h sessions. One hundred and ninety parents ent intervention group or a monitor group of 73 fi nished the study. The program, based on a struc- each. Treatment consisted of six 90-min group tured manual (Havighurst & Harley, 2007 ) sessions with the parents discussing the nature of encouraged changes in parenting beliefs and anxiety, principles of parent management behaviors while increasing the emotional con- techniques, highlighting the effects of overpro- nection between parent and child. Parents were tection. Later sessions dealt with the application encouraged to become aware of their own as well of exposure techniques and of cognitive restruc- as their children’s emotions and how to empa- turing. There was no direct therapeutic contact thize with them. One session dealt specifi cally with the children. Diagnostic interviews and with anxiety and problem solving. Parent and questionnaire measures were repeated at 12, 24, child ratings were obtained before and after and 36 months. Results showed a signi fi cant parental group training and at 6-month follow- group-by-time effect in the number of anxiety up. Parents in the treatment group reported being disorder diagnoses from baseline to 36 months less dismissive, more emotion coaching and ( p = 0.008) but none from baseline to 12 and 24 empathic at follow-up, whereas control parents months. The same was true when measuring the did not change. Children whose parents were in average severity of anxiety disorders. Children in the treatment group showed better emotional the parent education group also reported them- knowledge, less intensity in responding to stresses selves to be less anxious at age 6 on an anxiety and a signi fi cant reduction in behavior problems scale. The investigators suggest that the group reported by parents and teachers in comparison meetings altered the trajectory of anxiety in these to their control peers. children because of the widening gap between While the assessment instruments used in this the children in the treatment and control groups study did not allow to arrive at DSM-IV-based over time. Moreover, all children in both the psychiatric diagnoses of the children, and there 7 Anxiety in Young Children 121 were no follow-up assessments beyond 6 months, The ultimate aim of any treatment is the long- one could nevertheless see this study, together term prevention of an anxiety disorder or at least with the one by Rapee et al., as a promising addi- a modifi cation of its course. Here again, the very tion to available parenting programs. In future recent literature presents hopeful signs. A com- work, it would also be of interest to explore paratively brief exposure to well designed educa- whether a program like “Tune in to Kids,” when tion programs appears to allow parents to provided to early childhood educators, would signifi cantly modify their interactions with their improve their mentalizing ability and assist them children and to bring about behavioral change of in helping preschool-aged children with or with- up to 3 years. One would hope that similar educa- out validated anxiety disorders. tional efforts could be directed at teachers of preschoolers in the future so that a wider range of anxious children could face life with hope and Summary self-con fi dence.

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Christopher A. Flessner , Abbe Garcia , and Jennifer B. Freeman

Obsessive-compulsive disorder (OCD) is a tation of OCD is identical from early childhood complex psychiatric condition. The empirical lit- to late adolescence and adulthood. Our group has erature has documented at least two, age-related begun to more rigorously examine the experi- subtypes of the disorder, child- and adult-onset. ence of and effi cacious psychosocial interven- As may be inferred, child-onset OCD is charac- tions for children with OCD who fall within the terized by an onset of OCD symptoms prior to 18 very young end of this developmental spectrum years of age. Compared to adult-onset OCD, (e.g., 4Ð8 years of age). The aim of this chapter is children with OCD are more likely to have at to provide an overview regarding the nature of least one fi rst-degree relative with the disorder OCD in very young children, factors that may con- (Nestadt et al., 2000) . In combination with a tribute to the disorder’s complexity at this age, and growing body of corroborating evidence (e.g., treatment approaches to address these factors. We the role of parental accommodation of a child’s conclude with a case study designed to provide an symptoms), this data suggests that understanding example of the complexities surrounding the the family environment may be important for assessment and treatment of OCD during early advancing science’s knowledge regarding the childhood and areas for future research. pathogenesis and treatment of child-onset OCD. Even within the child-onset subtype, however, there are important developmental differences to Age Appropriate vs. Potentially consider. Unfortunately, children under 7 years Disordered Behavior of age are often left out of many clinical and treatment outcome studies (Barrett, Healy-Farrell, A common theme throughout this chapter is the & March, 2004; Piacentini, Bergman, Jacobs, importance of understanding developmental con- McCracken, & Kretchman, 2002 ; Storch, Geffken, sideration for very young children with OCD. In & Merlo, 2007 ; Storch et al., 2004 ) . Failure to this vein, it is equally important to distinguish include these younger children in empirical between what may be developmentally appropri- research may inaccurately imply that the presen- ate vs. potentially disordered behavior. For example, young children engage in a variety of C. A. Flessner, Ph.D. (*) ¥ A. Garcia, Ph.D. superstitious games (e.g., crossing one’s fi nger J. B. Freeman, Ph.D. when telling a lie) and exhibit repetitive themes Rhode Island Hospital, Child and Adolescent Psychiatry, during solitary play (e.g., only using the blue Bradley/Hasbro Children’s Research Center , 1 Hoppin Street, Suite 204, Coro West, 02903 Providence , RI , USA blocks when building a tower; Francis & Gragg, 1996 ) yet very young children with and without Warren Alpert School of Medicine at Brown University , Providence , RI , USA OCD exhibit these behaviors. A useful approach e-mail: cfl [email protected] for differentiating pathological (e.g., diagnostic

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 125 DOI 10.1007/978-1-4614-6458-7_8, © Springer Science+Business Media New York 2013 126 C.A. Flessner et al. of OCD) from “normal” child behavior is the child- vs. adult-onset). Evidence suggests though degree to which modifi cation of the child’s that prepubertal (hereafter referred to as early routine(s) is possible. For example, most young childhood), pubertal (adolescent), and adult-onset children will become distressed if told they must OCD may be useful distinctions. Despite these use blue and red blocks yet it is the degree of dis- distinctions, common core symptoms of OCD tress exhibited that may best differentiate behav- are observed across the life span (Rettew, Swedo, ior as age appropriate or disordered. This will be Leonard, Lenane, & Rapoport, 1992 ) suggesting important to keep in mind throughout the remain- that use of the same general diagnostic nomen- der of this chapter. clature from early childhood to late adulthood is useful. With that said, unique features of early childhood OCD exist including the gender distri- Nature of the Problem bution of those affected, rates of comorbidity, and symptom expression. OCD is characterized by intrusive thoughts, ideas or images and/or repetitive, intentional rituals that Gender distribution . It has generally been thought cause marked distress and/or interference in one’s that children demonstrating a younger age at OCD life (APA, 2000 ) . The disorder affects 1.5Ð2.2 mil- onset are more likely to be male. (Geller, 2006 ) lion children in the United States alone (Valleni- This gender difference is reversed in adults. Basile et al., 1995 ; Zohar, 1999 ) . Childhood OCD (Craske, 2003 ) Many studies note a male predom- is also associated with signifi cant impairment in inance in children (3:2) with the gender distribu- day-to-day functioning (Adams, Waas, March, & tion becoming more equal in adolescence (Geller Smith, 1994 ; Cooper, 1996 ; Leonard, Lenane, et al., 1998 ; Swedo et al., 1989 ) . However, Garcia & Swedo, 1993 ; Piacentini, Bergman, Keller, et al. (2009 ) recently found that 60.3% (n = 35) of & McCracken, 2003 ; Toro, Cervera, Osejo, & their sample of 4Ð8 years olds with OCD was Salamero, 1992 ) . The majority (e.g., 75Ð84%) of female. These recent fi ndings suggest the need for children with OCD are also frequently diagnosed further research to better elucidate the gender dis- with comorbid psychiatric conditions (Geller, tribution in children with OCD and perhaps 2006 ) . Despite this growing empirical evidence, whether early childhood OCD in fact represents childhood OCD is still under-diagnosed and under- another unique subtype of the disorder. treated. Epidemiological fi ndings indicate that less than 25%of a community sample of adolescents Rates of comorbidity. Among very young chil- with OCD received any mental health services, dren with OCD, comorbid diagnoses such as tic and none received treatment speci fi cally for OCD disorders, ADHD, and learning disabilities (Flament et al., 1988 ) . These fi ndings clearly sug- (Geller, Biederman, Grif fi n, Jones, & Lefkowitz, gest that childhood OCD constitutes a signi fi cant 1996 ; Pauls, Alsobrook, Goodman, Rasmussen, public health concern. Compared to disorders such & Leckman, 1995 ) are more common. For as major depression, schizophrenia, or even many example, family studies have established other anxiety disorders (e.g., generalized anxiety signi fi cantly elevated rates of comorbidity disorder, social phobia), scant research is available between OCD and tic disorders (Pauls & regarding the pathogenesis and treatment of OCD. Leckman, 1986 ) . This fi nding is particularly This is particularly true of very young children strong for children with onset of OCD before with the disorder. age 9 years (Pauls et al., 1995 ) . In addition, a OCD has been documented in children as recent study found that 20.6%of children with young as 3 years old and demonstrates an aver- OCD between 4 and 8 years of age met diagnos- age age of onset at approximately 10 years tic criteria for a tic disorder (Garcia et al., 2009 ) . (Hollingsworth, Tanguay, Grossman, & Pabst, Further examination of these data revealed 1980 ; Swedo, Rapoport, Leonard, Lenane, & similarly high rates of both attention-defi cit Cheslow, 1989 ) . Clinical researchers typically hyperactivity disorder (22.4%) and generalized parse OCD into two, age-related subtypes (e.g., anxiety disorder (20.7%) in this sample. Perhaps 8 Treating OCD in the Very Young Child 127 not surprisingly, these authors also found very mental considerations and the role of the family in low rates of both major depression (1.7%) and their child’s OCD-related symptoms are particu- dysthymia (1.7%). Due to the limited literature larly important factors contributing to the complex- in this area additional research is necessary to ity of this form of the disorder. Therefore, we replicate and extend these fi ndings. provide a brief review of these two factors and the impact they may have on the assessment and treat- Symptom expression . Child-onset OCD cases have ment of very young children with this disorder. been identifi ed as having an atypical pattern of symptom expression (Geller et al., 1996, 1998 ) . In Developmental considerations . From a develop- early childhood OCD, compulsions without clearly mental perspective, very young children may not defi ned obsessions are common. In fact, the com- yet posses the cognitive skills necessary to ade- pulsive behaviors themselves may be different quately describe obsessions or worries preceding than those observed in adolescents or adults their compulsive behavior. As a result, the assess- (Swedo et al., 1989 ) . For example, Garcia et al. ment of early childhood OCD can be quite (2009 ) found that 58% ( n = 28) of very young chil- diffi cult. Adding to this trouble is the potential dren with OCD exhibited aggressive or cata- dif fi culty differentiating OCD-related concerns strophic (e.g., something bad happening to a parent from (1) developmentally appropriate behavior if the child does not complete his/her ritual) obses- (e.g., rigid following of rules associated with a sions while 68% (n = 34) and 60% (n = 30) exhib- favorite game); (2) a comorbid psychiatric condi- ited checking (e.g., 68%, n = 34) and/or rituals tion marked by repetitive behaviors (e.g., tic dis- involving other person (60%, n = 30). These results orders); and (3) repetitive behaviors characteristic also highlight the frequency with which younger of other psychiatric conditions entirely (e.g., ste- children often involve family members in their reotypies common to autism spectrum disorders). ritualistic behavior, often in the form of reassur- Differentiating these diagnoses may be markedly ance seeking (verbal checking; Flessner et al., more challenging among very young children 2009 ) . This pattern of interaction is often referred with OCD because of the child’s diffi culty in elu- to as family accommodation and is described in cidating preceding thoughts or feelings or feared greater detail below (Family Involvement ). consequences associated with not engaging in Many differences in the symptom picture their ritualized behavior. Because these disparate between very young children with OCD and ado- conceptualizations require different therapeutic lescents or adults are likely due to developmental interventions, the developmentally appropriate factors. Early childhood cognitive development assessment of very young children with OCD- may make it less likely that obsessional thoughts like behavior(s) is of the utmost importance. are prominent features in the symptom picture. The Children’s Yale-Brown Obsessive- Further, children are more embedded in the fam- Compulsive Scale (CY-BOCS; Scahill et al., ily context contributing to family involvement in 1997) is largely viewed as the “gold standard” the disorder. As a result, both of these factors instrument for assessing OCD symptoms among serve as key contributors to case complexity in adolescents. The methods and procedures vali- early childhood OCD. dated for use in the assessment of older youths with OCD may not be as well suited for early childhood OCD. For example, younger children Factors That Contribute to Complexity are less able to adequately describe their anxiety symptoms. Therefore, the developmentally appro- Few, if any, psychiatric conditions are homoge- priate assessment of younger children will place a neous. Complications exist with the treatment greater reliance on parent(s)-report of symptoms. of any form of psychopathology because it is Descriptions of speci fi c symptom dimensions extremely rare for all patients to exhibit identical (e.g., excessive concern regarding urine, feces, backgrounds or symptom presentations. Early and saliva) must also be tailored to the child’s childhood OCD is no different. Important develop- developmental level (i.e., worry or grossed out by 128 C.A. Flessner et al. pee, poop, or spit). Because very young children facilitating avoidance of situations, events, or may be less likely to report obsessions or intrusive persons, or any other activity the family may thoughts, it may be advantageous to assess for perform in response to the individual’s OCD compulsions fi rst. In the absence of obsessions, symptoms (Amir, Freshman, & Foa, 2000 ; CY-BOCS total score may not be re fl ective of Calvocoressi et al., 1995, 1999; Storch, Geffken, overall symptom severity. With the employment Merlo, Jacob, et al., 2007 ) . Recent evidence of these subtle modi fi cations, the CY-BOCS has suggests that as many as 88%of parents may demonstrated adequate psychometric properties engage in at least mild accommodation of their for the assessment of OCD symptoms in children child’s OCD symptoms (Merlo, Lehmkuhl, 4Ð8 years of age (Freeman, Flessner, & Garcia, Geffken, & Storch, 2009 ) . Independent investiga- 2011 ) . As is illustrated below (see section “Case tions have found similarly high rates of parental Example: Aaron”), use of the CY-BOCS in com- accommodation and suggest that accommodation bination with additional data designed to parse is ubiquitous across the families of children with out potential differential diagnoses (e.g., age OCD (Storch et al., 2007 ; Peris et al., 2008 ) . appropriate behavior, autism spectrum disorder, Patterns of family behavior (e.g., accommoda- tics) can help re fi ne the conceptualization of a tion), parent–child interactions, and parents’ own child’s presenting concerns and guide the selec- interpretations of potentially anxiety provoking tion of appropriate therapeutic intervention(s). stimuli, are likely to affect their young children with OCD and impact treatment. Merlo et al. Family involvement. Increasing attention has ( 2009) recently found that changes in parental been paid to the role of family factors in the accommodation (e.g., parents becoming less development of psychopathology, and speci fi cally involved in their child’s rituals) predicted treat- to OCD; as well as to literature supporting the ment response to cognitive-behavioral therapy role of the family in understanding and treating (CBT). One important caveat to the research childhood psychopathology. It is commonly described above, however, should be noted. The accepted that OCD can result in a marked, nega- majority of these studies have failed to speci fi cally tive effect on both the patient and their family examine parental accommodation among very (Waters & Barrett, 2000 ) . Some researchers have young children. Accommodation is most often suggested that, within the context of the family, studied in relation to the families of children with OCD demonstrates a bidirectional relationship. OCD broadly defi ned (e.g., patients under 18 That is, families have an affect on and are affected years of age). Given important developmental by OCD. Within the context of childhood OCD, differences among very young children and ado- this suggests that the interactions between the lescents or adults (see Development Consideration parent and child are of great importance (March, above) and the fi ndings noted previously, family 1995 ) . Young children are embedded in a family involvement in treatment may be of particular context in a way that is meaningfully different importance for very young children presenting from that of adults. Parents are more likely to with OCD. Consequently, it is imperative that play an active role in young children’s rituals treatment approaches for these children incorpo- (e.g., physically assisting with washing or check- rate both developmentally sensitive approaches ing; Garcia et al., 2009 ; Lenane, 1989 ) . Therefore, to treatment and the family. the family’s participation in their child’s OCD- related rituals (e.g., accommodation) has received growing empirical investigation in recent years. Treatment Approaches to Address The term accommodation is most often opera- Complexity tionally defi ned as the participation of family member(s) in the ritual(s) of a child with OCD. In Cognitive Behavior Therapy has consistently practice, accommodation may take several forms, demonstrated ef fi cacy for the treatment of chil- including aiding in completion of the ritual, dren with OCD (de Haan, Hoogduin, Buitelaar, 8 Treating OCD in the Very Young Child 129

& Keijsers, 1998 ; Franklin et al., 1998 ; POTS ment to be effective, parent behavioral training Team, 2004 ; Piacentini et al., 2002 ) , and expo- may also be necessary. Therefore, teaching sure with response prevention (ERP) is viewed parents basic behavior management techniques, by most experts as representing the key ingredi- developing behavior modifi cation plans, and ent to CBT for the successful treatment of OCD. teaching parents strategies to manage their child’s As we move further down the developmental anxiety and distress is important for this spectrum, however, different factors become population. increasingly important for incorporation into Finally, young children with OCD are more treatment protocols (e.g., developmental consid- embedded in their families than older children or erations, family involvement). In this section, we adolescents. The dependence of children on their provide an overview of important additions, caregivers makes them vulnerable to multiple modifi cations, or refi nements to CBT-based treat- infl uences over which they have little control. ment protocols that we believe are important for Parental mental health, marital functioning, and enhancing the ef fi cacy of therapeutic interven- family functioning are just a few of the contex- tions for very young children with OCD. We con- tual factors that affect nature and severity of clude this section with a brief discussion of impairment, treatment progress, and maintenance empirical evidence supporting this approach to of treatment gains for children (Kazdin, 1995 ; treatment. Kazdin & Weisz, 1998; Tharp, 1991; Weisz & Developmental differences between children Weiss, 1991 ) . Further, the family unit and sub- and adolescents have important implications for systems are also affected by the child’s symptoms treatment (Kazdin & Weisz, 1998 ) . The cognitive of OCD (Freeman et al., 2003 ) . component of CBT protocols applied to the treat- The presence of a child with OCD symptoms ment of OCD, has limited its utility at best during is likely to compromise the functioning of the the early childhood period. Young children do family unit and/or specifi c subsystems (e.g., par- not yet posses the skills necessary to fully com- entÐchild, marital relationship). Therefore, it has prehend and bene fi t from cognitive therapy tech- been suggested that therapy with very young niques (e.g., abstract thinking, cause and effect, children by necessity is “de facto family context understanding probability). Further, current therapy” regardless of the theoretical underpin- approaches are based on individual modality of nings (Kazdin & Weisz, 1998 ) . However, exist- treatment. While adolescents may be able to ing treatment protocols incorporate parents at a independently attend a therapy session, under- cursory level only and include a minor focus on stand and retain weekly assignments, and com- the role of parents in effecting child behavior plete between session homework—all integral change. This approach to treatment may be steps in existing treatment protocols—young appropriate for older children, adolescents or children cannot. In therapy with young children, adults but is insuffi cient for very young children caregiver involvement is essential, as they are as they are embedded in a unique way in their often required to take on a supportive or even pri- family context. Focusing on OCD symptomology mary role in administering treatment. Thus, the alone in lieu of considering involving the family individual therapy modality is not an optimal system in treatment, may be insuf fi cient for mode of treatment delivery for this age group. symptom amelioration and long-term improve- Earlier in this chapter (see Rate of Comorbidity ment. Although only a fi rst step in the process, above), we explained that very young children preliminary evidence suggests that this approach with OCD are more likely to present with comor- to treatment may be ef fi cacious for the treatment bid tic disorders, hyperactivity and learning dis- of early childhood OCD. abilities. From a developmental perspective, Recently, research has begun to examine the these increased rates of comorbidity must also be ef fi cacy of a family-based cognitive-behavioral taken under consideration when modifying exist- approach to the treatment of very young children ing treatment protocols. In order for OCD treat- with OCD (Freeman et al., 2008 ) . Freeman and 130 C.A. Flessner et al. colleagues recruited 42 children between 5 and 8 the K-SADS interview was conducted with his years of age with a primary diagnosis of OCD. mother while Aaron played with toys in the thera- Children were randomized to either family-based pist’s of fi ce. CBT, utilizing the approach to treatment described in the preceding paragraphs, or family-based Assessment. Administration of the K-SADS relaxation therapy (RT). Completer analysis (e.g., revealed that Aaron met diagnostic criteria for participants who completed all 12 sessions of OCD, Tourette’s disorder (e.g., head-jerking, treatment) revealed that family-based CBT dem- throat clearing, facial grimacing), and separation onstrated a large effect size (d = 0.85) with a anxiety disorder (e.g., worries about bad things signifi cant treatment group difference. In total, happening to his mother when separated). With 69%of children receiving CBT achieved symp- regard to OCD-related symptoms, Aaron’s mother tom remission compared to only 20%in the RT reported that he is very reluctant to touch “germy” group. Clearly, a more rigorous, randomized con- objects (e.g., anything that he knows other peo- trolled design is necessary to replicate and ple, besides himself or his mother, have touched) strengthen these fi ndings. However, this study and needs to touch objects until it feels “just provides preliminary support for a developmen- right.” She also reports excessive hand washing. tally sensitive, family-based approach to the Aaron’s second major OCD symptom involved treatment of early childhood OCD. What follows his mother. Whenever he and his mother part, below is a case example utilizing this tailored including at bedtime, she kisses him, he puts his approach to the assessment and treatment of very head on her arm, and then he touches/hugs her young children with OCD. until it feels “just right.” Aaron must be the last one to touch his mother. In the event that his mother touches him last, Aaron feels the need to Case Example: Aaron touch her again. Administration of the CY-BOCS revealed a score of 24 indicating moderate to Referral . Aaron is a 74-month (6 years, 2 months) severe OCD symptoms. old boy referred to our clinic by an area pediatri- Aaron’s mother also reported that he often lines cian for assessment and possible treatment. The up his toys when playing and becomes very angry chief complaint upon referral was in regard to if someone messes up the order he has established “doing things until they are ‘just right’” and (e.g., places toy A in front of toy B). His mother “washing his hands all the time.” Aaron’s bio- reports that this behavior has been present for “a logical mother attended his fi rst visit to our clinic. couple of years” with little fl uctuation in frequency During this visit, he and his mother met with a over time. At fi rst, it was unclear whether Aaron’s psychologist who administered the Schedule for behavior was age appropriate or OCD-related. Affective Disorders and Schizophrenia for Upon further evaluation, it was revealed that School-Age Children-Present and Lifetime Aaron’s proclivity towards ordering and arranging Version (K-SADS; Kaufman et al., 1997 ) , several objects in this manner occurred only during play- parent-report measures, and the CY-BOCS. time. He and his mother denied that Aaron engaged in this behavior in relation to other objects (e.g., Background. A brief psychosocial history revealed toys on his bed, other objects in his room or house). that Aaron has one, older brother. His parents Teacher-report corroborated these fi ndings. His have been divorced for approximately 2 years and teacher reports that although Aaron becomes more share custody. Aaron is presently in fi rst grade, upset than some of his peers when others “mess and he reports that he likes school. Family history with” his toys, she did not believe that his behavior is positive for Tourette’s disorder (brother, mater- was signi fi cantly out of the ordinary for his age. nal uncle), OCD (brother, father), “anxiety” Collectively, this evidence led the treatment team (mother), and depression (maternal grandmother). to conceptualize Aaron’s behavior as age appropri- Because of Aaron’s age and his limited ability to ate and thereby not an immediate target for describe his symptoms, a signifi cant portion of intervention. 8 Treating OCD in the Very Young Child 131

Treatment. Aaron was treatment naïve prior to to “boss back” The OCD Monster. Aaron the start of family-based CBT for his OCD- completed exposure exercises in session. Initially, related symptoms. Aaron’s mother attended the the therapist modeled “bossing back” OCD with fi rst two CBT sessions alone. She was provided Aaron (e.g., both Aaron, his mother, and the ther- with education about OCD as a neuropsychiatric apist engaged in the weeks’ exposure exercise). condition, common co-occurring diagnoses, and Over the next several sessions, Aaron slowly the rationale behind family-based CBT (e.g., became more capable of “bossing back” The parental modeling, scaffolding, ERP/habitua- OCD Monster on his own. Also during these ses- tion). The therapist also began to work on a hier- sions, Aaron’s mother was provided with educa- archy of Aaron’s symptoms for exposure exercises tion regarding important parenting behaviors that later in the courses of treatment. Aaron and his play a signifi cant role in the maintenance and mother attended sessions 3Ð12. effective treatment of OCD (e.g., modeling, dif- Aaron was eager to begin treatment. It was ferential reinforcement, and scaffolding). His also evident that he exhibited some diffi culty mother was asked to practice these parenting understanding more complex elements to the strategies within the context of OCD-related treatment protocol (e.g., fear thermometer, symp- behaviors (e.g., asking mom to “boss back” her tom hierarchy). As a result, modi fi cations were own anxiety). As treatment progressed, the thera- made. Rather than utilizing a 10-point fear ther- pist played less and less a part in developing mometer, as is typical of CBT for childhood exposure exercises. Instead, Aaron’s mother was OCD, a visual analog scale was employed which asked to develop exercises in collaboration with allowed Aaron to report his OCD symptoms Aaron. The goal of this strategy was both to (which he and his therapist referred to as “The slowly fade the importance of the therapist for OCD Monster”) using faces that ranged from successful treatment and to “practice” what the “happy” to “worried.” After talking in greater family would do if OCD symptoms returned in detail about The OCD Monster, the therapist, the future. By session 12, Aaron had successfully with the help of both Aaron and his mother, was reached the apex of his symptoms hierarchy. The able to construct several potential exposure exer- CY-BOCS was administered 1 week following cises to attempt in the coming weeks. However, the family’s fi nal session as a “wrap-up” session. Aaron demonstrated diffi culty ordering these Administration of the CY-BOCS revealed a score exercises from easiest to hardest. To remedy this of 9 indicating only mild symptoms of OCD. problem, the therapist decided to write each of the exposure exercises on a piece of paper. Next, he found and cut a long piece of string and placed Conclusion and Future Directions the string perpendicular to Aaron. One at a time, the therapist read the exercise that was written on A small but growing body of empirical research each piece and asked Aaron to place them on the has begun to examine the assessment and treat- string with the hardest one as far away from him ment of very young children with OCD. Science as possible. Although somewhat unusual, this is beginning to develop a greater understanding approach worked well and resulted in Aaron, his of potentially important differences between mother, and the therapist agreeing on a hierarchy early childhood, adolescent, and adult-onset for Aaron’s OCD symptoms. A reward program forms of OCD. Though room for improvement was also established in which Aaron received one exists, evidence has begun to suggest that point every time he completed both his in-session modifi cations to existing measurement strategies and out-of-session homework exercises. These may yield reliable and valid assessment of the points could be turned in to receive agreed upon disorder (Freeman et al., 2011 ) . Perhaps most prizes throughout the course of treatment. importantly, preliminary evidence has demon- Sessions 4Ð12 centered upon the therapist strated that a developmentally sensitive, family- working closely with both Aaron and his mother based approach to early childhood OCD may be 132 C.A. Flessner et al. effi cacious for the treatment of very young chil- with OCD that has demonstrated preliminary dren with the disorder. Despite all of these effi cacy. Currently, a large multisite randomized advances, a plethora of areas have yet to be controlled trial is being conducted to more ade- examined or are in need of stronger empirical quately examine the effi cacy of family-based support. CBT for the treatment of early childhood OCD. Regardless of the outcome of this ongoing trial, Future directions . Several areas of future research additional research by independent investigators may help to advance’s science understanding will be necessary to further test the bene fi t of regarding the complexity of early childhood OCD. family-based CBT for very young children with OCD. In addition, researchers are advised to con- Etiology. Science has begun to obtain a greater tinue examining new treatments or modi fi ed ver- understanding regarding the etiology of OCD yet sions of existing treatment protocols making use more research is necessary. Preliminary evidence of data from basic laboratory or clinical studies. suggests that early childhood OCD may represent It is only through continued scientifi c investiga- a useful distinction in comparison to adolescent tion that clinical researchers will be able to under- and adult-onset OCD. However, a more reliable stand more regarding the etiology, maintenance, body of empirical research has generally sup- and treatment of childhood OCD. ported two, age-related subtypes of the disorder. If early childhood OCD does indeed represents a distinct subtype, more research is necessary. References Researchers may wish to examine genetic, neurobiological, or environmental factors that are com- Adams, G., Waas, G., March, J., & Smith, M. (1994). mon or unique to these distinct ages at OCD onset. Obsessive-compulsive disorder in children and adolescents: The role of the school psychologist in It is likely that research of this nature, however, identifi cation, assessment, and treatment. School will require strong collaborations among many Psychology Quarterly, 9 , 274Ð294. researchers sharing a common goal of better elu- American Psychiatric Association. (2000). Diagnostic cidating the pathogenesis of OCD. and statistical manual of mental disorders (4th ed., Text revision (DSM-IV-TR)). Washington, DC: APA. Amir, N., Freshman, M., & Foa, E. (2000). Family dis- Longitudinal research . Remarkably little is tress and involvement in relatives of obsessive-com- known about the pathogenesis of childhood OCD pulsive disorder patients. Journal of Anxiety Disorders, and, in turn, very young children with the disor- 14 (3), 209Ð217. Barrett, P., Healy-Farrell, L., & March, J. S. (2004). der. One way in which our scienti fi c understand- Cognitive-behavioral family treatment of childhood ing of this disorder can be greatly enriched is to obsessive-compulsive disorder: A controlled trial. examine the developmental course of OCD. Journal of the American Academy of Child and Research of this nature might include the recruit- Adolescent Psychiatry, 43 (1), 46Ð62. Calvocoressi, L., Lweis, B., Harris, M., Trufan, S. J., ment of children at-risk for the disorder, those Goodman, W. K., McDougle, C. J., et al. (1995). exhibiting subclinical symptoms, or those already Family accommodation in obsessive-compulsive dis- meeting diagnostic criteria for OCD. A critical order. The American Journal of Psychiatry, 152 , component to such a line of research would 441Ð443. Calvocoressi, L., Mazure, C., Kasl, S. V., Skolnick, J., include the recruitment of both very young chil- Fisk, D., Vegso, S. J., et al. (1999). Family accommo- dren and adolescents to more adequately exam- dation of obsessive-compulsive symptoms. The Journal ine differences in the progression of the disorder of Nervous and Mental Disease, 187 (10), 636Ð642. (e.g., wax and waning nature of the disorder, Cooper, M. (1996). Obsessive-compulsive disorder: Effects on family members. The American Journal of response to environmental stressors, symptom Orthopsychiatry, 66 (2), 296Ð304. expression and progression over time). Craske, M. G. (2003). Origins of phobias and anxiety disorders: Why more women than men? Oxford, UK: Treatment . We provided a brief summary of one Elsevier. de Haan, E., Hoogduin, K. A., Buitelaar, J. K., & Keijsers, approach to the treatment of very young children G. P. (1998). Behavior therapy versus clomipramine 8 Treating OCD in the Very Young Child 133

for the treatment of obsessive-compulsive disorder in Kaufman, J., Birmaher, B., Brent, D. A., Rao, U., Flynn, C., children and adolescents. Journal of the American Moreci, P., et al. (1997). Schedule for affective disor- Academy of Child and Adolescent Psychiatry, 37 (10), ders and schizophrenia for school-age children—Pres- 1022Ð1029. ent and lifetime version (K-SADS-PL): Initial reliability Flament, M. F., Whitaker, A., Rapoport, J. L., Davies, M., and validity data. Journal of the American Academy of Berg, C. Z., Kalikow, K., et al. (1988). Obsessive com- Child and Adolescent Psychiatry, 36 , 980Ð988. pulsive disorder in adolescence: An epidemiological Kazdin, A. E. (1995). Child, parent and family dysfunc- study. Journal of the American Academy of Child and tion as predictors of outcome in cognitive-behavioral Adolescent Psychiatry, 27 (6), 764Ð771. treatment of antisocial children. Behaviour Research Flessner, C. A., Sapyta, J., Freeman, J. 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Piacentini, J., Bergman, R. L., Keller, M., & McCracken, Swedo, S. E., Rapoport, J. L., Leonard, H. L., Lenane, M., J. (2003). Functional impairment in children and ado- & Cheslow, D. (1989). Obsessive compulsive disor- lescents with obsessive-compulsive disorder. Journal ders in children and adolescents: Clinical phenome- of Child and Adolescent Psychopharmacology, nology of 70 consecutive cases. Archives of General 13 (Suppl 1), S61ÐS69. Psychiatry, 46 , 335Ð343. Rettew, D. C., Swedo, S. E., Leonard, H. L., Lenane, M. C., & Tharp, R. G. (1991). Cultural diversity and treatment of Rapoport, J. L. (1992). Obsessions and compulsions children. Journal of Consulting and Clinical across time in 79 children and adolescents with obsessive- Psychology, 59 (6), 799Ð812. compulsive disorder. Journal of the American Academy of Toro, J., Cervera, M., Osejo, E., & Salamero, M. (1992). Child and Adolescent Psychiatry, 31 , 1050Ð1056. Obsessive-compulsive disorder in childhood and ado- Scahill, L., Riddle, M. A., McSwiggan-Hardin, M., Ort, S. lescence: A clinical study. Journal of Child Psychology I., King, R. A., Goodman, W. K., et al. (1997). Children’s and Psychiatry, 33 (6), 1025Ð1037. Yale-Brown Obsessive-Compulsive Scale: Reliability Valleni-Basile, L. A., Garrison, C. Z., Jackson, K. L., and validity. Journal of the American Academy of Child Waller, J. L., McKeown, R. E., Addy, C. L., et al. and Adolescent Psychiatry, 36, 844Ð852. (1995). Frequency of obsessive-compulsive disorder Storch, E., Geffken, G., & Merlo, L. (2007). Family-based in a community sample of young adolescents. Journal cognitive-behavioral therapy for pediatric obsessive- of the American Academy of Child and Adolescent compulsive disorder: Comparison of intensive and Psychiatry, 34 (2), 128Ð129. weekly approaches. Journal of the American Academy Waters, T., & Barrett, P. (2000). The role of the family of Child and Adolescent Psychiatry, 46 (4), 469Ð478. in childhood obsessive-compulsive disorder. Storch, E. A., Geffken, G. R., Merlo, L. J., Jacob, M. L., Clinical Child and Family Psychology Review, 3(3), Murphy, T. K., Goodman, W. K., et al. (2007). Family 173Ð184. accommodation in peditric obsessive-compulsive dis- Weisz, J. R., & Weiss, B. (1991). Studying the “referabil- order. Journal of Clinical Child and Adolescent ity” of child clinical problems. Journal of Consulting Psychology, 36 (2), 207Ð216. and Clinical Psychology, 59 (2), 266Ð273. Storch, E. A., Murphy, T. K., Geffken, G. R., Soto, O., Sajid, Zohar, A. H. (1999). The epidemiology of obsessive-com- M., Allen, P., et al. (2004). Psychometric evaluation of pulsive disorder in children and adolescents. Child the Children’s Yale-Brown Obsessive-Compulsive and Adolescent Psychiatric Clinics of North America, Scale. Psychiatry Research, 129 (1), 91Ð98. 8 (3), 445Ð461. Treatment of Childhood Tic Disorders with Comorbid OCD 9

Martin E. Franklin, Julie Harrison, and Kristin Benavides

the effect of OCD on treatment response in Introduction primary TDs) has not been explored in the context of a randomized treatment trial, so clinicians We have been charged with the task of presenting need to exercise their empirically informed readers with a logical, empirically grounded, and judgment when considering treatment of primary clinically informed approach to the treatment of TD when OCD is also present. TDs in children and adolescents when obsessive- First we will provide a focused review of compulsive disorder (OCD) is comorbid. Our psychopathology for each of these conditions, review below highlights the fact that this comor- followed by consideration of what is known when bidity is quite common, and poses a signifi cant they are both present. A heuristic is then pre- challenge to treating clinicians; what is also evi- sented for arriving at judgments for managing dent from the literature is that there are empiri- both symptoms clinically when they co-occur. cally supported pharmacotherapies and cognitive This discussion is then followed by presentation behavioral therapies (CBT) for each disorder of a case composite that fl ows from the heuristic (e.g., Abramowitz, Whiteside, & Deacon, 2005 ; presented. Our view is that there is much reason Cook & Blacher, 2007 ; Franklin et al., 2011 ; for optimism that children who have TDs and co- Piacentini et al., 2010 ) . Moderator analyses of occurring OCD can be successfully treated, but treatment response in the Pediatric OCD that the treating clinicians have much to keep in Treatment Study I (Pediatric OCD Treatment mind as they do so. Study (POTS) Team, 2004 ) indicated that comorbid tic symptoms predicted poorer response to pharmacotherapy alone but not to CBT alone or Tic Disorders and Tourette Syndrome to combined treatment in a trial in which OCD was classifi ed as the primary disorder (March TDs (TDs) and Tourette syndrome (TS) are et al., 2007 ) ; this information needs to be con- chronic neuropsychiatric disorders that are char- sidered when making selection of treatment acterized by “sudden, rapid, recurrent, non-rhythmic, choice for individuals with both disorders pres- stereotyped motor movements or vocalizations” ent. As yet, the converse (moderator analyses of (American Psychiatric Association, 2000 ) . To meet criteria for a diagnosis of Chronic Motor or Vocal TD, tics must occur multiple times a day M. E. Franklin , Ph.D. (*) ¥ J. Harrison ¥ K. Benavides most days or intermittently for at least a period of University of Pennsylvania School of Medicine , a year with onset occurring before the age of 18 3535 Market Street, 6th floor , Philadelphia , PA 19104 , USA years. Chronic TDs are classifi ed as either motor e-mail: [email protected] or vocal and can be either simple or complex in

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 135 DOI 10.1007/978-1-4614-6458-7_9, © Springer Science+Business Media New York 2013 136 M.E. Franklin et al. nature. Motor tics are repetitive contractions of throughout the illness (Leckman et al.; Lin discrete muscle groups that can occur in any part et al., 2002 ; Robertson et al., 1999) , and a of the body. Simple motor tics are brief, sudden diminishing in symptom severity by the age of contractions that typically affect only one muscle 20 years, with less than 20% of individuals group (e.g., eye blinking or head-jerking). with TS continuing to bear moderate impair- Complex motor tics are longer, sequenced, or ment past the second decade of life (Bloch more exaggerated movements that may present et al., 2006 ) . Although persistence of severe as jumping, touching, or squatting. Vocal tics are impairment into adulthood is uncommon, stud- repetitive sounds, with simple phonic tics pre- ies report a variety of percentages of slight to senting as meaningless sounds such as humming, moderate symptoms continuing into adult grunting, snif fi ng, or throat clearing. Complex years, ranging from 20 to 90% of individuals vocal tics are longer in duration, more meaning- (Bloch et al.; Leckman et al., 1998 ; Pappert, ful, and appear purposeful and might present as Goetz, Louis, Blasucci, & Leurgans, 2003 ) . echoing a word or phrase of another or repeating Tic Disorders can be diffi cult to distinguish one’s own utterances (APA). To be classifi ed as a from symptoms of hyperkinetic movement dis- TD, only vocal or motor tics can be present; when orders, such as Parkinson’s disease and both are present, the diagnosis of TS is given. Huntington’s chorea (Kompoliti & Goetz, 1998 ) Tourette syndrome typically presents with multi- but the main distinguishing factor of TDs may be ple motor tics and at least one vocal tic that occur the volitional nature of the tic itself. In contrast either simultaneously or at different periods dur- to movement disorders, most individuals with ing the course of illness (APA). Important to note TDs can suppress the urge, but experience a is that understanding the function of the repetitive mounting tension that they then consciously behavior is critical for accurate diagnosis: for choose to alleviate by performing a tic to relieve example, a repeated head movement designed to the tension. As a result of this partial control, tics neutralize unwanted thoughts and to reduce the are commonly described as semi-volitional, likelihood of a feared outcome (e.g., physical since they are typically executed voluntarily in injury or death of parents) would be accurately response to uncomfortable, involuntary sensa- diagnosed as a compulsion rather than a tic. The tions, or premonitory urges. Similar to scratch- clinician responsible for the assessment of youth ing an itch, performing a tic in response to a with both conditions will have to make these premonitory urge provides a temporary feeling kinds of fi ne-tuned distinctions frequently, since of relief (Banaschewski, Woerner, & somewhat different treatment strategies would be Rothenberger, 2003; Kwak, Vuong, & Jankovic, used depending on whether the behavior was 2003) . The prevalence of these urges is high; in a conceptualized as a tic or a compulsion. sample of 28 child and adult participants, 82% In terms of prevalence, it was determined in reported experiencing premonitory urges imme- a large community sample of 4,475 youth that diately preceding motor and vocal tics (Cohen & 0.8% had chronic motor tics, 0.5% had chronic Leckman, 1992 ) . Interestingly, 57% of this sam- vocal tics, and 0.6% had TS (Khalifa & von ple felt the urges were more vexing than the Knorring, 2003 ) . Studies report the range of tic actual tics themselves. Another study found that onset from 5.6 to 7.6 years (Comings & Comings, 93% of 135 participants reported the existence 1985 ; Freeman et al., 2000; Janik, Kalbarczyk, of these premonitory urges, 82% felt the perfor- & Sitek, 2007 ; Leckman et al., 1998 ; Lees, mance of the tic relieved the urges, and 92% Robertson, Trimble, & Murray, 1984 ) with divulged the tics were either wholly or partly a symptom severity commonly peaking at 10 years voluntary response to the urges (Leckman, of age (Leckman et al., 1998 ) . Typically, the Walker, & Cohen, 1993 ) . As will become evi- course of the illness follows the pattern of dent later in the chapter, these observations about symptom emergence in childhood, an ebb and tic phenomenology are of great relevance to the fl ow in severity and frequency of symptoms implementation of behavioral treatment of TDs. 9 TDS and OCD 137

Tic severity and frequency are sensitive to effects may well become treatment targets once the numerous factors, such as common, daily envi- tics and more challenging comorbid symptoms ronmental occurrences (Conelea & Woods, 2008 ) are addressed. as well as anxiety-provoking situations, height- Academic functioning also appears to be neg- ened emotions, and fatigue (Findley et al., 2003 ; atively affected by symptoms of TS. Storch, Hoekstra et al., 2004 ) . Results from a study inves- Lack, et al. ( 2007) found that in a sample of 59 tigating the effects of nearly 30 environmental children diagnosed with TS, 36% of youth factors in a sample of 14 youth with TS indicated reported their tics as the cause of diminished aca- that common causes of tic increases were anxi- demic functioning, affecting their preparedness ety-provoking situations, social settings, fatigue, for class, their abilities to write, do homework, watching television, and isolation (Silva, Munoz, and their overall levels of concentration. Barickman, & Friedhoff, 1995 ) . It is important to Additionally, a survey found that in a sample of note, however, that some individuals with tics 71 parents or guardians of children with TS, 50% report that some of these same environmental reported moderate to signi fi cant interference in factors are associated with decreases in tics for academic functioning due to tics, which included them. Thus, the treating clinician should conduct trouble in reading and writing (Packer, 2005 ) . a careful functional analysis with specifi c patients Not only do TS symptoms negatively impact rather than making assumptions about the rela- the individuals who have the disorder, but also tionship between tic urges and environmental their caregivers, and can cause impaired family triggers that are based on aggregated data. functioning. Studies have found that families Tics and the premonitory urges that typically with at least one member with TS report a height- precede them can cause high levels of distress and ened burden on caregivers, a diminished family impairment in individuals with TS and TDs. Studies cohesion, great dif fi culty in solving family issues, show that youth and adults with TS typically report and increased interference in the daily function- impairment in multiple areas of life, such as overall ing of family members (Bawden, Stokes, quality of life, social, academic, occupational, and Cam fi eld, Cam fi eld, & Salisbury, 1998 ; Cooper, family domains. Hindrance in overall quality of life Robertson, & Livingston, 2003 ; Hubka, Fulton, due to TS was studied in a sample of 59 youth, Shady, Champion, & Wand, 1988 ; Storch, Lack, where children with tics produced lower quality of et al., 2007 ) . life scores than a control group of healthy partici- The data reported above indicate that TDs are pants (Storch, Merlo, et al., 2007 ) . a worthy target for treatment intervention in and Although some tics affect muscle groups in of themselves, and may well suggest that the less noticeable sections of the body (e.g., abdom- reduction of core symptoms could be important inal tensing), most tics are visible to observers in improving the quality of life for affected youth and can produce great social discomfort, self- and their families. Comorbidity with OCD pres- consciousness, shame, and sadness (American ents an additional complication, and below we Psychiatric Association, 2000 ) . Social hindrances discuss OCD fi rst in order to provide the readers are commonly experienced in individuals with with enough information to fully appreciate the TS, such as dif fi culty in creating and maintaining complexity of their interrelationship, and the friendships, hardships in dating, rejection from clinical conundrum that ensues when patients peers, social withdrawal, teasing, aggression, low have prominent symptoms of both conditions. popularity, negative social perceptions, and lower social acceptability (Champion, Fulton, & Shady, 1988 ; Elstner, Selai, Trimble, & Robertson, 2001 ; Obsessive-Compulsive Disorder Lin et al., 2007; Marcks, Woods, & Ridosko, 2005 ; Packer, 2005 ; Stokes, Bawden, Cam fi eld, The DSM-IV Text Revision (DSM-IV TR; Backman, & Dooley, 1991; Storch, Lack, et al., American Psychiatric Association, 2000 ) de fi nes 2007 ; Woods, Fuqua, & Outman, 1999 ) . Such OCD by the presence of recurrent obsessions 138 M.E. Franklin et al. and/or compulsions that interfere substantially (e.g., preoccupation with food in the presence of with daily functioning. Obsessions are “persis- eating disorders). tent ideas, thoughts, impulses, or images that are Epidemiological data concerning OCD varies experienced as intrusive and inappropriate and across studies (Ruscio, Stein, Chiu, & Kessler, cause marked anxiety or distress” (p. 457). 2010) . OCD affects up to 1 in 50 people (Ruscio Common obsessions are repeated thoughts about et al.), is evident across development (Piacentini contamination, causing harm to others, and & Bergman, 2000 ) , and is associated with sub- doubting whether one locked the front door. stantial dysfunction and psychiatric comorbidity Compulsions are “repetitive behaviors or mental (Piacentini, Bergman, Keller, & McCracken, acts the goal of which is to prevent or reduce 2003; Swedo, Rapoport, Leonard, & Lenane, anxiety or distress” (p. 457). Common compul- 1989 ) . The National Comorbidity Survey sions include hand washing, checking, and Replication Study involving over 9,000 adult par- mental compulsions (e.g., repeated praying ticipants in the USA estimated that the 12 month silently). A functional link between obsessions prevalence rate of OCD was 1.0% (Kessler, Chiu, and compulsions is typically evident: for exam- Demler, & Walters, 2005 ) ; epidemiological stud- ple, in the DSM-IV fi eld trial on OCD, over 90% ies with children and adolescents suggest similar of participants reported that their compulsions lifetime prevalence rates in these samples (e.g., aim to either prevent harm associated with their Flament et al., 1988 ; Valleni-Basille, Garrison, & obsessions or to reduce obsessional distress (Foa Jackson, 1994 ) . Data concerning younger chil- et al., 1995) . For example, the obsessional thought dren suggest that approximately 1 in 200 young of an OCD patient that he or she might be respon- people has OCD, which in many cases severely sible for harm befalling someone by having disrupts academic, social, and vocational func- neglected to lock the door will likely give rise to tioning (Flament et al., 1988 ; Piacentini et al., anxiety or distress. Compulsively checking the 2003) . Among adults with OCD, one third to one door is a behavior that attempts to reduce distress half developed the disorder during childhood or and reassure the patient that the feared conse- adolescence (DeVeaugh-Geiss et al., 1992 ) which quence will not occur. Therefore, if the patient suggests that early intervention in childhood may does not demonstrate a clear relationship between prevent long-term morbidity in adulthood. the obsession and the compulsion (obsessions are Development of OCD is typically gradual, but distressing and compulsions aim at reducing this more rapid onset has been reported in some cases. distress), another diagnosis should be considered. The course of OCD is most often chronic with One of these diagnoses may well be a tic disorder some waxing and waning of symptoms, with if the repetitive behaviors observed serve the patients reporting some responsiveness to exter- function of reducing discomfort at the site of the nal stressors as well (Franklin & Foa, 2011 ) . In behavior (e.g., premonitory urge in the neck rare pediatric cases, however, onset is very sud- resulting in repetitive head jerking movements). den (e.g., overnight) and associated with strep In order to distinguish diagnosable OCD from infection; treatment of the infection is then asso- the virtually ubiquitous occasional and not terri- ciated with substantial reduction of symptoms, bly distressing phenomena of unwanted thoughts but recurrence of infection is associated with and repetitive behaviors reported by the vast symptom exacerbation (Pediatric Autoimmune majority of individuals without OCD (Crye, Neuropsychiatric Disorders Associated with Laskey, & Cartwright-Hatton, 2010; Rachman & Strep, PANDAS; Swedo et al., 1998 ) . de Silva, 1978 ) , obsessions and/or compulsions Among adults, OCD is ranked tenth among must be found to be of suffi cient severity to cause the leading causes of disability worldwide includ- marked distress, be time consuming, and inter- ing heart disease, diabetes, and cancer (Murray & fere with daily functioning. If another Axis I dis- Lopez, 1996 ) . Given what is known about the order is present, the obsessions and compulsions tendency for OCD symptoms to persist over time, cannot be restricted to the content of that disorder it would be prudent for clinicians who encounter 9 TDS and OCD 139

OCD in their practices to be prepared to provide In order to differentiate the stereotyped motor the CBT protocols of established ef fi cacy for this behaviors that characterize TS and TDs from condition, which appear to be effective both with compulsions, the functional relationship between and without concomitant pharmacotherapy these behaviors and any preceding obsessive (Abramowitz et al., 2005 ) . Providing CBT in thoughts must be examined. Like compulsions, cases in which TD symptoms are also present has complex tics may appear intentional and produce been speci fi cally recommended as preferable to a sense of relief (Mansueto & Keuler, 2005 ) . treatment with medication alone (March et al., However, research suggests that there are phe- 2007 ) . The interplay between the clinical man- nomenological differences in the antecedents to agement of OCD and tics in practice is the pri- the primary symptoms of the two disorders: sen- mary focus of our clinical discussion below. sory urges and vague somatic tension are associated with TS, while physiological arousal and speci fi c cognitions are linked to obsessive- Comorbidity of Tics/Tourette and OCD compulsive behavior (Miguel et al., 1995, 1997, 2000; Scahill, Leckman, & Marek, 1995 ; Shapiro Although there are differences in symptom pre- & Shapiro, 1992 ) . Further, while there is no con- sentation that can be helpful in distinguishing the ventional way of differentiating tics from “pure” two disorders, such as the more prominent role of compulsions, the discerning diagnostician should cognitive symptoms (e.g., compulsions) in OCD be aware that OCD with “pure” compulsions is as opposed to in TDs, there are times when the extremely rare (Foa et al., 1995 ) . symptoms of complex motor tics can be dif fi cult Common clinical correlates of both disorders to distinguish from compulsions. To make mat- include childhood onset, a chronic waxing and ters more confusing, comorbidity rates between waning course, and familial occurrence (Coffey OCD and tics are high, with studies reporting et al., 1998 ) . Tic Disorders and OCD can also rates of OCD in samples of individuals with TS share similar clinical presentations including ranging between 22 and 41% (Freeman & the repetitive behaviors, intrusive sensations, and Tourette Syndrome International Database impairment in behavioral inhibition (Lewin, Consortium, 2007 ; King, Leckman, Scahill, & Chang, McCracken, McQueen, & Piacentini, Cohen, 1998 ; Termine et al., 2006 ) . Conversely, 2010) . The key point for the clinician to consider some 20Ð30% of individuals with OCD reported here is not simply to assess for the presence of a current or past history of tics (Pauls, Towbin, comorbidity but rather to consider its treatment Leckman, Zahner, & Cohen, 1986 ) ; the comor- implications. Comorbidity of OCD in TDs may bidity rate for TDs in the recently completed be present in many cases but, if the OCD is pri- POTS II study was approximately 22% (Franklin mary, then CBT targeting OCD will likely prove et al., 2011 ) . The case composite we discuss effective regardless. There is also some evidence below includes symptoms of both disorders, with other comorbid conditions, such as depres- some which are easier to distinguish from one sion, that targeting OCD in treatment can result another, whereas some of the symptoms (e.g., in reductions of the nontargeted comorbid symp- “Not Just Right” feelings and associated “eve- toms (Franklin, Abramowitz, Kozak, Levitt, & ning out” rituals) seem to fall right on the border Foa, 2000) . Although the assessment of OCD and of both conditions. What is important clinically is TDs can be diagnostically tricky, the competent that patients are taught to use the proper tech- clinician should endeavor with the patient and niques to address those symptoms that are clearly parents to discern which disorder surfaced fi rst emanating from one disorder or the other, and and which is currently responsible for the most that they become comfortable experimenting impairment. Once these questions have been with different techniques for those symptoms that carefully considered, the next step is to consider could be classifi ed as either one. We will discuss the implications of the comorbid symptoms for this issue in detail in the case presentation. treatment. This task becomes more dif fi cult, 140 M.E. Franklin et al. however, when clinicians, parents, the child, and functioning. However, research in adults with the child’s school have different opinions as to both TDs and OCD suggests that having comor- where the greatest area of impairment lies. bid TDs and OCD does lead to increased Indeed, it may even be the case that the context symptom severity levels compared to those with matters a great deal when it comes to symptom TDs or OCD alone (Coffey et al., 1998 ) . The dif- expression, severity, and impairment. For exam- ference in outcomes in these two studies could ple, children may well be better able to suppress refl ect developmental differences given the use of tic urges at school because they allocate their pediatric and adult samples. attention away from tic urges and towards the In terms of expecting a “two birds with one many activities that require increased attention in stone” effect from treatment, there may be some school, whereas higher demands on their atten- support for the possibility that exposure treat- tion are not nearly as prominent at home. When ment, which has been found effi cacious for OCD forming a treatment plan, these contextual factors across the developmental spectrum, may also should be taken into account when deciding have positive effects on tics and tic urges. where best to begin treatment, which treatment Verdellen et al. found that tics were similarly techniques to emphasize, and which treatment responsive to an exposure plus response preven- components would be most likely to generalize to tion (ERP) protocol when compared in a random- the other areas. ized study to habit reversal training where a Although the research reviewed above indi- competing response is used to substitute for the cates that tics alone can cause impairment in tic (Verdellen, Keijsers, Cath, & Hoogduin, functioning, several studies provide support for 2004) . However, it is important to note that an the hypothesis that comorbidities, rather than emphasis on imaginal exposure to obsessional tics, are often responsible for functional impair- content would be prominent in treating an indi- ment. In 98 adults with TS, Thibert, Day, and vidual who engages in repetitive tapping behav- Sandor (1995 ) showed that those with TS and ior to prevent a speci fi c dreaded outcome (e.g., obsessive-compulsive symptoms had signifi cantly death of a parent in an accident); whereas, an lower self-concepts and greater social anxiety individual who reports engaging in a nearly iden- than subjects with TS alone. Likewise, Wilkinson tical tapping behavior in order to reduce discom- et al. ( 2001 ) showed that families of children with fort associated with premonitory urges would be TS and comorbid conditions experienced greater unlikely to bene fi t from imaginal exposure impairment than families having children only (Woods et al., 2008 ) . Thus, the degree to which diagnosed with TS. In a study assessing tic per- the OCD and tic symptoms are formally similar sistence and associated impairment in 50 children may well assist the clinician in devising and adolescents with TS, results showed that, approaches that can be used for both phenomena, from baseline to 2-year follow-up, the percentage provided of course that the patient is able to carry of youth meeting criteria for tic persistence out the relatively simple yet perhaps more effec- remained the same, while the percentage meeting tively challenging task of permitting unpleasant criteria for tic impairment decreased signifi cantly emotions to go unaddressed while they habituate, in proportion. This suggests that tic persistence which is essentially what exposure entails. and impairment may not be associated (Coffey et al., 2004 ) . Research interested in determining the functional impairment for people with comor- Clinical Decision-Making with bid TDs and OCD has produced varying results. Comorbid Problems Lewin et al. ( 2010 ) did not fi nd that having a diagnosis of both a TD and OCD increased the There are several potentially reasonable options severity of either disorder in children when to consider when treating a child or adolescent with examining severity levels, comorbidity burden, an impulse control disorder, like TD or TS, who emotional and behavioral problems, or global has comorbid OCD. Previous work concerning 9 TDS and OCD 141 comorbidity of impulse control disorders (in this the patient remain focused on the exposure tasks case trichotillomania) has provided effective at hand without becoming distracted by tic urges. guidelines to aid in conceptualizing the clinical The details of the case are presented in the management of comorbid TDs and OCD (Franklin following section. & Tolin, 2007 ) . These guidelines are as follows: (1) continue the focus on the disorder classifi ed as primary regardless of the presence of other Case Composite symptoms; (2) attempt to incorporate some clinical procedures and session time to manage the The case composite we describe below represents symptoms of the co-occurring disorder but con- a combination of cases we have treated in our tinue to focus most session time and effort on the clinic over the years which have presented with primary disorder; (3) shift the focus of treatment symptoms of both OCD and TDs. We have cho- to address the symptoms of the secondary disor- sen to feature a case in which there were symp- der because their presence makes it diffi cult to toms that were clearly attributable to OCD treat the primary disorder successfully, but move (contamination fears with speci fi c feared conse- back to the primary disorder as soon as possible; quences and associated washing compulsions), to or (4) treat the primary disorder only after the a chronic motor tic disorder (repetitive head jerk- symptoms of the secondary disorder are under ing in response to a premonitory urge that ema- better control. In the clinical circumstance we are nated from the shoulder and neck muscles), and considering here, treatment of TDs with co- to symptoms that appeared to rest squarely on the occurring OCD, the data on OCD driving the border of the two (“Not Just Right” experiences functional impairment when both disorders are and associated “evening up” rituals). We do this present makes us inclined to consider Option 1 for two reasons: (1) this sort of case complexity is likely to be the least effective approach, unless common in children and adolescents with both the OCD symptoms are very mild and are not of disorders; and (2) it permits us to discuss the need paramount importance in the eyes of the child. to adjust the plan in response to clinical needs. The conceptual overlap between the disorders Susan was a 15-year-old sophomore at an aca- and the procedural similarity between some of demically challenging local high school who the core interventions for OCD and TDs also sought treatment for “repetitive movements that probably renders Option 4 a suboptimal choice, she does all the time and intense worries about since differentiating so clearly between the two getting sick.” Her initial evaluation in our fee-for- phenomena is diffi cult and in some cases may not service clinic included the interviewer-rated even be necessary. Children’s Yale-Brown Obsessive Compulsive Thus, the options that we are most likely to Scale (CY-BOCS; Scahill et al., 1997 ) and the consider with TDs and comorbid OCD is to Yale Global Tic Severity Scale (YGTSS; Leckman incorporate procedures for both conditions into et al., 1989) to assess symptoms of OCD and one treatment, or given the likelihood that OCD TDs, respectively, as well as a broader diagnostic will drive the majority of the functional impair- survey of other internalizing and externalizing ment, to address the OCD fi rst while carefully conditions (KID-MINI, Sheehan et al., 1998 ) . examining the effects of the OCD treatment pro- Given her age, the patient was interviewed alone; cedures on tic symptoms. In the case composite at the end of the intake, both parents were invited we present below, clinical circumstances neces- in to discuss the fi ndings of the intake and to dis- sitated a blend of these two approaches: we made cuss treatment alternatives. Susan’s CY-BOCS a clinical decision with the patient and family to total score was a 23, which re fl ects symptoms of attempt the OCD treatment fi rst, but when tic moderate severity. The CY-BOCS checklist revealed symptoms began to worsen in the context of the primary contamination fears with speci fi c feared most diffi cult exposures, we incorporated habit consequences (getting the fl u and missing school), reversal training procedures into the mix to help associated compulsions (excessive and ritualized 142 M.E. Franklin et al. hand washing, use of hand sanitizer), and passive had to do with Susan’s excessive fears of academic avoidances (e.g., waiting until someone else failure and preoccupation with performing per- opened a door to pass through doorways at school fectly in school. If she had to miss classes, she rather than touching the contaminated door worried she would get behind on work and then knob). Her YGTSS total score was a 19, which would consequently be less prepared for exams. also re fl ected symptoms of moderate severity. Susan’s perfect 4.0 grade point average provided Her primary tics involved neck and shoulder her little assurance that her academic goals shrugging movements which were done in (admission to the country’s most prestigious response to a premonitory urge emanating in colleges and universities) would eventually be those areas of the body. In addition, the patient realized, and thus her concerns about getting sick reported frequent “Not Just Right” phenomena were linked to a long litany of undesirable that frequently affected walking, sitting, and outcomes: diminished academic performance, coming into contact with objects and people. suboptimal transcripts, rejection letters from the Physical responses to those “Not Just Right” sen- colleges “that mattered,” compromised career sations, included engaging in stepping rituals, goals, and a diffuse sense that at the end of her fi dgeting in her seat until she felt it was correct, life she would have failed to make the most of her and performing “evening off” rituals that involved talents, which would then affect her standing with putting equal pressure on the right side of the God upon transition to the afterlife. body if the physical contact had occurred on the Susan’s broad and highly specifi c worst-case left and visa versa. Given the absence of a clear scenario was in fl uential as the therapist worked cognitive prompt, one could make a logical argu- with the patient to determine whether to focus on ment for placing these “Not Just Right” symp- OCD or on tic symptoms. Since tics were not toms under the diagnostic umbrella of tics; associated with such dire consequences in the however, they were instead classi fi ed as OCD eyes of the patient, it seemed imperative to move symptoms (Coles, Frosty, Heimberg, & Rheaume, towards the OCD and related beliefs fi rst. Her 2003 ) and included in the CY-BOCS total score. parents agreed to this plan, and were encouraged The broader diagnostic interview did not reveal to remain an active part of the treatment by pro- any additional diagnoses or clinical problems viding Susan with emotional support as she other than OCD and a chronic motor tic disorder worked on the dif fi cult content area pertaining to (which became the formal diagnosis given the contamination. It was also suggested that her par- absence of a history of vocal tics). ents do their best to create a “tic-neutral” envi- Discussion with the patient revealed that ronment at home (Woods et al., 2008 ) . Strong although both sets of symptoms were problem- negative reactions to her tics proved only to tematic, the patient was primarily concerned about porarily reduce them, and actually increased the OCD symptoms since they were beginning to stress, and her vulnerability to stronger tic urges affect her functioning both in school and at in the wake of this stress. lacrosse practice. These were of particular impor- Given that the target of treatment began with tance to her since she was a sophomore in high contamination-related fears, associated rituals, school and, despite her year, was already one of and avoidance behaviors, the therapist began by the league’s best players. Concerns about show- following the outline detailed in March and ering after practice led her to avoid doing so, Mulle’s (1998 ) manual which served as the study which was beginning to draw comment from manual for POTS I and POTS II. The fi rst teammates. In addition, there were times when 4 h-long treatment sessions are conducted twice she was unable to handle worksheets or books at per week, and devoted to: (1) Psychoeducation home that she feared had been contaminated by about OCD and a description of the treatment someone at school (e.g., teacher, classmate) procedures that would fl ow from this conceptual whom she suspected was already sick. Moreover, model; (2) cognitive training, which essentially the consequences of catching the fl u or a bad cold involves teaching the patient to “talk back” to 9 TDS and OCD 143

OCD when it makes its demands about the possibly even inaccurate responses to queries patient’s behavior; (3) development of a treat- about her anxiety level. The therapist and patient ment hierarchy; and (4) a trial exposure in the both noted only a slight increase in tics when area targeted for initial focus in ERP. Given what conducting the trial exposure. was already known about the tic symptoms— Subsequent sessions were conducted weekly their phenomenology, relationship to premoni- given the patient’s relatively moderate symptom tory urges, and responsiveness to stress—it was levels, busy academic and athletic schedules, also agreed that in these early sessions we would demonstrated ability to understand the concep- “keep a watchful eye” on these symptoms to tual model that served as the foundation for treat- determine whether the stress of exposure itself ment, and high between sessions compliance would exacerbate them. If so, the therapist and with exposure tasks and response prevention. patient agreed her tics would be addressed using These sessions were devoted to moving up the a basic competing response procedure which is patient’s contamination hierarchy from more central to the more detailed tic treatment manual anxiety-provoking objects in the therapist’s offi ce (Woods et al., 2008 ) . (e.g., inside door handle) and in the environment Early sessions proceeded as hoped—the outside the of fi ce. The therapist and patient con- patient worked diligently on grasping the conducted these exposures in session, then decided ceptual model and even requested readings from together on how best to conduct exposures the cognitive-behavioral literature to augment between sessions that would be challenging but what she had learned in session. Though her not too diffi cult to complete without engaging in enthusiasm was laudable, the therapist declined rituals. to do this out of concern that it would yield more It was during the eighth treatment session dif fi culties than it could solve because given her when the therapist and patient both observed perfectionistic symptoms, the patient might have signi fi cant increases in the neck and shoulder been prone to worrying excessively whether she tics. In keeping with the overarching goal of con- was implementing treatment “incorrectly.” A fronting the most anxiety-provoking stimuli rel- hierarchy for contamination fears was created, atively early on in treatment, this session was ranging from low level exposures of indirect conducted on the fl oor of the bathroom in the exposure to surfaces that might be contaminated therapist’s of fi ce suite. The patient and therapist (known in our lab as “the principle of the thing that both sat on the fl oor with their palms down at touched the thing,” which allows the therapist to fi rst, then moved their now-contaminated hands create exposures that would be anxiety-provoking, up to their faces so that the patient could con- but less so than direct contact would be) all the front her most prominent fear of ingesting germs way up to the most feared items, which included that would lead her to become ill. The patient’s surfaces in the bathroom and direct contact with agitation increased in this session to the point individuals known to be sick. The trial exposure where it was diffi cult for her to complete the was conducted in session four and went accord- exposure properly, although she was eventually ing to plan: Susan was able to touch the thera- able to do so. The therapist sent Susan home pist’s offi ce desk and fi le cabinets with some with a “souvenir” of their work for the day, a anxiety and with a relatively low urge to wash. In paper towel contaminated by the same bathroom this exposure, the therapist encouraged the patient fl oor, which she was to use to contaminate her to maintain direct contact with these items until room and other parts of her home environment anxiety was substantially diminished, (which was that she typically kept as pristine as possible defi ned as a 50% reduction on the fear rating (e.g., bookbag, kitchen counter where she made scale of 0Ð10). Given the patient’s maladaptive her lunches for school). The patient was able to perfectionism to further the exposure, the thera- complete these exposures between sessions 8 pist gave the patient speci fi c instructions to use and 9, but noted continuing diffi culty with tics rough estimates and provide immediate and while doing so. This increase was beginning to 144 M.E. Franklin et al. demoralize Susan somewhat and leave her less Susan with increased con fi dence that she could con fi dent that she would be able to successfully return to climbing her exposure hierarchy, which manage her symptoms As she reported at the still involved mastering public bathrooms both in beginning of session nine, “It’s like playing that school and beyond. As the treatment for contami- little kid game ‘Whack – a – Mole.’ I work on nation fear moved forward she and the therapist one thing only to see the other thing get worse. planned for the use of competing response to I’m not sure I can do this any more.” address tic urges in the context of contamination- In response to her increasing distress and wan- related exposures. Some initial “tests” were con- ing resolve to manage her OCD symptoms as ducted to assure that focus on competing planned, the therapist provided emotional sup- responses would not block anxiety in response to port but also changed the focus of session 9 to the contamination-related stimuli being competing response training. The overlap in the addressed. These tests for Susan proved informa- conceptual model for the maintenance of tics and tive: she was able to better manage tic urges via compulsions was fi rst presented to the patient. competing response while also concentrating on This model was described as following: both the exposure at hand (pardon the pun), and behaviors are engaged in intentionally in order to became more and more successful at doing so as reduce anxiety and obsessional distress (in the the next several sessions and weeks of exposure case of OCD) or physical discomfort (in the case practice were completed. Not surprisingly, and of tics), and completion of the repetitive behavior without speci fi c instruction to do so, Susan also provides negative reinforcement, (i.e., the relief began to implement the competing responses experienced strengthens the association between when she noticed that her tics were increasing in the unwanted, non-volitional thoughts or sensa- other settings, such as on the bench before tions and the completion of the volitional behav- lacrosse games or in the midst of taking tests in ior designed to provide this relief). Susan was class. able to grasp this commonality relatively quickly, By the end of session 12 Susan’s contamina- and then was given the rationale for engaging in tion-related OCD symptoms were substantially a competing response. The competing response reduced, as was the associated impairment. was described to her as a physical behavior that is Notably, her use of competing response had incompatible with tic completion that the patient increased her sense of control over tic urges when should implement for 1 min at the fi rst sign of the she felt that it was important to exercise this con- premonitory urge or, if the urge is missed, at the trol. At this point in treatment the decision was sign of the fi rst tic. reached to address residual symptoms pertaining The therapist and patient practiced competing to the “Not Just Right” phenomena that affected responses in session that were not associated with walking, sitting, and situations in which she was anxiety related to high-level exposures. This inadvertently contacted on one side of her body. method was taken simply to ensure that the Interestingly, she noted that she did not experi- patient understood how to use the procedure. For ence any of these symptoms while playing homework the patient was given only the assign- lacrosse, which often involves inadvertent con- ment of using competing response at home for tact; nevertheless, it was Susan’s view that her 30 min per day after dinner, which was a time concentration on game situations while playing that the patient noted was “pretty free.” No expo- distracted her from the sensations in this context. sure homework was given, although Susan was The therapist and Susan decided to approach given general encouragement to “do the best you these phenomena using an exposure paradigm: can” in handling OCD-triggering situations with- Susan was instructed to intentionally prompt the out ritualizing or avoiding. Report of the success “Not Just Right” feelings by walking and sitting of the procedure and grasp on the theoretical incorrectly, and by bumping into objects and rationale for its use was evident during the initial other people on purpose. Susan found these expo- stages of session 10. This success then provided sures especially uncomfortable, to the point 9 TDS and OCD 145 where her neck and shoulder tics began to emerge these uncertainties and demands, her OCD, tic, again in session. Repeated practice proved unsuc- and “Not Just Right” symptoms remained cessful in alleviating the distress, although her subclinical, and were not addressed at all in these reintroduction of competing response did afford subsequent sessions. her some increased control over the emerging tics. Susan was encouraged to attempt these practices between sessions, but reported upon her References return in session 13 that she had “given up on them” because her discomfort was coming down Abramowitz, J. S., Whiteside, S. P., & Deacon, R. J. so slowly. (2005). The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis. At this point the therapist decided to utilize a Behavior Therapy, 36 , 55Ð63. competing response to help with the discomfort American Psychiatric Association. (2000). Diagnostic associated with unevenness prompted by touch- and statistical manual of mental disorders (4th ed., ing something on one side of her body. The thera- text revision). Washingtion, DC: American Psychiatric Association. pist asked Susan to touch something against her Banaschewski, T., Woerner, W., & Rothenberger, A. right upper arm and then, rather than attempting (2003). Premonitory sensory phenomena and sup- to touch the object to the exact same spot with her pressibility of tics in Tourette syndrome: Developmental left arm, she was encouraged to push her upper aspects in children and adolescents. Developmental Medicine and Child Neurology, 45 , 700Ð703. arms against her body and hold them steady there Bawden, H. N., Stokes, A., Cam fi eld, C. S., Cam fi eld, P. for 1 min. 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Storch, E. A., Lack, C. W., Simons, L. E., Goodman, W. K., Tourette’s syndrome. Canadian Journal of Psychiatry, Murphy, T. K., & Geffken, G. R. (2007). A measure of 40 , 35Ð39. functional impairment in youth with Tourette’s syn- Valleni-Basille, L. A., Garrison, C. Z., & Jackson, K. L. drome. Journal of Pediatric Psychology, 32 , 950Ð959. (1994). Frequency of obsessive compulsive disorder in Storch, E. A., Merlo, L. J., Lack, C., Milsom, V. A., a community sample of young adolescents. Journal of Gefken, G. R., Goodman, W. K., et al. (2007). Quality the American Academy of Child and Adolescent of life in youth with Tourette’s syndrome and chronic Psychiatry, 33 , 782Ð791. tic disorder. Journal of Clinical Child and Adolescent Verdellen, C. W., Keijsers, G. P., Cath, D. C., & Hoogduin, Psychology, 36 , 216Ð227. C. A. (2004). Exposure with response prevention ver- Swedo, S. E., Leonard, H. L., Garvey, M., Mittleman, B., sus habit reversal in Tourette’s syndrome: A controlled Allen, A. J., Perlmutter, S., et al. (1998). Pediatric study. Behaviour Research and Therapy, 42 , autoimmune neuropsychiatric disorders associated 501Ð511. with streptococcal infections: Clinical description of Wilkinson, B. J., Newman, M. B., Shytle, R. D., Silver, A. the ﬁ rst 50 cases. The American Journal of Psychiatry, A., Sanberg, P. R., & Sheehan, D. (2001). Family 155 , 264Ð271. impact of trichotillomania: Results from two nonre- Swedo, S. E., Rapoport, J. L., Leonard, H. L., & Lenane, ferred samples. Journal of Child and Family Studies, M. (1989). Obsessive-compulsive disorder and chil- 10 , 477Ð483. dren and adolescents: Clinical phenomenology of 70 Woods, D. W., Fuqua, R., & Outman, R. C. (1999). consecutive cases. Archives of General Psychiatry, 46 , Evaluating the social acceptability of persons with 335Ð341. habit disorders: The effects of topography frequency Termine, C., Balottin, U., Rossi, G., Maisano, F., Salini, and gender manipulation. Journal of Psychopathology S., Di Nardo, R., et al. (2006). Psychopathology in and Behavioral Assessment, 21 (1), 1Ð18. children and adolescents with Tourette’s syndrome: A Woods, D. W., Piacentini, J., Chang, S., Deckersbach, T., controlled study. Brain & Development, 28 , 69Ð75. Ginsburg, G. S., et al. (2008). Managing Tourette Thibert, A. L., Day, H. I., & Sandor, P. (1995). Self- syndrome: A behavioral intervention for children and concept and self-consciousness in adults with adults . New York: Oxford University Press. Treatment of Childhood Anxiety in the Context of Limited Cognitive 1 0 Functioning

Jill Ehrenreich-May and Cara S. Remmes

Anxiety disorders are the most common mental Reiss, 1996 ) , further supporting the need for health problem in the United States (Kessler, ef fi cacious interventions targeting childhood Chiu, Demler, Merikangas, & Walters, 2005 ) . It anxiety in this population. is estimated that approximately 13% of children Nevertheless, the lack of empirical evidence suffer from anxiety disorders that cause at least a about the epidemiology of ID and comorbid anx- mild level of functional impairment, making this iety disorders re fl ects a highly understudied the most prevalent psychiatric concern in youth domain as a whole. In fact, effective treatment (Costello et al., 1996 ) . While the incidence of modalities for anxiety have not been well studied anxiety disorders in children with a concurrent in individuals with limited cognitive functioning intellectual disability (ID) has received little (Hagopian & Jennett, 2008) . A number of poten- empirical attention (Ollendick, Oswald, & tial reasons for this lack of research on effective Ollendick, 1993 ) , recent studies suggest that indi- treatments exist. First, since evidence-based pro- viduals with cognitive impairment are at higher tocols for the treatment of anxiety disorders in risk for anxiety disorders than those without ID. youth have historically not included children or Ramirez and Kratochwill (1997 ) found that chil- adolescents with ID in their samples (e.g., Kendall dren with ID were more likely to report specifi c et al., 1997 ; Silverman et al., 1999 ; Walkup et al., fears and generalized anxiety than children with- 2008) , systematic research is unavailable to sub- out ID. Dekker and Koot ( 2003 ) also found that stantiate whether such treatments are at all appro- 22% of youth (ages 7Ð20 years) diagnosed with priate or what specifi c modifi cations might make ID met DSM-IV-TR (American Psychiatric them most useful for this population. Additionally, Association, 2000 ) criteria for at least one anxi- professionals who work with ID populations may ety disorder. According to the World Health be trained primarily to educate and teach their Organization (2007 ) , the true prevalence rate of patients basic daily-living skills. This training ID is estimated to be around 3%, suggesting that may supersede the professional preparation nec- a substantial minority of individual youth may essary to diagnose and treat mental health-related present for treatment with ID and comorbid anxi- concerns within this population (Tanguay & ety disorders. Within the ID population, higher Szymanski, 1980 ) . Diagnostic overshadowing, in levels of anxiety have been associated with poorer which anxiety symptoms may be de-prioritized performance on achievement tests, relative to by clinicians and researchers due to a diagnosis those without anxiety concerns (Feinstein & of ID, may also play a role in the decreased attention to anxiety disorders within this population (McNally & Ascher, 1987 ) . J. Ehrenreich-May , Ph.D. (*) ¥ C. S. Remmes , B.S. Department of Psychology , University of Miami , Keeping such empirical limitations in mind, in P.O. Box 249229, Coral Gables , FL 33124 , USA this chapter we will review the existent literature

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 149 DOI 10.1007/978-1-4614-6458-7_10, © Springer Science+Business Media New York 2013 150 J. Ehrenreich-May and C.S. Remmes on the phenomenology, diagnosis, and treatment also highly comorbid with anxiety symptoms of anxiety in youth with mild to moderate ID. We within the ID population (Glenn, Bihm, & will then forward recommendations for the treat- Lammers, 2003 ) . ment of anxiety disorders in children with limited In the literature on anxiety within the ID pop- cognitive functioning based on both empirical ulation, anxiety disorders have generally been fi ndings regarding those with ID and evidence- treated as a single entity as opposed to separate based treatment for anxiety in children without disorders; however, there has been some research ID. Finally, a brief case study is provided to fur- examining the presentation of individual anxiety ther demonstrate such treatment recommenda- disorders among those with ID. For example, tions and guide suggestions for further research generalized anxiety disorder (GAD) in adoles- in this area. cents and young adults with ID appears similar to As noted, we will only be discussing youth the presentation of GAD within a non-ID popula- who are identi fi ed as having a borderline IQ (IQ tion; with the exception that individuals with ID of 70Ð79; WHO, 1992 ) , mild or moderate ID in report decreased amounts of rumination, this chapter. While we recognize that the assess- decreased sleep disturbance, and decreased ment and treatment of anxiety in children with somatic complaints compared to their non-ID severe and profound ID also merit discussion, counterparts (Masi, Favilla, & Mucci, 2000 ) . In unfortunately, there has been no documented the same study, Masi and colleagues ( 2000 ) research on anxiety in this more severe popula- found that those with ID and concurrent GAD tion (Crabbe, 2001 ) . Additionally, anxiety disor- had higher rates of comorbid panic disorder, but ders appear to be more prevalent in individuals equal rates of comorbid depression and other with moderate ID, as opposed to those with severe anxiety disorders as the group with GAD, with- and profound ID (Holden & Gitlesen, 2004 ) , fur- out an ID diagnosis. ther supporting a focus on those with milder cog- Speci fi c phobias in youth with ID appear to be nitive impairments within this chapter. concentrated on similar fears to children without ID. However, children with ID are likely to report fears that are somewhat more concrete and tend to Phenomenology involve animals more frequently (Ramirez & Kratochwill, 1997 ) . Additionally, specifi c phobias While the research on child anxiety within the ID in adults with ID may more closely resemble the population is lacking, several risk factors and content of childhood phobias, as opposed to fears common symptom presentations have been observed among typically developing individuals. identifi ed. Identifi ed risk factors for anxiety For instance, some common fears reported among within the youth ID population include experi- adults with ID may include fears of the dark and encing a greater number of stressful life events, dogs (Stavrakaki & Lunsky, 2007 ) . While there including the presence of only one caregiver in has been no research to date on the prevalence or the home (Emerson, 2003 ) . As is the case with presentation of social anxiety disorder within the typically developing children, Stavrakaki and ID population, there is reason to believe that indi- Mintsioulis (1997 ) also found that speci fi c life viduals with ID are particularly vulnerable to this events often precede the onset of anxiety-related disorder, given the heightened potential for social symptoms. These life events include rape/sexual exclusion and peer victimization in this popula- assault, physical assault, accidents, illness, move, tion (McNally & Ascher, 1987 ) . or a loss of caregiver. As previously indicated, Obsessive-compulsive disorder (OCD) is there is an increased risk for the development of identifi ed as frequently occurring in individuals an anxiety disorder among individuals with ID with ID (Szymanski & King, 1999 ) . While those that have relatively higher general cognitive abil- with ID may have diffi culty reporting on the con- ity scores (Einfeld & Tonge, 1996 ) . Similar to the tent of obsessions, observation of compulsive typically developing population, depression is behaviors may be used as an indicator of an 10 Child Anxiety in the Context of Limited Cognition 151 underlying OCD diagnosis. However, it is notable IQ scores or mild ID can accurately provide that such obsessions or compulsive behaviors responses to questions on a Likert-type scale or may also be part of stereotypies or tic-like behav- questions that require basic yes or no responses iors in this population (Bodfi sh & Madison, (Hartley & MacLean, 2006 ) . The comprehensi- 1993 ) , further complicating the diagnosis of OCD bility of self-report measures among those with in this population. Posttraumatic stress disorder ID may be further improved by using pictorial (PTSD) may also often be found in individuals representations of items or constructs and limit- with ID (Szymanski & King, 1999 ) and appears ing the number of words within the response to be signifi cantly under-diagnosed in this popu- choices (Hartley & MacLean, 2006 ) . There have lation (Ryan, 1994) . The presentation of PTSD in been multiple measures either designed this population typically involves violent or dis- specifi cally to assess anxiety within this popula- ruptive behavior and is frequently comorbid with tion, or modifi ed from other self-report rating depression (Ryan, 1994 ) . scales to assess anxiety in the context of limited cognitive functioning. Unfortunately, none of these self-report measures are speci fi cally Assessment designed for youth. A brief review of such measures, as indicated for adults with ID, is provided When presented with a child or adolescent client to serve as a basis from which clinicians and exhibiting ID, issues immediately become appar- researchers may consider the potential utility of ent when endeavoring to conduct an effective existent measures or the future development of clinical assessment of the child and family’s con- similar scales for children and adolescents. cerns. Typically, youth anxiety disorders are The Glasgow Anxiety Scale for those with diagnosed through a number of methods includ- Intellectual Disability (GAS-ID; Mindham & ing self-report or parent-report questionnaires, Espie, 2003 ) is a self-report measure designed diagnostic interviews, behavioral observations, speci fi cally to assess anxiety in adults with ID. It and physiological assessment (Velting, Setzer, & uses a three-point Likert-type scale with visual Albano, 2004 ) . While time is often limited for representations of response options in order to such comprehensive assessment, at least a degree assess the domains of worry, speci fi c fears, and of self-report measurement is typically recom- physiological symptoms of anxiety. The GAS-ID mended for use with children over the age of 7 appears to have good psychometric properties (March & Albano, 1996 ) . However, limited cog- when used with individuals in the mild to moder- nitive and communication skills may lead to chal- ate range of ID (Mindham & Espie, 2003 ) . lenges in the accurate completion of self-report Another self-report measure designed specifi cally measures with this population (Ollendick et al., to assess anxiety among adults with limited cog- 1993 ) . It may also be dif fi cult to discriminate nitive functioning is the Fear Survey for Adults between behavioral avoidance due to anxiety and with Mental Retardation (FSAMR; Ramirez & avoidance that stems from personal preferences Lukenbill, 2007 ) . This measure uses a yes or no in this population (Hagopian & Jennett, 2008 ) . In response format to identify frequency and inten- spite of these challenges, some modifi ed diagnos- sity of speci fi c fears. Initial fi ndings using the tic tools exist to aid in the identifi cation of anxi- FSAMR indicate that the measure demonstrates ety among those with ID. good reliability, supporting its use among individuals in the mild to moderate ID range (Ramirez & Lukenbill, 2007 ) . In addition to GAS-ID and Rating Scales FSAMR, which were designed specifi cally to assess anxiety in individuals with ID, the Zung While individuals with ID may have some Self Rating Anxiety Scale has been modi fi ed for dif fi culty completing rating scales, there has been use with adults exhibiting ID (Lindsay & Michie, evidence suggesting that those with borderline 1988) . Adaptations from the original version of 152 J. Ehrenreich-May and C.S. Remmes the Zung include the use of simpli fi ed language, Anxiety Disorders Interview Schedule for the verbal presentation of items, and the use of yes or DSM-IV, Child Version (ADIS-IV-C/P; Silverman no responses. This modi fi ed version of the Zung & Albano, 1996 ) or Diagnostic Interview was found to be reliable in individuals with mild Schedule for Children (DISC-IV; Shaffer, Fisher, to moderate ID (Lindsay & Michie, 1988 ) . Lucas, Dulcan, & Schwab-Stone, 2000 ) , and Given the dif fi culties in using self-report scales behavioral observation paradigms (Dadds, Rapee, to assess anxiety in individuals with limited & Barrett, 1994 ) . Particularly when working with cognitive functioning, an observation-based infor- children exhibiting limited cognitive functioning, mant rating scale has also been developed for this parents and other care providers are instrumental population. The Anxiety , Depression , and Mood in providing information through an interview Scale (ADAMS; Esbensen, Rojahn, Aman, & format. Identi fi cation of anxious and avoidant Ruedrich, 2003 ) measures symptoms related to behaviors, as well as attributions about the cau- anxiety, depression, and mania among adults with sality of such behaviors may be challenging for mild to profound range ID. The factor structure of caregivers, particularly in the context of lower the 55 items of the ADAMS evidenced a fi ve cognitive functioning; therefore, the diagnostic factor model. The factors identifi ed include interview should be a starting point for the for- “Manic/Hyperactive Behavior,” “Depressed mation of hypotheses or case conceptualization Mood,” “Social Avoidance,” “General Anxiety,” within the assessment, and may not be ideal as a and “Compulsive Behavior.” A confi rmatory fac- sole diagnostic tool in the identi fi cation of anxi- tor analysis was conducted to verify these factors ety disorders. Furthermore, commonly used diag- and the model fi t was found to be acceptable. nostic interviews such as the ADIS-IV-C/P and Additionally, internal consistency of the subscales DISC-IV do not have published data regarding and test-retest reliability for both the total scale their use or utility with the ID population, indi- and the subscales was high. Interrater reliability cating that results, even those from a parent or was acceptable. The validity of the ADAMS was caregiver portion of the interview only, should be measured by comparing responses from 129 interpreted with caution. adults with a diagnosis of ID and a concurrent Hagopian and Jennett (2008 ) recommend the psychiatric diagnosis vs. the responses of a con- use of behavioral observation paradigms, such as trol group of 323 individuals with ID, but no con- the Behavioral Activation Test (BAT; Dadds et al. current psychiatric diagnosis. The resultant data 1994 ) , indicating that such paradigms may pro- supports the use of the ADAMS to screen adults vide more confi dence regarding the presence of with ID for bipolar disorder, depression, and anxiety and avoidance-related behaviors within OCD. Unfortunately, the data is limited regarding this population. The BAT is a structured method validity for the general anxiety subscale, given the of assessing avoidant behavior through progres- lesser number of individuals in this study with sive exposure to feared stimuli. Comprehension anxiety symptoms. Further research is warranted of the clinical severity and functional impairment on the convergent and discriminant validity of this associated with anxiety can be aided by identify- measure; however, these initial results were prom- ing points at which the youth displays avoidance ising regarding the utility of the ADAMS in or escape-oriented behaviors. While the use of a screening for anxiety and mood symptoms among BAT has not been studied for its clinical utility in individuals with ID (Esbensen et al., 2003 ) . individuals with ID per se, clinical case studies regarding the treatment of anxiety in this population frequently employ the BAT in the measure- Diagnostic Interviews and Behavioral ment of anxiety symptoms. For example, Erfanian Observation Tasks and Miltenberger (1990 ) used a BAT to aid in the characterization and diagnosis of specifi c pho- As noted, assessments of youth anxiety often bias of dogs and the formation of an appropriate consist of structured interviews, such as the fear hierarchy for two individuals with ID. 10 Child Anxiety in the Context of Limited Cognition 153

In addition to the use of a BAT, naturalistic (e.g., Silverman’s “ Transfer of Control ” model ; observation can also be used to assess anxiety in Silverman & Kurtines, 1996 ) , and those devel- individuals with ID. While, it may be diffi cult for oped with similar modi fi cations for children with the clinician to be present when a particular anx- autism and anxiety disorders (e.g., Wood, iety-evoking situation occurs, they may work Drahota, 2005 ) may be relevant models from with a child’s parents and care providers to moni- which a clinician may work to tailor the interven- tor anxious behavior, along with antecedent and tion to the needs of speci fi c youth with anxiety consequent events using functional analytic tech- disorders and ID. niques (Hagopian & Jennett, 2008 ) . Bogacki, Newmark, and Gogineni ( 2006 ) also suggest that a combination of treatment approaches, including pharmacological, psycho- Interventions for Anxiety in social, and behavioral may be appropriate for the Individuals with Intellectual Disability treatment of anxiety disorders among those with ID, refl ecting the potential for multiple service While treatments for anxiety within the general needs and complexity of case presentation among youth population have been well studied those with ID. A review of the existent literature (Barrett, Farrell, Pina, Piacentini, & Peris, 2008 ; in this domain suggests that certain behavioral, Silverman, Ortiz et al. 2008 ; Silverman, Pina, & cognitive, and pharmacologic treatment compo- Viswesvaran, 2008 ) , there is little research nents may have particular relevance when craft- regarding interventions for anxiety among chil- ing a multicomponent intervention strategy for dren, adolescents or adults within the ID popula- youth with ID and anxiety disorders. These com- tion. The literature that does exist detailing the ponents and treatment strategies are now reviewed treatment of anxiety and concurrent ID is limited in greater depth below (also see Fig. 10.1 ). to clinical case reports that focus on general symptom presentations and fail to include formal DSM diagnoses (Hagopian & Jennett, 2008 ) . Behavioral Treatment Components From a review of such published case studies, Davis, Saeed, and Antonacci (2008 ) found that Classical conditioning, operant conditioning, and youth with developmental disorders, including social learning theories have all contributed to the ID, might bene fi t from modi fi ed versions of exist- development of ef fi cacious treatments for anxiety ing cognitive-behavioral interventions for anxi- through the roles of paired association and avoid- ety. Modi fi cations suggested by these authors ance learning in the development and maintenance include the presentation of treatment concepts in of anxiety. Jennett and Hagopian (2008 ) identi fi ed a more concrete manner, increased repetition of selected behavioral procedures, including gradu- concepts over a greater number of sessions, ated exposure and reinforcement, as useful tech- greater use of behavioral reinforcement and niques for the treatment of phobic avoidance in the modeling techniques, and increased parental ID population. In another study by the same involvement in the conduct of treatment (Davis authors (Hagopian & Jennett, 2008 ) , they recom- et al., 2008 ) . These recommendations suggest mend the use of a BAT to form a fear and avoid- that evidence-based treatment packages with a ance hierarchy for those unable to verbalize strong cognitive-behavioral focus, particularly experiences of anxiety, in addition to its usage as those with similar modi fi cations for younger an initial assessment tool. These authors also sug- children (e.g., Being Brave ; Hirshfeld-Becker gest the use of a systematic preference assessment, et al., 2010 ; Parent Ð Child Interaction Therapy based on nonverbal choice responses, to identify for Separation Anxiety Disorder ; Pincus, preferred reinforcers. Systematic preference Santucci, Ehrenreich, & Eyberg, 2008 ) , those tar- assessments are performed by methodically expos- geting school-aged children that include explicit ing individuals to varying stimuli while recording involvement of parents in a “coaching” capacity their responses and can either take the form of an 154 J. Ehrenreich-May and C.S. Remmes

Treatment Components

Behavioral Cognitive Pharmacological

Selective Serotonin Graduated Exposure Cognitive Restructuring Reuptake Inhibitors (SSRls) Combined with Relaxation Techniques Aided by Concrete Benzodiazepines Serotonin-Norepinephrine Reinforcement illustrations Reuptake lnhibitors (SNRls)

Fig 10.1 Various intervention strategies used for the treatment of anxiety in youth with ID approach-based or an engagement-based assess- to watch the owner engage with his dog. Over the ment (Hagopian, Long, & Rush, 2004) . In addition next few sessions, the participants were told to to the use of the BAT and a systematic preference move one foot closer to the dog and then they assessment, Hagopian and Jennett ( 2008) also were physically guided to move closer to the dog, emphasized the heightened importance of not pair- while engaging in reinforcing activities. With ing feared stimuli with aversive stimuli during each approach, the trainer brought the partici- exposures, given the potential negative condition- pant’s awareness to the dog and praised them for ing effect of this pairing. their efforts. Once the participant could comfort- In addition to these speci fi c recommendations, ably approach within three feet of the dog, a Hagopian and Jennett (2008 ) further identi fi ed larger dog was used. behavioral treatment components that may be In addition to other behavioral techniques, used in combination with graduated exposure relaxation training, including the use of muscle and reinforcement in the treatment of anxiety in relaxation and breathing exercises, have also been individuals with ID. These additional compo- investigated with ID samples. Commonly used nents include prompting, response prevention, relaxation training procedures include Progressive and the use of distracting stimuli. The use of a Relaxation (Jacobsen, 1938 ) and Abbreviated “least-to-most” prompting hierarchy when assist- Progressive Relaxation (APR; Bernstein & ing an individual to comply with the steps of an Borkovec, 1973 ) . These techniques have been exposure hierarchy is also recommended. In this applied to adults with ID to treat a range of behav- model, the clinician fi rst uses a participant model, ioral and cognitive diffi culties, including phobic then a verbal prompt, and fi nally a physical symptoms (Guralnick, 1973 ; Peck, 1977 ) . In these prompt to expose the individual to the feared studies, relaxation exercises were combined with stimuli. For a case study previously mentioned, other behavioral techniques to systematically Erfanian and Miltenberger ( 1990 ) used such a desensitize individuals to feared stimuli. However, “least-to-most” prompting hierarchy during treat- APR alone has also been shown to reduce anxiety ment for specifi c phobia of dogs in two individu- in individuals with mild ID, although less so als with moderate to profound ID. In the fi rst among individuals with moderate to severe ID session of treatment, a small dog and its owner (Rickard, Thrasher, & Elkins, 1984 ) . were positioned on the opposite side of the room Alternative relaxation techniques may be used from the participant, while the participant when working with individuals exhibiting mod- engaged in rewarding activities and was prompted erate to severe ID. Schilling and Poppen ( 1983 ) 10 Child Anxiety in the Context of Limited Cognition 155 developed Behavioral Relaxation Training (BRT) thought processes. Cognitive therapy techniques after discovering that APR was ineffective with for anxiety are often aimed at teaching the patient boys exhibiting learning disabilities. In BRT, the to evaluate and modify distorted cognitions or instructor models the unrelaxed and relaxed states threatening appraisals regarding anxiety-provok- in different body areas and then the patient is ing situations. While there has been some support asked to imitate the relaxed states. BRT has dem- for the use of cognitive components in the treat- onstrated enhanced ef fi cacy vs. APR for adult ment of anxiety in ID populations (Dagnan & patients with moderate and severe ID (Lindsay, Lindsay, 2004 ) , research in this area is also lack- Baty, Michie, & Richardson, 1989 ) . ing. Dagnan and Chadwick ( 1997 ) identi fi ed two distinct approaches to cognitive therapy used in Ethical considerations in the use of behavioral interventions for adults with ID. One approach is treatment components for youth with ID . While based on a cognitive distortion model, in which behavioral treatment elements, such as exposure anxiety is seen as being caused and maintained techniques, are clearly vital treatment compo- by the individual’s misinterpretations of feared nents for youth anxiety disorders, it is important stimuli. The second, and more widely used to consider the ethical implications of their usage approach, is based on a defi cit model, which when treating anxiety in children with limited assumes that emotional and behavioral dif fi culties cognitive functioning. Exposure exercises may are due to a lack of cognitive skills and processes be distressing for some children, even in the among those with ID. hands of a master clinician. However, in treating Unfortunately, no research exists on the individuals without ID, the rationale for the expo- effi cacy or usage of cognitive components with sure and corresponding distress can often be youth exhibiting ID and anxiety disorders. effectively communicated before the child ini- Although implications of the defi cit model (e.g., tially confronts feared stimuli in the presence of a a need for cognitive skill-building and enhance- helpful and guiding clinician. This psychoeduca- ment of positive social interactions) may also be tion allows time for the child to generally assent useful for children and adolescents with anxiety to the exposure or at least comprehend its ratio- disorders and ID, the use of cognitive techniques nale, in spite of the distress that may result. alone seems unlikely to be benefi cial for such However, in treatment of youth with ID, it may youth, unless substantially aided by concrete not be possible for the child to fully gain this illustrations, visual depictions of complex con- understanding before they engage in exposure structs, and other modi fi cations similar to those exercises. In these cases, extra care and consider- suggested by Davis and colleagues ( 2008 ) . For ation should be taken to slowly and gradually example, children with ID and social anxiety may move along a fear hierarchy when exposing the bene fi t from viewing depictions of appropriate patient to a feared stimulus, carefully reiterating social skills or responses to the evocation of the rationale and bene fi t of the process repeat- social anxiety in the popular media (e.g., viewing edly. Although not ideal in most exposure sce- a clip from a movie such as “Mean Girls”), dis- narios, the alternate usage of systematic cussion of the appropriateness of the skill exhib- desensitization paradigms vs. graduated exposure ited and its relevance for the individual client, may be considered to maintain rapport and moti- rather than relying on self-generated examples in vation for treatment. session alone.

Cognitive Treatment Components Pharmacotherapy

Cognitive theories emphasize the role of thought Medications often recommended for the treat- in in ﬂ uencing behavior and posit that maladap- ment of adults and youth with anxiety disorders tive behaviors ultimately stem from dysfunctional include selective serotonin reuptake inhibitors 156 J. Ehrenreich-May and C.S. Remmes

(SSRIs), serotonin-norepinephrine reuptake There have been no systematically controlled inhibitors (SNRIs), benzodiazepines, and buspirone, trials conducted to assess the ef fi cacy of anxi- among others (Vanin & Helsley, 2008 ) . When olytic medication in individuals with ID (Crabbe, administered to youth, SSRIs have demonstrated 2001 ) . However, anxiolytics are commonly pre- ef fi cacy for the acute treatment of social anxiety scribed in this population to control disruptive disorder, separation anxiety disorder, OCD, and behavior and for symptoms related to GAD GAD (Vitiello & Waslick, 2010 ) , although rates (Aman, Collier-Crespin, & Lindsay, 2000 ) . Due of remission and long-term improvements vary to the lack of research on the effects of anxiolytics on widely by disorder. Despite a black box warning children with ID, these authors advised using cau- regarding suicidal ideation (Food and Drug tion when considering whether to prescribe this Administration [FDA], 2007 ) , a recent review class of medication to youth (Aman et al., 2000 ) . concluded that SSRIs are generally safe when administered to children; however, side effects including insomnia, nervousness, restlessness, Case Study fatigue, dizziness, sedation, nausea, and headaches may be reported in some children (Vitiello Katrina M.1 is a 9-year-old girl of Cuban- & Waslick, 2010 ) . American descent that presented for treatment, Like most research on youth with ID and anxi- along with her mother and father, to an anxiety ety, evidence regarding the use of pharmacother- research clinic situated in an academic psychol- apy to treat youth with ID and anxiety disorders ogy department. During an initial assessment ses- is extremely scarce. Davis et al. (2008 ) identi fi ed sion, Mrs. M provided a copy of a recent three studies that have tested the utility of SSRIs psychoeducational evaluation indicating that on the reduction of anxiety in children with a Katrina currently had a full-scale IQ of 72, with variety of pervasive developmental disorders no signi fi cant discrepancies between her factor (PDDs). While all of these studies were limited scores on the Wechsler Intelligence Scale for methodologically, some reduction of anxiety Children, Fourth Edition (WISC-IV; Wechsler, symptoms was seen, providing preliminary sup- 2004) . Katrina was currently enrolled full-time in port for the use of SSRIs with this population. a special education classroom at her school that One of these studies consisted of a retrospective utilized a curriculum suitable for children and chart review assessing the bene fi ts and negative young adolescents with a variety of developmen- side effects of citalopram in youth, ages 4Ð15 tal and intellectual disabilities. Katrina was able years, with PDD (Couturier & Nicolson, 2002 ) . to speak to clinicians clearly in English and Eight of these 17 subjects had a concurrent ID Spanish, but primarily spoke English using brief, diagnosis. Ten of these patients (59%) were rated clearly distinguishable statements in sessions. as much or very much improved on the Clinical Using the ADIS-IV-C/P (Silverman & Albano, Global Impression scale (CGI; Guy, 1976 ) in 1996 ) , the initial examiner indicated that Katrina regard to their target symptoms following citalo- was currently experiencing clinically signi fi cant pram usage. While citalopram was prescribed to symptoms of Specifi c Phobia, Animal Type address a variety of target symptoms in this study, (Dogs) with a Clinical Severity Rating (CSR) at a anxiety and aggression were the most likely to six (range = 0Ð8). This interview and additional improve. These fi ndings did not differ across lev- questionnaire measures completed by Mrs. and els of cognitive ability. In regard to negative side Mr. M indicated that no other emotional disorder effects, citalopram was well tolerated by most or behavioral symptoms were currently present at child patients. However, four families discontinued their child’s medication within the fi rst 2 months of treatment due to adverse responses, 1 Katrina’s case information is a composite of several prior including increased agitation, insomnia, and pos- cases. No identifying or descriptive data from any prior sible tics. case is used in this case presentation. 10 Child Anxiety in the Context of Limited Cognition 157 a clinical level. However, Katrina’s parents did recently made a friend with a dog that she wished report subclinical symptoms of social anxiety to see more often and was motivated to try and and depression that did not currently result in any work more directly on her fears. noticeable impairment. Treatment consisted of 12 sessions, inclusive of During the diagnostic interview, Katrina and an initial rapport building and psychoeducation- her parents discussed the functional impairments oriented session, a baseline BAT and reinforcer that Katrina experienced reportedly in response to assessment session, nine in vivo exposure sessions, her fears about interacting with dogs of any breed and a concluding BAT and relapse prevention- or size. No signi fi cant phobic behaviors regarding focused session. During the initial rapport building dogs were noted for Katrina prior to age 5. At age session, the clinician developed her relationship 5, Mrs. M reported that Katrina was playing with with Katrina through the use of a “memory game” her older brother at a local fi eld when a large, off- adapted from Wood and colleagues ( 2005 ) , in leash dog came ran over to them unexpectedly. which Katrina was prompted to state fi ve “fun” Mrs. M reported that Katrina did not see the dog facts about herself and the clinician did the same, approach and when she turned, the dog was very then both restated as many of these facts about near to her and immediately jumped up and licked each other as possible at intervals throughout the her face. Katrina was reportedly startled and began session. Katrina responded very positively to this crying uncontrollably. She was immediately sepa- game and was able to discuss her feeling that dogs rated from the dog by nearby relatives and removed were “very scary” and her concurrent desire to from the area. However, she apparently was unable play regularly at her classmate’s home. Much of to calm herself suffi ciently for several hours fol- this initial session was also spent providing psy- lowing the incident. Mrs. M indicated that although choeducation about the nature of fear to Katrina’s they knew it was “not the right thing to say”, the parents, with them guiding the clinician regarding only thing that seemed to suf fi ciently reduce how best to share this information with Katrina in Katrina’s distress at that time was to repeatedly a concrete manner. Before ending session, the cli- state that Katrina would not have to interact with a nician presented Katrina and her parents with the dog “ever again.” rationale for the BAT and exposure as a means to During the intervening 4 years, Katrina devel- reduce Katrina’s anxious and avoidant behaviors. oped a systematic line of questioning related to The family agreed to a BAT session with a “small, dogs that she “required” family members to friendly dog” to aid the clinician in creating a fear answer prior to entering most new situations, and avoidance hierarchy that would eventually including unfamiliar homes, parks, and other sit- facilitate graduated exposures. uations where a dog may be present. These ques- Although the initial BAT made use of only one tions related to the likelihood of a dog being dog (a small, Chihuahua mix), it was effective in present and the plan for removing Katrina from assessing spontaneous statements made by the situation immediately, if one were present. If Katrina that were suggestive of specifi c fears Katrina were entering the home of a familiar per- about being licked and jumped on by the dog. son with a dog, she would require that the dog be Prior to the BAT, a reinforcer preference assess- placed in a room with the door closed before ment suggested that having a small amount of entering the house. Prior to the onset of the cur- soda, juice, or candy during session would be rent course of treatment, Katrina received 27 ses- useful as Katrina took steps toward a dog or sions of “supportive psychotherapy and family engaged in new behaviors (e.g., touching a dog, therapy” from a clinical social worker that subse- allowing a dog to lick her, giving a dog a treat) quently referred the family to the anxiety research and these were used throughout the BAT and clinic. The referring clinician indicated that she most subsequent exposure sessions. believed Katrina was now in need of “exposures” During the nine exposure sessions, a “least-to- and may be amenable to receiving such at this most” prompting hierarchy was utilized, similar time. Katrina’s parents concurred that Katrina to that recommended by Erfanian and Miltenberger 158 J. Ehrenreich-May and C.S. Remmes

(1990 ) . Katrina was able to steadily progress come to mind as a barrier to effective treatment. from smaller and more familiar dogs to those that As this chapter re fl ects, numerous treatment strat- were larger and more overtly intimidating to her. egies may be attempted with such youth in hopes She was also prompted to use a set of questions of alleviating their anxiety-related distress and when encountering a new dog owner (e.g., Is behavioral avoidance. Furthermore, the usage of your dog friendly? Do you think it would be safe modifi ed cognitive-behavioral treatment (CBT) for me to pet your dog? Can you show me how packages that have demonstrable ef fi cacy among your dog likes to be pet?) and then engage with typically developing youth with anxiety disorders the dog as directed by the owner. Memory for may hold potential to bene fi t children with ID. these questions was prompted by her parents and Nonetheless, it is fair to suggest that the state of by allowing Katrina to carry a laminated card the literature on youth with anxiety disorders and with her that included what she referred to as her ID is poor. Further research is clearly indicated “brave puppy questions.” At home, Mrs. and Mr. regarding the etiology, epidemiology, assess- M aided in the generalization of these new, ment, and treatment of this population. approach-oriented behaviors by ensuring that In terms of treatment research, although inter- Katrina was given opportunities to practice esting modi fi cations and suggested applications acquired skills with new dogs and those that she of behavioral and pharmacologic treatment had avoided in the past. They were asked to ini- approaches have been proposed for children with tially follow the same exposure procedure as they ID and anxiety, it is unclear how well such treat- observed and participated in with their clinician. ments might apply to the greater population at By session eight, they and the clinician were able hand, given that the available data is limited to a to fade the provision of a reinforcer to the end of handful of case examples and limited open trial Katrina’s interactions with a dog, rather than research on pharmacologic approaches. Clearly, throughout the exposure, with an equivalent the further study of such approaches using care- amount of success. fully controlled designs and randomization para- At the concluding BAT session, Katrina was digms is needed. Although such treatments able to easily approach the same small dog she appear quite plausible for children with ID, these initially demonstrated much fear and reticence in interventions are likely to be presented to fami- approaching during session two. She indicated lies in the context of a necessarily limited assess- that dogs were still “scary” to her, but that she ment process that may fail to fully identify the now knew how to use her “brave puppy ques- function and reinforcement of anxious and tions” and approach skills to manage such inter- avoidant behaviors, particularly if time con- actions across a range of dog sizes and activity straints limit use of techniques such as the BAT levels. Her parents indicated high levels of satis- or other observational methods that appear par- faction with the treatment. Finally, at a posttreat- ticularly important to the assessment of youth ment assessment, the examining clinician rated with ID and anxiety. Therefore, the matching of a Katrina’s specifi c phobia at a CSR of three, indi- particular treatment approach to the functional cating that she still possessed and vocalized some impairments of a given child may be challenging fears about dogs, but was no longer demonstrat- to achieve. ing clinically signi fi cant levels of such or notable Acceptability and satisfaction data regarding functional impairment. potentially ef fi cacious approaches, including behavioral techniques and modifi ed CBT protocols, also appears vital to future treatment Conclusions and Future Directions research. For instance, even families of typically developing children may have a diffi cult time When discussing the presentation of anxiety dis- comprehending the value and relative safety of orders in the context of a child with ID, inevita- exposure techniques. 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clinical trial. Journal of Consulting and Clinical E. Tanguay (Eds.), Emotional disorders of mentally Psychology, 67 (6), 995Ð1003. retarded persons (pp. 19Ð28). Baltimore, MD: Silverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. University Park Press. J., Kolko, D. J., Putnam, F. W., et al. (2008). Evidence- Vanin, J. R., & Helsley, J. D. (Eds.). (2008). Anxiety disor- based psychosocial treatments for child and adolescent ders: A pocket guide for primary care . Totowa, NJ: exposed to traumatic events: A review and meta-anal- Humana Press. ysis. Journal of Clinical Child and Adolescent Velting, O. N., Setzer, N. J., & Albano, A. M. (2004). Psychology, 37 , 156Ð183. Update on and advances in assessment and cognitive Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). behavioral treatment of anxiety disorders in children Evidence-based psychosocial treatments for phobic and adolescents. Professional Psychology, Research and anxiety disorders in children and adolescents. and Practice, 35 , 42Ð54. Journal of Clinical Child and Adolescent Psychology, Vitiello, B., & Waslick, B. (2010). Pharmacotherapy for 37(1), 105Ð130. doi: 10.1080/15374410701817907 . children and adolescents with anxiety disorders. Stavrakaki, C., & Lunsky, Y. (2007). Depression, anxiety Psychiatric Annals, 40 (4), 185Ð191. and adjustment disorders in people with intellectual Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., disabilities. In N. Bouras & G. Holt (Eds.), Psychiatric Compton, S. N., Sherrill, J. T., et al. (2008). Cognitive and behavioural disorders in intellectual and develop- behavioral therapy, sertraline, or a combination in child- mental disabilities (2nd ed., pp. 113Ð130). Cambridge: hood anxiety. The New England Journal of Medicine, Cambridge University Press. 359 (26), 2753Ð2766. doi: 10.1056/NEJMoa0804633 . Stavrakaki, C., & Mintsioulis, G. (1997). Implications of Wechsler, D. (2004). The Wechsler intelligence scale for a clinical study of anxiety disorders in persons with children (4th ed.). London: Pearson Assessment. mental retardation. Psychiatric Annals, 27 , 182Ð189. Wood, J., & Drahota, A. (2005). Behavioral interventions Szymanski, L., & King, B. H. (1999). Practice parameters for anxiety in children with autism (BIACA). UCLA. for the assessment and treatment of children, adoles- World Health Organization (WHO). (1992). International cents, and adults with mental retardation and comorbid classi ﬁ cation of diseases. Geneva: World Health mental disorders. Journal of the American Academy of Organization. Child and Adolescent Psychiatry, 38 (Suppl 12), 5Ð32. World Health Organization (WHO). (2007). Atlas: Global Tanguay, P. E., & Szymanski, L. S. (1980). Training of resources for persons with intellectual disabilities . mental health professionals. In L. S. Szymanski & P. Geneva: World Health Organization. Special Considerations in Treating Anxiety Disorders in Adolescents 1 1

Katharina Manassis and Pamela Wilansky-Traynor

2007 ; National Institute for Health and Clinical Nature of the Problem Excellence, 2007 ) . The addition of medication targeting serotonin may produce a more robust Anxiety disorders affect 6–7% of children and therapeutic effect than either intervention alone adolescents (Cartwright-Hatton, Roberts, (Compton et al., 2010 ) . Nevertheless, a substan- Chisabesan, Fothergill, & Harrington, 2004 ; tial number of children and youth fail to respond Compton et al., 2004 ) and are associated with to treatment in general and CBT in particular. wide-ranging personal and social consequences Despite the vast literature on the treatment of including poor school performance, disrupted adult and childhood anxiety disorders, the treat- relationships with peers and adults, as well as ment of adolescents with anxiety disorders has diminished participation in the typical activities received limited research attention (Bennett et al., of youth. Adolescence is often a time when the 2010 ; Masia-Warner, Fisher, & Reigada, 2008 ) . consequences of untreated anxiety become par- Furthermore, anxious adolescents who are willing ticularly damaging (Silverman, Pina, & and able to complete research protocols may not Viswesvaran, 2008 ) , the frequency of comorbid be representative of those typically seen in com- disorders increases (Carey & Oxman, 2007 ) , and munity settings (Manassis, 2009 ) . Thus, the effec- maladaptive coping styles and family interaction tive treatment of adolescents with anxiety disorders patterns become entrenched. continues to be a challenge that merits further Cognitive behavioral therapy (CBT) is the research and careful consideration. This chapter most established evidence-based treatment for reviews the developmental and social factors that anxiety disorders in youth and is considered may account for this challenge, key research probably efﬁ cacious based on meta-analytic evidence pertaining to the treatment of anxious reviews (Silverman et al., 2008 ; Canadian adolescents, and treatment approaches that may Psychiatric Association, 2006 ; Connolly, improve outcomes for anxious adolescents. These Bernstein, & the Work Group on Quality Issues, approaches are illustrated using a case example.

K. Manassis (*) Factors Contributing to Complexity Department of Psychiatry , Hospital for Sick Children, University of Toronto , 555 University Avenue , Empirical Evidence M5G 1X8 , Toronto , ON , Canada e-mail: [email protected] Interpreting the evidence for the treatment of P. Wilansky-Traynor Ontario Shores Centre for Mental Health Sciences , adolescents with anxiety disorders is complicated University of Toronto , Toronto , ON , Canada by the fact that few treatment studies have focused

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 163 DOI 10.1007/978-1-4614-6458-7_11, © Springer Science+Business Media New York 2013 164 K. Manassis and P. Wilansky-Traynor exclusively on this age group. The existing one study) an urban school setting. In a small studies reviewed have all employed various randomized controlled trial (n = 12), Ginsburg forms of CBT. and Drake ( 2002 ) reported symptomatic improve- Adolescent Social Phobia has received some- ment and 75% remission of primary anxiety dis- what more research attention than other adoles- order following school-based CBT for urban, cent anxiety disorders. Several authors have African-American adolescents. By contrast, only reported symptomatic improvement following 20% of adolescents remitted following an atten- group CBT for adolescents with this disorder in tion-support control condition. Siqueland, Rynn, both open and waitlist-controlled trials (Albano, and Diamond ( 2005 ) randomly assigned 11 Marten, Holt, Heimberg, & Barlow, 1995 ; Baer adolescents to CBT alone or CBT plus an & Garland, 2005 ; Hayward et al., 2000 ; Herbert attachment-based family treatment. Both groups et al., 2009 ) , with maintenance of gains at 1-year showed decreases in anxious and depressive follow-up (Albano et al., 1995 ; Hayward et al., symptoms, without a signi fi cant group differ- 2000 ) . Group therapy generally included some ence. Legerstee et al. (2008 ) examined the role of social skills training, in addition to cognitive parental psychopathology in moderating individ- strategies and behavioral exercises (e.g., expo- ual CBT results for 51 adolescents with various sure to social situations). Interestingly, a recent anxiety disorders. Maternal anxiety predicted study which included an active control condition more favorable treatment outcomes. (i.e., educational/supportive psychotherapy) Most CBT treatment studies have included found symptomatic improvement and improved some adolescents with anxiety disorders in sam- functioning following both the CBT and active ples that span a broad age range and are predomi- control conditions, except with greater behavioral nantly comprised of younger children. Only a few gains following CBT (Herbert et al., 2009 ) . of these studies have examined age as a potential Apart from Social Phobia, few other disorder- moderator of treatment effect, with equivocal speci fi c treatments have been evaluated in stud- results. While some studies found no age effects ies focused exclusively on adolescents. CBT to (Berman, Weems, Silverman, & Kurtines, 2000 ; address school refusal has been researched with Kendall, Hudson, Gosch, Flannery-Schroeder, & and without the concurrent use of the antide- Suveg, 2008 ) , others found better outcomes in pressant imipramine (Layne, Bernstein, Egan, younger children (Bodden et al., 2008 ; Southam- & Kushner, 2003 ) . Results have favored the Gerow, Kendall, & Weersing, 2001 ) , and only one combination of CBT and imipramine over study found better outcomes in older children CBT alone. Higher baseline attendance and the (Cobham, Dadds, & Spence, 1998 ) . A recent absence of Separation Anxiety Disorder or meta-analysis suggests that anxious adolescents Avoidant Disorder (an older diagnosis, similar bene fi t from CBT to the same extent than younger to generalized Social Phobia) also predicted children (Bennett et al., 2010 ) . However, most of more favorable outcomes (Layne et al.). CBT the research was developed in academic settings, combined with interpersonal skills training was where therapists are generally well-trained in studied in a small group of adolescent girls with developmentally appropriate adaptations of CBT. Generalized Anxiety Disorder in an open trial Results might differ in community settings. (Waters, Donaldson, & Zimmer-Gembeck, Results may be further confounded by the ten- 2008 ) . Improved interpersonal functioning and dency of most researchers to report only on treat- reductions in anxious and depressive symptoms ment completers. Focusing on treatment were found with treatment. completers obscures possible age-related differ- Treatments have also been developed and ences in treatment participation and dropout rates. evaluated for adolescents with various anxiety Furthermore, age is not always a good proxy for disorders (usually, one or more of Generalized developmental level, as adolescents of the same Anxiety Disorder, Social Phobia, or Separation age can vary widely in their physical, cognitive, Anxiety Disorder) in academic settings and (in emotional, and social level of maturity. 11 Anxiety Disorders in Adolescents 165

Developmental Factors of anxious adolescents may feel helpless to encourage age-appropriate independent behav- Cognitive, psychosocial, and physical changes as iors (Foa & Andrews, 2006 ) , as adolescents often well as the nature of anxiety disorders in adoles- argue with parents in an attempt to assert their cence can both help and hinder successful treat- autonomy while their physical size reduces the ment. Cognitively, adolescents have a greater parents’ ability to control them. capacity for abstract reasoning than younger chil- Physical development can also affect adoles- dren, including self-re fl ection and insight which cent anxiety and its treatment. For example, chil- are the capacities deemed most relevant to CBT dren who appear physically mature yet lack (Sauter, Heyne, & Westenberg, 2009 ) . Therefore, cognitive or emotional maturity may face unreal- they can often more readily recognize and chal- istically high expectations from others (who may lenge maladaptive, anxious thoughts compared assume they are older than they really are), con- to younger children. Due to their increasing tributing to anxiety. Likewise, therapists can also cognitive abilities, however, adolescents can also overestimate these adolescents’ abilities, generate more complex worries than younger adversely affecting the adolescent-therapist alli- children. Similarly, “the imaginary audience” ance and therapeutic outcomes. Additionally, (a belief that everyone is watching the adoles- response to medication can be affected by physi- cent) is a mild cognitive distortion that can be cal development (see Labellarte, Ginsburg, considered normative in adolescence (Kingery Walkup, & Riddle, 1999 ) . For example, rapid et al., 2006 ) yet can also contribute to social anxi- liver metabolism may result in a need for higher ety. Fear of social evaluation can affect treatment doses of certain medications for adolescents motivation, as many adolescents worry what their compared to adults of similar size, while other peers will say if they confess to seeing a “shrink.” medications may still need to be provided at Further, cognitive development is quite variable doses similar to those given to children. Some in adolescents, and some never acquire the high- side effects (such as sexual ones in serotonin- est levels of refl ective thought. Therefore, thera- specifi c medications) may be more concerning to pists must evaluate cognitive capacities relevant adolescents than to younger children. The risk of to CBT rather than assuming that all adolescents weight gain is another side effect that tends to be possess these necessary skills. of great concern to teenagers, even though this Psychosocial development in adolescence is risk may actually be greater for prepubertal chil- characterized by an increased need for autonomy dren than adolescents (Jerrell, 2010 ) . (Stallard, 2002 ) . Autonomous behavior can aid The nature of anxiety disorders is also differ- therapy, such as allowing an adolescent to travel ent in adolescents than in younger children, often to and from appointments independently or orga- affecting treatment. For example, comorbid nize exposures to feared situations without depression and substance abuse are more com- parental help. Unfortunately, a desire for auton- mon in anxious adolescents than children (Carey omy can also interfere with engagement in ther- & Oxman, 2007 ) , which may undermine anxiety apy, particularly if the therapist is seen as treatment if undiagnosed. If they are detected, authoritarian (rather than collaborative), being therapy may need to be tailored to address these allied with the adolescent’s parents, or coercing conditions in addition to the adolescent’s anxiety the adolescent into attending therapy. Once in disorder. In children who have suffered with anx- therapy, a desire to assert his or her autonomy iety disorders for years, maladaptive coping can also result in the adolescent avoiding styles and patterns of family interaction may exposure tasks or completing homework between become entrenched in adolescence. For example, sessions. Appropriately, involving parents in families may accommodate some manifestations therapy can also be diffi cult in some adolescents, of their child’s anxiety by tolerating immature who may assert their autonomy by trying to pre- behavior, avoiding discussions that might be anx- vent parental contact with the therapist. Parents iety-provoking for the child, or allowing the child 166 K. Manassis and P. Wilansky-Traynor to avoid age-appropriate activities. Maladaptive associated with anxiety symptoms and anxiety coping styles can make CBT more challenging, disorders in children and youth, possibly con- as adolescents are sometimes more resistant to tributing to a higher rate of anxiety disorders and change than younger children or have little hope anxiety-related impairment among adolescent for change. Maladaptive patterns of family inter- girls than adolescent boys (Ginsburg & action may require additional family therapy or Silverman, 2000 ) . For all of these reasons, limit- targeting these issues in treatment. ing anxiety-related impairment is often an important therapeutic focus in adolescents. Key transition points where the adolescent Social Factors faces new challenges may be particularly diffi cult for someone with an anxiety disorder yet may Children are expected to function at an increas- also represent a therapeutic opportunity. For ingly independent level as they progress through example, the need to cope with increased aca- adolescence. School work completion, transpor- demic work, multiple teachers and classrooms, tation, and social conduct increasingly become and a larger peer group can make the start of high the adolescent’s responsibility rather than that of school a stressful change for many anxious his or her parents. Subjectively, anxious adoles- youngsters. Adolescents with anxiety disorders cents may fi nd these expectations stressful, espe- are vulnerable to increased distress and deteriora- cially if their families have been overly protective tion in functioning in response to this change. in the past, limiting their experience with inde- However, as a result, their willingness to engage pendent behavior. The cognitive distortions com- in treatment may also be heightened. monly associated with anxiety (e.g., perfectionistic beliefs or biases toward threat perception) may contribute to this stress, as they may result in Treatment Approaches to Address anxious adolescents perceiving societal expecta- Complexity tions as being higher than they actually are (Lonigan, Vasey, Phillips, & Hazen, 2004 ) . An approach to treatment must address some of the As a result of these developmental changes, complexities encountered in adolescents with anx- anxiety disorders often result in greater actual iety disorders is shown in Fig. 11.1 . Prior to treat- and perceived impairment at this age than in ment, it is important to do a developmentally younger children. For example, Silverman et al. sensitive assessment. Assessments with adolescents (2008 ) have argued that social anxiety symptoms differ from those with younger children mainly in that may cause minor impairment in an elemen- that extra attention is devoted to engaging the young tary school child could be catastrophic for a high person in a developmentally appropriate manner. school student who was unable to pass an oral Such engagement is essential for obtaining com- examination required for graduation. Societal plete and accurate information and subsequently for expectations can also place anxious adolescents successfully initiating psychotherapy. at a disadvantage relative to their peers. In particular, anxious adolescents are expected to function more independently from their families than Engaging the Adolescent in Therapy anxious children. The inability to do so (e.g., due to Separation Anxiety or Social Phobia) can sin- Due to their desire for autonomy, concern about gle out these youth among their peer group. When social stigma, and greater identi fi cation with peers a young person is less independent and socially rather than adults, adolescents can be diffi cult to competent than average, there can be detrimental engage in therapy. Although various strategies to effects on self-esteem and social functioning. improve engagement have been described, the Gender role expectations also change at adoles- most consistently advocated strategy is that the cence. Gender-speci fi c expectations have been therapist adopts a collaborative rather than author- 11 Anxiety Disorders in Adolescents 167

Developmentally Sensitive Assessment

Primary Diagnosis Primary Diagnosis not Amenable to CBT Amenable to CBT

Refer or Appropriate Treatment Case Formulation

Contextual Factors Likely Co-morbidity Likely to Severe Impairment to Affect CBT Affect CBT

Address Contextual Consider Pharmaco- Treat Co-morbidity Factors Therapy

Contract for CBT

Developmental Issues Low Motivation Likely to Affect CBT

Adapt CBT to Address Motivation Using Developmental Level Engagement Strategies

Proceed with CBT

Fig. 11.1 Flow Chart of Treatment Approach

itarian stance toward the adolescent. By eliciting term usually associated with younger children. A and considering the adolescent’s ideas throughout benign but frank attitude is also helpful, as adoles- therapy, the therapist shows respect for those ideas cents generally react negatively if they perceive and for the adolescent’s emerging autonomy. If a the therapist as insincere (Sauter et al., 2009 ) . younger adolescent often looks to the therapist for Engaging adolescents in therapy may also guidance, a more directive stance may be war- require one or more initial sessions to build moti- ranted, especially if parents report that the adoles- vation and de ﬁ ne their therapeutic goals. cent is not yet asserting his or her autonomy at Motivational interviewing questions (e.g., “How home. In most cases though, adolescents appreci- would your life be different if this problem were ate the opportunity to have their opinions heard. solved?” or “What do you hope to get from ther- Therapist language should also be adjusted to apy?”) may be useful. These questions may also avoid “talking down” to teens. For example, ask- help distinguish the adolescent’s goals from those ing “How do you get along with people at school?” of his or her parents or of the therapist, allowing may be more appropriate than asking “How do the development of a mutually agreed upon you get along with kids at school?” as “kids” is a agenda for therapy. 168 K. Manassis and P. Wilansky-Traynor

Other engagement strategies are designed to stress of a graduated exposure exercise; Kingery make CBT seem relevant to adolescents’ devel- et al., 2006 ) . Some authors have also cautioned opmental needs. Adolescents may appreciate against meeting with parents without the teen (as more detailed psychoeducational information on teens may resent “feeling talked about”), yet this anxiety, emphasis on coping strategies that are problem does not occur in all families of anxious respectful of their grasp of formal operational adolescents. It may be helpful to give the teen a thought (e.g., use of the evidence to test hypoth- choice such as “Would you like to be here when eses about certain cognitions), being given I talk to your parents?” and respect his or her choices about the therapy (e.g., choosing a name wishes on the matter. for it; Kendall, Choudhury, Hudson, & Webb, The optimal role of parents in CBT with ado- 2002 ) , relating CBT principles to their individual lescents is unclear. In younger children, parents interests, and use of age-appropriate rewards often “coach” the implementation of new coping (e.g., extra time with friends, “screen” time (e.g., strategies outside the of fi ce, but most adolescents computer, videogames), and gift certifi cates; would consider this condescending. It has been Kingery et al., 2006 ) . An emphasis on peer-related suggested that parents are used more as “consultants” and other interpersonal situations can also by teens in therapy or sometimes merely as increase an adolescent’s interest in CBT “chauffeurs” (i.e., providing transportation to (Scapillato & Manassis, 2002) , as can the use of facilitate exposure and attendance of appoint- computers and other interactive media. By con- ments). A sensible approach may be to assess the trast, assigning written homework between ses- adolescent’s need for autonomy at the start of sions is sometimes perceived by adolescents as therapy and involve parents accordingly (Sauter alienating. Given that some practice of CBT et al., 2009 ) . Moreover, despite the fact that par- strategies outside sessions is essential, therapists ents often feel helpless to change their teens’ working with youth may prefer to place greater behavior, they can still model adaptive coping emphasis on experiential exercises between ses- strategies, assist with problem-solving when the sions as opposed to written homework. teen wants or needs this, encourage and support exposure to anxious situations, and set helpful behavioral limits for the teen when needed. The Role of Context and Comorbidity Educational materials for parents of anxious adolescents (e.g., Foa & Andrews, 2006 ) can further A thorough case formulation needs to include enhance their ability to support therapeutic contextual factors, comorbidities, and develop- progress. mental factors so that these can be addressed. As mentioned, the transition to high school Because transparency is a hallmark of CBT, ther- can pose new challenges for many anxious youth, apists are advised to share the formulation with and many anxieties manifest in the school set- adolescents, to the extent that they are able to ting. Unfortunately, high schools are often more understand it (Sauter et al., 2009 ) , and their diffi cult to involve in treatment than elementary parents. schools, given that students typically rotate Anxious adolescents’ family, school, and among multiple teachers and classrooms. Smaller social environment must be understood in detail, high schools are sometimes less overwhelming as these environments provide the context for for adolescents with anxiety disorders, but the therapy. Parental expectations of the adolescent willingness of school leadership to support the and of therapy may need to be adjusted, as some adolescent’s therapeutic goals may be a more parents’ expectations are unrealistically high critical factor. School avoidance can be a particu- (e.g., the idea that the anxious teen should imme- larly challenging issue in adolescence and usu- diately participate in all age-appropriate activi- ally requires an individualized treatment plan ties) or unrealistically low (e.g., an anxious parent (see Layne et al., 2003 ) . On the other hand, offer- who feels that their teen could not manage the ing school-based CBT programs may be helpful 11 Anxiety Disorders in Adolescents 169 for adolescents with mild anxiety disorders or be incorporated into the overall treatment plan subclinical anxiety symptoms (Christensen, (Chorpita). Pallister, Smale, Hickie, & Calear, 2010 ) and less stigmatizing than treatment in a clinic setting. Although adolescents’ identi fi cation with Adapting Therapy to Developmental peers can heighten their sensitivity to peer criti- Level cism, it can also be useful in therapy. Sometimes, a close peer can be engaged in accompanying the Most adolescent CBT programs are based on adolescent to certain exposures, if the adolescent child CBT programs that have been adapted feels comfortable acknowledging his or her anxiety “upward” or adult CBT programs that have been to the peer. CBT treatment groups involving peers adapted “downward.” Adolescent programs are can sometimes engage adolescents in treatment generally less complex than adult programs. that would otherwise be dif fi cult to engage in For example, they often avoid multicolumn individual therapy. The universality of groups recording of anxious and adaptive responses to (members knowing that they are not alone) is also situations found in adult programs. However, appreciated by adolescents, and members are these programs often contain wording and strate- often more receptive to suggestions from other gies that are more sophisticated than in child- members than from a therapist, facilitating thera- focused ones. Sauter et al. (2009 ) and Kingery peutic progress (Scapillato & Manassis, 2002 ) . et al. (2006 ) have described some adolescent- Optimally addressing comorbid diagnoses speci fi c adaptations of CBT in more detail than may require some planning. Sometimes, a comor- outlined here. bid condition must be treated before the teen can Affective, behavioral, and cognitive adapta- bene fi t from CBT. For example, severe substance tions are all important factors in creating CBT abuse may interfere with a teen’s ability to attend program for adolescents. Accurate recognition of appointments consistently and may be associated affect in oneself and others is a basic requirement with cognitive impairment that interferes with to do CBT. Many adolescents already have some use of CBT strategies. Signifi cant family turmoil ability to do this before starting therapy, so the can also interfere with consistent treatment and time spent on affect recognition exercises is may therefore need to be prioritized. Often how- often shorter than in child-focused programs. ever, comorbid conditions can be addressed con- Relaxation strategies to address anxious affect, currently. This can be done by combining different however, may be helpful at all ages. Adolescents treatments (e.g., combining CBT for an anxiety can often understand the rationale for these exer- disorder with stimulant medication for attention cises in more detail than younger children. For defi cit hyperactivity disorder), by using a CBT example, they can be helped to understand sym- program relevant to both conditions (e.g., pro- pathetic and parasympathetic nervous system grams that address both anxious and depressive responses rather than just agreeing to do “belly symptoms; Manassis, Wilansky-Traynor, Farzan, breathing.” They may also be amenable to more Kleiman, Parker, & Sanford, 2010 ) , or by provid- complex emotion regulation strategies than ing CBT modules that address key elements of younger children (Kingery et al., 2006 ) , such as both conditions (e.g., activity scheduling, cogni- mindfulness-based strategies. For example, an tive restructuring, relaxation, and exposure mod- adolescent with good metacognitive skills can ules for anxiety disorder with comorbid often identify “worried thinking” and deliber- depression). A modular approach to anxiety dis- ately disengage from it, instead of challenging orders in children and adolescents is further speci fi c worries. In addition to relaxation/mind- described by Chorpita ( 2007 ) . Sample CBT mod- fulness strategies, adolescents can also learn ules are provided, with emphasis on careful other aspects of self-soothing, such as regularly assessment to determine which modules are engaging in physical exercise, talking to friends, appropriate in a given case and how they should listening to calming music, and avoiding self- 170 K. Manassis and P. Wilansky-Traynor medication with illicit substances. These strategies pist, he or she is likely to be able to engage in may be particularly helpful for those with con- CBT successfully. In general, less cognitively current depressive symptoms. sophisticated adolescents will require more Exposure exercises in adolescents require behavioral and fewer cognitive strategies and personal motivation, as parents are generally not concrete reminders in order to use cognitive strat- able to “force” adolescents to engage in them. egies consistently. More cognitively sophisticated Explaining the rationale for exposure in adult adolescents can bene fi t from both cognitive and language (e.g., using terms such as “hierarchy” behavioral strategies. or “habituation”; Kingery et al., 2006 ) and col- As with all aspects of CBT, a collaborative, laboratively developing the specifi c exercises to respectful approach is needed to engage adoles- be tried show respect for the adolescent’s emerg- cents in cognitive work. In recognition of the ado- ing autonomy and can sometimes enhance moti- lescent’s cognitive maturation, the therapist must vation. Then, the therapist can ask the adolescent avoid simplistic language, use age-appropriate “How could your parents help with this?” and materials, and encourage the adolescent’s own discuss possible parental involvement rather ideas. Use of culturally sensitive materials can than unilaterally assigning a role to parents. show respect for the adolescent’s heritage and his Peers can sometimes be involved as helpers too or her emerging identity. Examination of the evi- if the adolescent is comfortable confi ding in dence for or against a particular thought or them. Despite adolescents’ greater maturity, assumption may be helpful, as adolescents are their anxieties may require that they start with often skeptical and welcome such an empirical tasks ordinarily required by younger children. approach. Complex thought challenges (e.g., For example, a socially anxious adolescent may examining the pros and cons of several perspec- need to start with ordering food at a restaurant tives) may also be possible (Kingery et al., 2006 ) . rather than asking someone out on a date. The Use of computer-based learning and other tech- adolescent’s baseline functioning is used as a nology is a common part of adolescents’ school guide to the fi rst few exposure tasks such that and social experience and may therefore be wel- the fi rst task should be the consistent practice of come when used in CBT. a situation that the adolescent is already managing occasionally. Cognitive techniques that are most suitable for The Role of Medication a given adolescent depend on an accurate assessment of cognitive capacity. Sauter et al. ( 2009 ) Selective serotonin reuptake inhibitor medica- recommend using a standardized scale such as tions (SSRIs) are often used in combination with the Self-refl ection and Insight Scale for Youth CBT in adolescents with anxiety disorders. (Sauter et al.) and matching the cognitive tech- Although studies suggest therapeutic bene fi ts in niques used to the result. They caution, however, using SSRIs and in combining CBT and SSRIs in that techniques are context-dependent, so sophis- young people with anxiety disorders, they encom- ticated techniques should not be used when the passed a broad age range that included children adolescent is in a highly emotional or challeng- in addition to adolescents (Compton et al., 2010 ; ing situation. Other authors have used cartoon RUPP, 2001 ) . Accordingly, adolescent-speci fi c bubbles or questions such as “What went through studies are needed. Given the generally higher your mind?” to gage the adolescent’s capacity for levels of impairment in adolescents with anxiety refl ection and access to his or her thoughts disorders, adolescents are more likely to receive (Kendall et al., 2002 ) . Another option is to test SSRIs than younger children. the adolescent’s capacity for CBT by demonstrat- As with CBT, a collaborative, respectful ing a sample CBT exercise and asking him or her approach is needed with respect to medication if it makes sense. If the adolescent can understand in adolescents. Adolescents will usually take the sample exercise when modeled by the thera- medication only if they feel they have been 11 Anxiety Disorders in Adolescents 171 consulted in medication-related decisions. They Carlos’ current symptoms began shortly after often want more detailed information on poten- the start of high school, an important transition tial benefi ts and potential side effects than point for many adolescents. He attended a large younger children and often look up information public school (over 2,000 students), which he (or misinformation) about various medications found quite overwhelming. His parents had made on the Internet. Prescribing physicians may sure that appropriate academic supports were need to help them evaluate the quality of vari- available to Carlos at the new school, but he was ous types of evidence so that therapeutic deci- not making use of these. He said he felt embar- sions are based on accurate information. If CBT rassed about leaving class or staying behind after and medication are provided by the same pro- school to go for extra help. He reported that, in fessional, there may be some value in stabiliz- his peer group, it was more socially acceptable to ing the medication before starting CBT so that be “not very smart” than to go for extra help. the adolescent can see the benefi t of his or her Consequently, his grades were poor, and his efforts in CBT, not just the bene fi t of medication. teachers considered him unmotivated. If two professionals are involved (one prescrib- At home, Carlos’ parents had different opin- ing medication, the other providing CBT), close ions about their son. His mother understood his collaboration between them is essential so that embarrassment about going for extra help but the two therapeutic modalities can complement still encouraged him to go. She worried, how- each other. Such collaboration also ensures that ever, that his panic attacks might become life- the adolescent does not receive mixed messages threatening or that he might become depressed or pit one professional against the other (as or suicidal if forced to go to school despite his some are inclined to do). anxiety. Carlos’ father, by contrast, considered his son undisciplined and didn’t think his anxiety should be an excuse for school failure. “He Case Study just needs to take the initiative more” was his father’s view. Both parents agreed, however, that To illustrate some of the above concepts related apart from his school diffi culties, Carlos was to anxiety disorders in adolescents, we now con- well-behaved, becoming more responsible (e.g., sider the case of Carlos. Carlos was a 14-year-old looking after his younger brother on occasion), boy who presented to our clinic because he and not associating with peers who were antiso- missed several weeks of school after suffering a cial or abusing substances. He struggled to leave panic attack in class. the house independently though, fearing he Carlos had been seen previously in our clinic would have a panic attack on the street. His mood at age 10. At that time, he was diagnosed with had also appeared more downcast in the previous generalized anxiety disorder and a specifi c learn- couple of weeks. ing disability. He had already been started on a Carlos himself thought that his anxiety serotonin-speci fi c medication ( fl uoxetine) by his occurred because his medication was no longer pediatrician, which had resulted in some decrease working. He had been prescribed 10 mg per day in anxiety symptoms. We recommended partici- of fl uoxetine at age 10 years by his pediatrician pation in an individual CBT program based on and had remained on this dose ever since. Carlos “Coping Cat” (Kendall, 2006 ) , with minor vaguely remembered his CBT program and con- modi fi cation in view of his learning disability. tinued to do some deep breathing when anxious, Academic modi fi cations and supports were rec- but did not practice any other CBT skills. He ommended to the school. Carlos responded well recalled “I used to just tell myself it would be to the CBT program and showed a further OK, but that doesn’t work anymore.” He had also decrease in anxiety symptoms. He also became developed a habit of looking up possible causes more con fi dent and more engaged in his school for his physical symptoms of anxiety on the program. Internet, which usually made him more anxious. 172 K. Manassis and P. Wilansky-Traynor

He often worried about these symptoms, about Carlos’ parents about his dilemma. His father his friends’ opinions of him, and other subjects. needed to understand that his son could not simply After a thorough diagnostic assessment, we “take the initiative” but needed treatment for his concluded that Carlos suffered from Panic anxiety and encouragement to return to a place Disorder with agoraphobia and Generalized (i.e., school) where he had once experienced Anxiety Disorder. He continued to have a extreme fear. His mother needed to understand signi fi cant learning disability. He had some that Carlos’ anxiety attacks were not life-threat- depressive symptoms related to his recent school ening and that his risk of depression was actually problems, but these were not severe enough to lower if he faced his fears by going to school than warrant a diagnosis of Major Depression. His if he remained at home. Once both parents were self-esteem was clearly deteriorating though, able to empathize with Carlos’ dif fi culty but suggesting that he was at risk for depression if his con fi dently encourage him to leave the house, he struggles with anxiety continued. was willing to walk on the street again with a Carlos’ medication, although helpful to him at friend. By enlisting the help of a friend, we were age 10 years, was now clearly inadequate in view able to use Carlos’ adolescent focus on his peer of his physical development since then. He was at group to help rather than hinder his progress. least six inches taller and 50 pounds heavier than Parental accompaniment (often used in younger he had been at age 10 years so defi nitely needed children) would have been embarrassing to a higher dose. Carlos’ CBT skills were also no Carlos, but he really valued his parents’ encour- longer adequate, as his cognitive development agement and faith in him. since age 10 years made vague, general reassur- Returning to school was something Carlos ances like “It will be OK” seem silly now. He clearly considered more diffi cult than walking needed to learn more sophisticated coping strate- down the street. Therefore, respecting his need to gies. He also needed to learn how to evaluate the participate in therapeutic decisions, we agreed to quality of the evidence he found on the Internet, have him desensitize to walking down the street so that this did not become a further source of fi rst. Within a couple of weeks, he had mastered anxiety. His parents indicated that they had this task. His panic attacks were also subsiding in already tried to discourage Carlos from looking response to his increased medication dose and up symptoms online, but their efforts had been the psychological interventions with Carlos and futile. his family. Carlos still hesitated to return to To address these issues, we agreed with Carlos school, however, fearing his peers’ reaction to his that neither his medication nor his CBT strategies school absence and to his need for extra help. We were working any more, and we offered to do role-played with Carlos some simple responses something about that. Thus, by validating his to questions his peers might ask about his absence, own description of the problem, we were able to and he found this reassuring. Unfortunately, we engage Carlos in further treatment. We increased were not successful in applying this approach to Carlos’ medication dose and scheduled a few ses- his fear of peer reactions when seeking extra sions to “update” his coping strategies. After help. Unable to overcome this obstacle with these sessions, Carlos liked and trusted his thera- Carlos, we approached his parents about seeking pist and was then amenable to addressing his private tutoring for their son outside of school. Internet habit, including learning how to evaluate After this was arranged, Carlos was willing to try evidence he found online. going back to school for part of the day. In con- Most urgently, Carlos needed to fi nd a way to sultation with his school, we were then able to return to school and obtain the academic support gradually reintegrate Carlos into his school pro- he needed without fearing he would be socially gram. He attended consistently for the rest of the ostracized. Realizing that this was unlikely to year. Avoiding Carlos’ anxiety about embarrass- occur without parental support, we talked with ment in this way might be considered suboptimal 11 Anxiety Disorders in Adolescents 173 from a CBT perspective, but we felt it was a (e.g., school) potentially improving adolescent reasonable compromise as it ensured timely engagement and offer broad-based anxiety pre- return to school so Carlos could successfully vention/early intervention while consistently complete his year. Once both his anxiety and his identifying those requiring more intensive treat- school problems decreased, Carlos became more ment. Client, therapist, and environmental differ- optimistic and did not need any further interven- ences and different means of payment from tion for depressive symptoms. specialized clinics were all cited as potential challenges. Computer-assisted CBT was suggested as an alternative means of increasing treat- Future Directions ment availability to adolescents (Khanna & Kendall, 2008 ; Sherrill, 2008 ) . Future studies speci fi c to the treatment of adoles- Re fl ecting the clientele in many community cents with anxiety disorders (rather than includ- sites, studies that included youth with psychiatric ing adolescents in studies of children of various comorbidity (Sherrill, 2008 ) and youth from ages) have been advocated by numerous authors minority groups (Ginsburg et al., 2008 ; Silverman (Field, Cartwright-Hatton, Reynolds, & Creswell, et al., 2008 ) were advocated. Developing func- 2008 ; Kendall & Choudoury, 2003 ; Silverman tionally equivalent strategies for various cultural et al., 2008 ; Masia-Warner et al., 2008 ) . Research groups was also suggested (Silverman et al.). recommendations that were made in several Integrating psychopharmacology into CBT treat- papers are reviewed below. ment studies was urged, as it would be informa- Consistent with the ideas in this chapter, the tive and allow inclusion of a broader range of need to tailor CBT to address developmental con- severity and comorbidity as well (Albano & siderations and to address specifi c disorders Kendall, 2002; Kendall & Choudoury, 2003 ; (rather than treating anxiety disorders as a group) Labellarte et al., 1999 ; Silverman et al., 2008 ) . was identi fi ed (Field et al., 2008 ; Kendall & Parental involvement was advocated, but Choudoury, 2003; Silverman et al., 2008 ; defi ning the optimal nature of that involvement Masia-Warner et al., 2008 ) . Furthermore, the was cited as a challenge (Field et al., 2008 ; infl uence of developmental factors on outcomes Kendall & Choudoury, 2003 ; Silverman et al., of adolescent-speci fi c CBT may merit evaluation 2008) . Examining processes whereby parents (Sauter et al., 2009 ) . Timing intervention in rela- infl uence therapeutic progress was suggested tion to key points in development such as the (Field et al., 2008 ) . The possibility that parental beginning of high school (Kendall & Choudoury, involvement may need to differ by age group or 2003 ) and the use of age-appropriate materials by speci fi c problem was raised (Kendall & and topics were suggested (Silverman et al., Choudoury, 2003 ; Silverman et al., 2008 ) . 2008 ) . Group and individual treatment have gen- Methodologically, several authors recom- erally been found equivalent (Silverman et al.); mended active rather than waitlist control groups however, it is not clear whether subgroups of and longer term follow-up (Adler-Nevo & adolescents would benefi t more from one or the Manassis, 2009; Albano & Kendall, 2002 ; other (Albano & Kendall, 2002 ) . Kendall & Choudoury, 2003 ; Silverman et al., Many authors advocated studies in commu- 2008 ; Masia-Warner et al., 2008 ) . Two groups nity settings with treatments provided by a vari- (Kendall & Choudoury, 2003 ; Silverman et al., ety of less specialized clinicians (e.g., pediatric 2008 ) made more detailed methodological sug- offi ce staff, primary care providers, school per- gestions pertaining to various aspects of measur- sonnel; Albano & Kendall, 2002 ; Ginsburg, ing outcome, factors moderating or mediating Becker, Kingery, & Nichols, 2008 ; Kendall & outcome, improved handling of non-completers Choudoury, 2003 ; Sherrill, 2008 ; Silverman and missing data, and broadening outcomes to et al., 2008 ; Masia-Warner et al., 2008 ) . Ideally, include the sequelae of adolescent anxiety (e.g., treatment would be offered in naturalistic settings substance abuse). 174 K. Manassis and P. Wilansky-Traynor

Bennett, K., Manassis, K., Walter, S., Cheung, A., Conclusion Wilansky-Traynor, P., Diaz-Granados, N., et al. (2010). Does age moderate cognitive behavioural therapy (CBT) treatment effect for child and adolescent anxi- In summary, treatment of adolescents with anxiety? Results from an individual patient data (IPD) ety disorders must be sensitive to the develop- meta-analysis . Manuscript in submission. mental and social infl uences in this age group. Berman, S. L., Weems, C. F., Silverman, W. K., & Kurtines, W. M. (2000). Predictors of outcome in Factors to consider include level of physical, cog- exposure-based cognitive and behavioral treatments nitive, and emotional maturity; the adolescent’s for phobic and anxiety disorders in children. Behavior need for autonomy; determining the appropriate Therapy, 31 , 713–731. role of parents and peers in treatment; presence of Bodden, D. H. M., Bogels, S. M., Nauta, M. H., de Haan, E., Ringrose, J., Appelboom, C., et al. (2008). Effi cacy comorbid diagnoses; anxiety-related impairment; of individual versus family cognitive behavioral ther- societal expectations; and challenges associated apy in clinically anxious youth. Journal of the with developmental transitions. Given these com- American Academy of Child and Adolescent plexities, a careful case formulation is essential in Psychiatry, 47 , 1384–1394. Canadian Psychiatric Association (CPA). (2006). Clinical order to best tailor CBT to the adolescent’s needs. practice guidelines: Management of anxiety disorders. Particular attention must be paid to strategies that Canadian Journal of Psychiatry, 51 (Suppl 2), 65S–72S. enhance adolescent engagement in therapy and Carey, T. A., & Oxman, L. N. (2007). Adolescents and that are appropriate to the adolescent’s level of mental health treatments: Reviewing the evidence to discern common themes for clinicians and areas for cognitive and emotional development. future research. 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Emily A. Voelkel , Kelly M. Lee , Catherine W. Abrahamson , and Allison G. Dempsey

Social anxiety disorder is a condition characterized anxiety may not meet diagnostic criteria for by abnormal fears of social situations and is one social anxiety disorder/social phobia, though of the most prevalent psychological problems fear of social situations and interference with among adolescents (American Psychiatric daily functioning are still present. For the sake of Association [APA], 2000 ) . The disorder typically conciseness, this chapter will refer to these phe- emerges in adolescence, with average age of onset nomena as “social anxiety disorder” from this between 12 and 16 years of age (Rapee & Spence, point forward (unless speci fi ed). Social anxiety 2004 ; Schneier, Johnson, Hornig, & Liebowitz, disorder is categorized into two subgroups, gen- 1992; Silverman et al., 1999 ; Strauss & Last, eralized and non-generalized. Social anxiety dis- 1993 ) . Without treatment, social anxiety typically order is speci fi ed as generalized when an runs a chronic course (APA, 2000 ; Turner & individual’s fears occur during most social situa- Beidel, 1989 ; Wittchen, Stein, & Kessler, 1999 ) . tions (APA, 2000 ), whereas non-generalized The terms social anxiety disorder, social (also known as performance-based, circum- phobia, and social anxiety are often used inter- scribed, or speci fi c social anxiety) denotes a fear of changeably in research literature, even though a single performance situation and/or some, but they may have different connotations. Social anx- not most, social situations (APA, 2000 ). Music iety disorder and social phobia refer to clinically performance anxiety and reading aloud in front of signifi cant features that meet specifi c diagnostic a class are examples of these non-generalized, criteria set forth by the Diagnostic and Statistical speci fi c situations. The debate over the useful- Manual of Mental Disorders — Fourth Edition ness of these subgroups has raised questions as to (DSM-IV) (APA, 2000 ) and are de fi ned as a whether social anxiety disorder can be under- “marked and persistent fear of one or more social stood as a continuum with different levels of or performance situations” (APA, 2000 , pp. 450). severity and presentation or as a categorical per- The term social anxiety typically serves as a more spective of either meeting criteria or not (Bögels general term for which the presentation of social et al., 2010 ; Marmorstein, 2006 ) . Another controversial topic within the conceptualization of E. A. Voelkel ¥ K. M. Lee ¥ C. W. Abrahamson social anxiety is the potential classi fi cation of Department of Educational Psychology , non-generalized (performance-based) social University of Houston , Farish Room 491, anxiety as a speci fi c phobia rather than simply a 4800 Calhoun Road , Houston , TX 77004 , USA subtype (Bögels et al., 2010 ) . A. G. Dempsey (*) Within the child and adolescent population, Department of Pediatrics , University of Texas Health studies have suggested that 1% meet diagnostic Science Center at Houston , 6431 Fannin Street, MSB 2.106 , Houston , TX 77030 , USA criteria for social anxiety disorder at any time for e-mail: [email protected] males and females (Beidel, Turner, & Morris,

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 177 DOI 10.1007/978-1-4614-6458-7_12, © Springer Science+Business Media New York 2013 178 E.A. Voelkel et al.

1999; Kashani & Orvaschel, 1990 ) . However, this 2007 ; Kingery, Erdley, Marshall, Whitaker, & percentage may underestimate the true prevalence Reuter, 2010 ; Mychailyszyn, Mendez, & Kendall, of the disorder in youth because many studies are 2010; Seipp, 1991) . Symptoms of anxiety in based on an outdated diagnostic criteria system childhood have been found to signifi cantly of social anxiety disorder that speci fi cally predict poorer standardized achievement scores excludes public speaking from the diagnostic (Ialongo, Edelsohn, Werthamer-Larsson, Crockett, category. Speaking or reading in front of a group & Keliam, 1995) , and teachers subjectively rate is one of the most common social fears in adoles- children with social anxiety children lower in cents, with percentages of adolescents with academic performance than their peers (Strauss, social anxiety disorder endorsing this speci fi c Frame, & Forehand, 1987 ) . fear as high as 90% (Beidel et al., 1999 ) . Additionally, academic problems associated Subclinical rates (i.e., symptoms that fall short with social anxiety often persist into adulthood, of meeting diagnostic criteria) of social anxiety with approximately 90% of college students with disorder are signifi cantly elevated. For example, social anxiety reporting academic diffi culties one study found 22% of 8-year-olds, 46% of such as poor grades, infrequent class participa- 12-year-olds, and 56% of 17-year-olds reported tion, avoidance of classes with public speaking fears associated with social situations (Kashani requirements, and decisions to not attend gradu- & Orvaschel, 1990 ) . Adolescence is a time of ate school (Turner, Beidel, Borden, Stanley, & social comparison and beliefs that others are Jacob, 1991 ) . Beyond academics, individuals evaluating oneself (Piaget, 1958 ) . During ado- with social anxiety also tend to have problems in lescence, self-awareness and self-consciousness other realms (e.g., occupational, addiction) that continue to develop, and shyness and withdrawal persist into adulthood. The small body of litera- often begin to be perceived as more problematic ture exploring the relationship between social by peers (Hymel, Rubin, Rowden, & LeMare, anxiety and occupational functioning suggests 1990 ) . As youth with social anxiety disorder that individuals with social anxiety exhibit occu- continue to develop cognitively, they begin to pational dif fi culties, including problems obtain- increase their abilities to see others’ perspectives ing employment, accepting job offers, and and compare themselves with others, potentially receiving promotions (Stein, Torgrud, & Walker, increasing any preexisting social evaluative fears 2000) . Furthermore, adults with social anxiety (Morris, Hirshfeld-Becker, Henin, & Storch, are signi fi cantly less likely to initiate conversa- 2004 ) . Avoidance of social interactions and anx- tions and engage in interactions with coworkers ious behaviors during social and school situa- and report greater hardships in work relationships tions may adversely affect overall social (Yeganeh, 2006 ) . functioning and development, and negative expe- The complex relationship between socializa- riences may increase anxiety regarding future tion and social anxiety symptoms has implica- social interactions (Inderbitzen, Walters, & tions for understanding the manifestation of Bukowski, 1997 ; Rubin & Burgess, 2001 ) . Thus, social anxiety disorder, as well as the develop- dif fi culties with socialization may serve as both ment of appropriate and effective interventions a cause and a consequence of social anxiety for youth presenting with its symptoms. This disorder. chapter will provide a brief overview of social Beyond socialization dif fi culties, youth with anxiety disorder among adolescents. Next, we social anxiety are likely to experience dif fi culties will discuss the relationships among social anxi- in academic and future occupational functioning, ety disorder, social development, and social expe- making this disorder a frequent impairment riences during adolescence. Finally, we will into and throughout adulthood. For example, conclude with a discussion of the implications children and adolescents with social anxiety often for treatment of this disorder among adolescents have poor academic performance that is coupled and the presentation of a case study to illustrate with diffi culty attending school (Beidel & Turner, these concepts. 12 Social Anxiety and Socialization Among Adolescents 179

researchers continue to more accurately de fi ne Physical, Cognitive, and Behavioral social anxiety among adolescents. Regardless, Symptoms symptom presentation among youth with social anxiety disorder has important implications for Symptoms of clinical and subclinical adolescent case conceptualization and treatment, as the vari- social anxiety disorder are usually classifi ed into ous types of symptoms may affect the social func- three categories: physical/somatic, cognitive, and tioning of adolescents in different ways. behavioral. However, the boundary between Social anxiety disorder can include a wide clinical and subclinical presentations of social variety of somatic symptoms, including nausea, anxiety has been controversial in recent literature. sweating, heart palpitations, choking, fainting, The DSM-III-R and DSM-IV do not provide clear headaches, stomachaches, and panic attacks guidelines for distinguishing between clinical and (Beidel et al., 1999 ; Beidel, Christ, & Long, subclinical presentations of social anxiety (Stein, 1991 ) . Adolescents who experience somatic 1995) , often making diagnostic decisions diffi cult. symptoms of anxiety may interpret threat in Social anxiety is prevalent in the general popula- social situations (thus, linking with cognitive tion (Stein & Walker, 1994 ) , and those with sub- symptoms) or may perceive that they are sick and clinical levels of social anxiety close to the therefore leave/avoid the social situation (thus, diagnostic cutoff often present with equal levels linking with behavioral symptoms). of disability (Stein, 1995 ) . Thus, due to the lack of Cognitive symptoms of social anxiety disorder speci fi c diagnostic thresholds, clinicians are often include expecting to perform poorly, negative forced to make a full diagnosis of social anxiety appraisal of personal performance, negative disorder based on other subjective factors. Some self-talk, social pessimism, perceived low social researchers have attempted to clarify the clinical acceptance and self-worth, increased levels of versus subclinical distinction by viewing anxiety loneliness, low expectations for social perfor- in children and adolescents on a continually mance, and overall, more negative thoughts and changing trajectory over time (Weems, 2008 ; less positive thoughts (Alfano, Beidel, & Turner, Weems & Stickle, 2005 ) . One way to view this 2006; Erath, Flanagan, & Bierman, 2007 ) . trajectory is to rede fi ne how we diagnose social Table 12.1 contains a review of various empirical anxiety disorder according to the DSM-IV studies investigating the cognitive domains asso- (Weems & Stickle, 2005 ). By casting what these ciated with social anxiety disorder. colleagues refer to as a wider “nomological net,” Finally, behavioral symptoms can be classi fi ed children experiencing social anxiety could have into three subcategories: social, school, and clinical diagnoses based both on symptoms and other behaviors. Social behavioral symptoms of mechanisms of anxiety. This would allow for social anxiety disorder include avoiding age- more precise classifi cation of types of social appropriate social behaviors, such as dating and anxiety among adolescents without a strict two- partying; fear or avoidance of situations where dimensional view of a child having either clinical scrutiny from others may occur; social with- or subclinical social anxiety. This view suggests drawal; social isolation; fewer friendships; and that most youth have varying levels of anxiety social impairment (Bögels et al., 2010 ; Ginsburg throughout their development, which is likely to et al., 1998 ; La Greca & Lopez, 1998; Sutker & fl uctuate in severity and impairment based on Adams, 2001 ; Vernberg, Abwender, Ewell, & continually changing biological, social, environ- Beery, 1992 ) . School behaviors of social anxiety mental, and other factors (Weems, 2008 ) . In other disorder include withdrawal, school refusal, and words, while some core characteristics of social decreased participation in physical, team-based, anxiety may remain stable and continuous for and competitive activities (Beidel & Turner, anxious adolescents, other symptoms are likely to 2007 ; Bögels et al., 2010 ; Van Roy, Kristensen, fl uctuate in clinical severity across time. The clin- Groholt, & Clench-Aas, 2009 ) . Other behavioral ical versus subclinical debate is likely to persist as signs of social anxiety disorder include crying, 180 E.A. Voelkel et al. Socially anxious children and adolescents were more likely to Socially anxious children and adolescents were more likely their performance as more to perform poorly and evaluate expect inferior compared to the control groups. Socially phobic adoles- self-talk in social interactions. cents engaged in negative Highly socially anxious children reported low perceived social perceived Highly socially anxious children reported low also reported more negative They acceptance and global self-worth. socially anxious children. interactions with peers compared to lower Socially phobic children reported extreme loneliness. Compared to Socially phobic children reported extreme the control group, socially phobic children rated higher on on extroversion. neuroticism and lower as less socially themselves The anxiety disorder group perceived competent compared to the control group and had negative about being accepted by peers. expectancies and less prosocial behavior Socially anxious adolescents exhibited compared to the control group. The socially more social withdrawal in expectations anxious adolescents were associated with negative social performance. general peer low Highly socially anxious adolescents perceived to others. acceptance and felt less romantically attractive cognitions in of negative Socially phobic children had higher levels outcomes in social tasks, and social tasks, anticipated negative as compared to performance more negatively their own evaluated the control group. self-evaluative Socially phobic participants reported more negative in social thoughts on behaviors thoughts and had more negative situations as compared to the control groups. Rejected children exhibit higher levels of social distress and higher levels Rejected children exhibit other status group. Rejected children were more loneliness than any culties fi peers as the cause for their social dif to view likely compared to other status groups. To examine different cognitive cognitive different examine To phenomena in children and adolescents socially phobic tendencies who exhibit anxiety and children’s emotional and anxiety and children’s social functioning socially anxious children social experiences anxiety and negative social anxiety with negative Evaluate coping social performance, maladaptive cits fi skills, and social skill de Measure social anxiety in relation with competence, social support, perceived and best friendships of performance, self-talk, self-evaluation and outcome expectancies to performance, self-talk, self-evaluation and actual performance Assessment of sociometric status in relation to loneliness, social anxiety, for and attribution social avoidance, social outcomes = 9.5) and fi fth grade = 11.4)

age age

M M adolescents ages 12Ð16 ( and seventh grades and seventh 10 through 12 ( ) Participants Objectives Key fi ndings N 72 Children ages 7Ð14 78 depict the clinical syndrome of To Children ages 9Ð15 the link between social examine To 54 Children ages 7Ð14 Measure social anxiety in relation to 154 Children ages 6Ð11 Examine the relationship between social 250 Adolescents in grades Sample size ( ) 36 Adults Measure social anxiety in relation to ) 338 Children in third grade ) 80 Children ages 7Ð11 and 1993 ) 84 Adolescents in sixth 1993 ) 2006 ) 2007 1998 Recent empirical literature concerning cognitive symptoms for social anxiety in children and adolescents symptoms for social anxiety in children and adolescents Recent empirical literature concerning cognitive 1999 ) ) ) 1997 1998 1999 Beidel, Turner, and Morris ( La Greca and Lopez ( Chansky and Kendall and Kendall Chansky ( ( Crick and Ladd La Greca, and Ginsburg, Silverman ( and Spence, Donovan, Brechman-Toussaint ( ( Stopa and Clark Erath et al. ( ( Erath et al. Table 12.1 Study Alfano et al. ( ( et al. Alfano 12 Social Anxiety and Socialization Among Adolescents 181 selective mutism, stuttering, limited eye contact, 2001 ) . Behavioral symptoms of social anxiety nail biting, and mumbling (Albano, DiBartolo, disorder involve avoiding social situations, lead- Heimberg, & Barlow, 1995 ; Ollendick & ing to a lack of peer interaction that limits oppor- Ingman, 2001 ) . tunities for adolescents to develop and practice Although symptom presentation will likely important social skills. Unfortunately, because vary by adolescent, each of the physical, cognitive, socially anxious youth often have limited oppor- and behavioral symptoms may affect the social tunities to develop and practice social skills with functioning of the individual (Langley, Bergman, peers, their skills are likely to continue to lag McCracken, & Piacentini, 2004) . The impact behind their peers across development, limiting of social anxiety disorder on the social functioning the experience of the benefi ts friendships can and peer interactions in adolescence will be pre- provide (Kingery et al., 2010 ; Siegel, La Greca, sented in detail in the following section. & Harrison, 2009 ) . These de fi cits in social skills may place the adolescents at risk for being targets of bullying and other forms of peer victimization. Social Anxiety and Socialization Additionally, as overt signs of anxiety become more severe, adolescents experience increased Peers play a critical role in infl uencing the risk for peer victimization (Ollendick & Hirshfeld- development of self-concept, health behaviors Becker, 2002 ; Siegel et al., 2009 ; Storch, and norms, feelings of belongingness in school, Brassard, & Masia-Warner, 2003 ) . Finally, nega- psychosocial adjustment, and social and risk- tive social interactions may lead to increased taking behaviors during adolescence through social anxiety, lower expectations of social situa- interactions, friendships, and romantic relation- tion performance, and lower self-esteem (Rubin ships (for a review of relevant studies, please see & Burgess, 2001 ) . Figure 12.1 presents a pro- Table 12.2 ). In fact, imaging studies show that posed model depicting the cyclical nature of the areas of the brain associated with social cogni- relationships among social anxiety, social devel- tions and processing continue to develop during opment, and social experiences. Each component adolescence and thus may be shaped, in part, by of the model is described in detail in the follow- social experiences (Sebastian, Viding, Williams, ing section. & Blakemore, 2010) . Thus, engagement in positive peer friendships, social activities, and romantic relationships is critical for psychoso- Decreased Interactions with Peers cial adjustment and healthy transition into adulthood (Simon, Aikins, & Prinstein, 2008 ; One early correlate with social anxiety that tends Waldrip, Malcolm, & Jensen-Campbell, 2008 ) . to be stable across time (often extending into Youth with social anxiety disorder may not expe- adolescence) is behavioral inhibition (a pattern of rience the same quality or quantity of positive withdrawal, avoidance, fear of the unfamiliar, interactions with peers. That is, the somatic, and sympathetic nervous system hyperarousal; cognitive, and behavioral symptoms may affect Morris et al., 2004 ) . Children with behavioral the frequency by which the adolescent interacts inhibition tend to approach early school years with peers, as well as place the individual at (e.g., preschool, kindergarten) with reserve, reti- risk for future negative interactions with peers. cence, and quiet watching behavior, particularly An understanding of the complex interplay of when they are with unfamiliar peers (Hirshfeld- social experiences, socialization, and social anxiety Becker, 2010; Hirshfeld-Becker et al., 2008 ; is critical to developing treatment strategies for Kagan, Reznick, & Gibbons, 1989 ) . Although adolescents with social anxiety disorder. these children are likely unable to articulate fears The relationship between social anxiety and of social evaluation, they at the least tend to dem- withdrawal can be conceptualized as cyclical in onstrate debilitating fears of adults and other nature (Inderbitzen et al., 1997; Rubin & Burgess, children that prohibit them from talking to new 182 E.A. Voelkel et al. Perceived parent values predicted academic and social behaviors at predicted academic and social behaviors parent values Perceived for all Peer group norms predicted social behavior each grade level. predicted by peers only for older was academic behavior grades, but students. of the self and Expressions of autonomy were associated with behavior ict fl con and restrictive facilitative For of the romantic partner. behavior uniquely associated with her behavior; responses, female autonomy was from himself and his girlfriend. ected contributions fl male autonomy re friends, and lower Adolescents who had less peer acceptance, fewer maladjustment. friendship quality had greater teacher-reported against adjustment problems when peer Friendship quality buffered acceptance and number of friends were low. Friendless youth demonstrated a more elevated trajectory of depressed Friendless youth demonstrated a more elevated mood than youth who had reciprocated relationships with nonde- trajectory of pressed friends. Friendless youth demonstrated a lower depressed mood than youth who had friends. Girls’ level of identi fi cation with certain peer crowds was associated was cation with certain peer crowds fi of identi Girls’ level peer concern with with girls’ self-reported concern and perceived concern and peer norms were independently weight. Girls’ own related to girls’ weight control behaviors. symptoms of depression, relational Romantic partners’ popularity, cantly predicted fi aggression, and relational victimization signi time. Of these, only changes in functioning these areas over symptoms were important to partner popularity and depressive selection. to be friendless than White Hispanic students were more likely to form friends in counterparts, and Hispanics were also less likely a best school. Both Hispanic and White youth who reported having engagement problems and a higher sense of friend also reported lower only students whose best friend attended school belonging. However, of school belonging, their same school reported higher levels suggesting that school belonging is only promoted by friendships within the school. Examine associations among school-based perceptions of peer group norms for behaviors, and inferences of parent values these behaviors, during adolescent onset about these behaviors uence) fl (when parents and peers compete for in ict negotiation fl Explore associations between con of autonomy in adolescent and the expression romantic partners of peer acceptance, Examine unique contributions friendship, and victimization to adjustment Examine how friendship experiences (i.e., having (i.e., having friendship experiences Examine how nondepressed friends, and no friends, having depressed friends) relate to having mood trajectories in early adolescents Examine a model linking girls’ peer crowd Examine a model linking girls’ peer crowd liations (e.g., Jocks, Populars) with weight fi af peer weight norms, and concerns, perceived weight control behaviors Compare characteristics of participants’ friends to those of potential romantic partners. Examine how of similarity within friend and romantic degree the importance of general and dyads explains c peer selection criteria fi relationship-speci Explore relationships between friendship best friend at same formation (e.g., having school), school engagement, and belonging among White and Hispanic students sixth, and eighth grades couples ages 15Ð18 fth to fi in the eighth grades 11Ð13 13Ð18 sixth to eighth grades in grades 7 through 12 ) Participants Objectives Key fi ndings N 364 Children in fourth, 174 Adolescent 201 Children ages 236 Females ages Sample size ( ) 238 Adolescents ) ) 78 Children in )

) ) 2008 ) 90,000 Adolescents 2009 2008 2010 Recent empirical literature exploring how peers in ﬂ uence various aspects of childhood and adolescent development aspects of childhood and adolescent development uence various ﬂ peers in how Recent empirical literature exploring 2008 2008 2009 Brendgen, Lamarche, Wanner, ( and Vitaro Table 12.2 Study McIsaac, Connolly, Pepler, McKenney, ( and Craig ( Simon et al. Mackey Mackey and ( La Greca Masten, Juvonen, ( and Spatzier Vaquera ( ( et al. Waldrip 12 Social Anxiety and Socialization Among Adolescents 183

mance (e.g., avoiding speaking in class), refusing to attend school, and avoidance of participation in physical, team-based, and competitive activities (Beidel, Turner, & Young, 2006 ; Bögels et al., 2010 ; Van Roy et al., 2009 ) . Additional social behavior symptoms include avoiding age- appropriate social behaviors such as dating and partying, fear or avoidance of situations where scrutiny from others can occur, social withdraw, social isolation, fewer friendships, and social impairment (Beidel et al., 2006 ; Bögels et al., 2010 ; Ginsburg et al., 1998 ; Ginsburg & Grover, 2005; La Greca & Lopez, 1998; Sutker & Adams, 2001; Vernberg et al., 1992 ) . Decreased involve- Fig. 12.1 Proposed cyclical model depicting relation- ment in peer activities and avoidance of social ships among social anxiety disorder, socialization, and interactions can inhibit friendship formation. social experiences Indeed, adolescent females with social anxiety disorder report having fewer best friends and adults or peers, developing peer relationships, having friendships that are lower in intimacy, and going to places where new friends might be companionship, and emotional support (La Greca made (Morris et al., 2004 ) . As early years are & Lopez, 1998 ; Vernberg et al., 1992 ) . important in socialization, the presence of behavioral inhibition (an early risk factor for social anxiety; Biederman et al., 2001 ; Hirshfeld-Becker Social Functioning Defi cits et al., 2008 ; Morris et al., 2004) could be at least one preexisting trait that leads to socialization Adolescents who are isolated from engaging in problems and social skills de fi cits in early child- social activities show several dif fi culties with hood years. Socialization problems, which may social development due to the lack of contact with persist into adolescence, may include decreased peers, as they have fewer opportunities for correc- likelihood of forming friendships that are impor- tive socialization experiences (Rubin & Stewart, tant to overall development. However, it is 1996 ) . Socially anxious children and adolescents important to note that behavioral inhibition does demonstrate a range of social skills defi cits, such not necessarily lead to social anxiety and that as withdrawal and shyness and inappropriate social anxiety, negative appraisals, and social assertiveness and aggression (Inderbitzen-Nolan, evaluative fears are not always preceded by Anderson, & Johnson, 2007 ; Strauss, Lease, behavioral inhibition (Morris et al., 2004 ) . Kazdin, & Dulcan, 1989) . Furthermore, longitu- Regardless, any behavioral manifestations of dinal studies have demonstrated that adolescents social anxiety (e.g., extreme shyness, fear, with- with social skills de fi cits experience increased drawal) are likely to interfere with normal social psychosocial problems (including social anxiety) development in both childhood and adolescence. when encountering new stress in their environ- In fact, social skills defi cits and negative social ments (Segrin & Flora, 2000 ) , such as negative appraisals have often been cited as important peer interactions (e.g., bullying). childhood traits related to social anxiety disorder (Barrett, 2000 ; Hudson & Rapee, 2000; Ollendick & Hirshfeld-Becker, 2002 ) . Negative Peer Interactions During the adolescent years, behavioral symptoms of avoidance are often characteristic of Behavioral and cognitive symptoms of social youth with social anxiety disorder. These symp- anxiety disorder and corresponding defi cits in toms may include decreased classroom perfor- social functioning place adolescents at risk for 184 E.A. Voelkel et al. negative peer interactions, such as peer victim- ance (Vernberg et al., 1992 ) . Thus, adolescents ization (e.g., bullying) and peer rejection (Grills with social anxiety disorder and a history of negative & Ollendick, 2002 ; Inderbitzen et al., 1997 ; social experiences may experience disruptions in La Greca & Lopez, 1998; Storch & Masia- healthy social processing, such as perceiving Warner, 2004 ) . Speci fi cally, social avoidance and threat in social situations that most would withdrawal, coupled with decreased friendships interpret as benign and decreased perceptions of and de fi cits in social skills, make children with self-ef fi cacy. social anxiety disorder salient targets for aggressive peers. The link between social anxiety disorder and peer victimization may be particularly Treatment Approaches salient in the middle-school years when peer victimization is most prevalent (Nansel et al., 2001 ) . Because there are several components to the During the early adolescent years especially, proposed cyclical model linking social anxiety, unskilled and withdrawn behavior is likely to social development, and peer interactions, treat- invite harassment by peers who view youth with ment approaches for social anxiety disorder and social anxiety as easy targets (Egan & Perry, socialization diffi culties need to be directed to 1998 ; Grills & Ollendick, 2002 ) . various parts of the relationship. Treatment Adolescents who are repeatedly victimized by approaches should incorporate strategies that peers tend to report increased symptoms of social directly target cognitive and behavioral symptoms anxiety in adolescence and young adulthood of social anxiety, as well as behaviors and strate- (Dempsey & Storch, 2008 ; Grills & Ollendick, gies to promote socialization and coping with 2002 ; La Greca & Harrison, 2005 ; Siegel et al., negative peer experiences. 2009 ; Slee, 1994; Storch, Masia-Warner, Dent, Cognitive-behavioral therapy approaches Roberti, & Fisher, 2004 ; Storch, Nock, Masia- incorporate the multiple components into a com- Warner, & Barlas, 2003 ) , including fear of nega- prehensive treatment plan for adolescents with tive evaluation (a cognitive symptom of social social anxiety disorder. In addition, cognitive- anxiety; Slee, 1994 ; Storch, Brassard, et al., 2003 ; behavioral interventions that include social skills Storch & Masia-Warner, 2004 ) . training, exposure, and cognitive restructuring, such as the Stand Up , Speak Out program (Albano & DiBartolo, 2007 ) , have been promising for Negative Expectations Regarding Peer implementation for youth with social anxiety Interactions disorder and a history of peer victimization at reducing symptoms of social anxiety and improving Negative peer experiences in the form of peer social interaction skills (Berry & Hunt, 2009 ; victimization and peer rejection may place ado- Chu & Harrison, 2007 ; Herbert et al., 2009 ) . lescents at risk for the emergence or exacerba- Figure 12.2 provides a summary of the various tion of symptoms of social anxiety disorder. treatment strategies that should be included in The mechanism for this link may be the cognitions comprehensive cognitive-behavioral interventions of the adolescent. For example, negative peer and depicts how they related to the proposed experiences may result in reduced expectations model of social anxiety disorder, socialization, regarding success in future peer interactions, and social experiences. Each strategy will be decreased self-effi cacy for social relating, and reviewed in the following section. increased fear of negative evaluations (Flanagan, Erath, & Bierman, 2008 ; Grills & Ollendick, 2002 ; Inderbitzen et al., 1997) . Additionally, Exposure and Friendship Promotion peer rejection experienced by adolescents who relocated to a new school led to greater fears of Treatment of socially anxious adolescents that negative evaluation and subsequent social avoid- experience negative social experiences has showed 12 Social Anxiety and Socialization Among Adolescents 185

Fig. 12.2 Summary of treatment strategies related to the proposed model of social anxiety disorder, socialization, and social experiences

promising results when the treatment involves the with reduced symptoms of social anxiety in identifi cation and/or development of a social sup- adolescence (La Greca & Harrison, 2005 ). That is, port system (La Greca & Harrison, 2005 ) . Exposure peer crowd affi liation and corresponding peer to opportunities in which successful, positive peer acceptance may provide adolescents with oppor- interactions are likely (e.g., activities that involve tunities to develop companionship, which in turn prosocial peers and shared interests) will encour- will inhibit social anxiety disorder manifestation age the development of friendships with same-age (La Greca & Harrison, 2005 ). peers and challenge the veracity of maladaptive Additionally, close friendships serve as a buf- and irrational beliefs (see section on “Cognitive fer for adolescents who are exposed to repeated Restructuring ”). Thus, encouraging adolescents experiences of peer victimization and may actu- with social anxiety to identify target peers or ally decrease the likelihood that victimization activities in which successful peer interactions are will happen in the future (Bowker, Spencer, & likely is a critical component in the treatment of Salvy, 2010 ; Davidson & Demaray, 2007 ; social anxiety disorder. This should include expos- Hodges, Boivin, Vitaro, & Bukowski, 1999 ; ing adolescents to activities for which they previ- Pellegrini, Bartini, & Brooks, 1999 ) . As socially ously exhibited avoidance behaviors and are likely anxious youth are particularly at risk for being to be successful with appropriate support and targets of aggressive peers, factors found to build training (Chu & Harrison, 2007 ) . resilience among victims of bullying and peer In addition to providing opportunities for pos- victimization may be especially important to itive interactions with peers via exposure, thera- include in a comprehensive treatment approach. pists should also work with adolescents with In support of this, one research study indicated social anxiety disorder to develop close friend- that adolescents with social anxiety who had ships, as the presence of close friendships may close friendships were less likely to experience help reduce symptoms of social anxiety and pro- loneliness and peer victimization than those with- vide a buffer against future negative peer interac- out close friendships (Erath, Flanagan, Bierman, tions (Hall-Lande, Eisenberg, Christenson, & & Tu, 2010 ) . Additionally, adolescents with Neumark-Sztainer, 2007 ; La Greca & Lopez, additional friendships (secondary friendships) 1998 ) . In support of this idea, af fi liation with a also reported greater self-ef fi cacy related to peer crowd, no matter the status, is associated interacting with peers. 186 E.A. Voelkel et al.

Social Skills Instruction Cognitive Restructuring

Simply presenting adolescents with opportunities A fi nal critical component of cognitive-behavioral for positive social interactions and friendship treatment strategies for adolescence with social development may be insuf fi cient for some ado- anxiety disorder is cognitive restructuring to lescents with social anxiety disorder, as they may reduce negative cognitions associated with social not have the social skills to facilitate positive anxiety (e.g., fear of negative evaluation, low interactions (Strauss et al., 1989 ) . Existing social self-effi cacy, and social competence). In a meta- skills defi cits may inhibit success in such interac- analysis examining the effectiveness of cognitive- tions without adequate preparation. Therefore, behavioral therapy for adolescents with social a critical component of cognitive-behavioral anxiety disorder, Chu and Harrison (2007 ) noted treatment for many adolescents with this disorder that treatment should include modifi cations of is social skills training and rehearsal (Spence, maladaptive thinking and attitudes, identifying Donovan, & Brechman-Toussaint, 2000 ) . In non- thinking errors, Socratic questioning, and devel- clinical populations, social skills training leads to oping coping thoughts. Therapists may work with decreased symptoms of social anxiety and adolescents to challenge automatic and irrational increased self-esteem (Bijstra & Jackson, perceptions of social situations as threatening 1998 ) , though social skills instruction alone is and to instead use self-talk to train themselves to not suffi cient for monumental or lasting change. use more adaptive cognitions. In fact, interventions including exposure are often noted as critical for the treatment of social anxiety disorder (Chu & Harrison, 2007 ; La Greca & Illustrative Case Study Harrison, 2005 ) . The problem of social anxiety disorder as it relates to socialization is clearly complex, and Development of Coping Strategies treatment must be multifaceted to address multiple issues in the relationship. The following case In addition to promoting positive, successful study describes an adolescent who presented for interactions with peers and developing close therapy with one of the authors. Care has been friendships, therapist should work with adoles- taken to alter details of the case to protect the cents with social anxiety disorder to develop anonymity of the individual. healthy coping with feelings of anxiety and nega- Lauren was a 16-year-old student who moved tive peer interactions, such as bullying. to a new school at the start of her 11th grade year. Adolescents with social anxiety disorder are Her mother referred her for therapy midway more likely to exhibit other comorbid psychoso- through the school year due to diffi cult interac- cial problems, such as alcohol and drug use tions Lauren was experiencing with her peers, (Amies, Gelder, & Shaw, 1983 ; DeWit, including social exclusion, rumor spreading, MacDonald, & Offord, 1999 ) and depression teasing, and mild physical aggression (e.g., push- (Sterba et al., 2010) . In addition, adolescents who ing her in the hallways). Her mother noted con- are exposed to negative peer experiences are cerns that Lauren begged and cried most mornings more likely to experience negative psychosocial (particularly on Mondays) to be excused from outcomes (including depression and anxiety) school. Lauren’s mother allowed her to stay home when they employ maladaptive coping strategies approximately once per week. (Hampel, Manhal, & Hayer, 2009 ) , whereas ado- During the fi rst few therapy sessions, it quickly lescents who display problem-solving-oriented became apparent that Lauren had a history of coping styles are less likely to experience social isolation. She had only one close friend psychosocial problems associated with bullying who had lived in a different city from her for several (Baldry & Farrington, 2005 ) . years. Lauren saw her best friend approximately 12 Social Anxiety and Socialization Among Adolescents 187 once each summer and talked to her intermittently increased her avoidance of social situations, as via email. She was not involved in any clubs, evidenced by her refusal to accept social invitations, sports, or group activities, though did regularly and prevented her from forming friendships with attend private violin lessons and attended a her fellow students. Thus, instead of befriending 1-week music camp two summers before with her, students at school selected Lauren as a target her best friend. for bullying. Her ability to cope with the bullying When moving to the new school, Lauren ini- was diminished, as she did not have a strong tially received invitations from peers to join them social support network and her existing coping on social activities. However, Lauren told her strategies were insuffi cient for handling the high mother she did not want to go to such activities level of stress. Finally, the bullying contributed to because she did not really know the other girls an exacerbation of her social anxiety symptoms, and would feel awkward because she did not as she felt even more fearful that she would know what they would talk about. After several behave in a way that would cause her to be nega- declines, the invitations stopped and bullying at tively evaluated, thus leading to heightened school began. Lauren’s peers reportedly teased behavioral avoidance. her about her clothes and hairstyle, called her Therapy for Lauren was multifaceted and tar- names, did not talk with her at lunch, and threw geted multiple domains of functioning. First, the bits of paper at her during class. therapist provided Lauren with psychoeducation Lauren revealed that she hated to attend school about social anxiety and the types of strategies because she expected that her peers would tease that would be implemented in therapy, including her. During class, she did not speak for fear that exposure and cognitive restructuring. Next, the she would say something wrong that would target therapist worked with Lauren to review social her for further bullying. Lunch was particularly approach strategies and conversation topics for diffi cult for Lauren. Her school had assigned peer interactions and rehearse these skills with seating at lunch, and Lauren did not talk to her her. Lauren worked with the therapist to identify peers sitting near her. She reported feeling so social settings in which she could implement upset at lunch that she would do or say something these strategies and success would be likely. wrong that she often did not eat and would ask to Lauren identifi ed one peer who sat near her at go to the nurse’s of fi ce due to nausea. Prior to lunch who did not engage in bullying and who presenting for therapy, Lauren’s distress had had originally attempted to befriend Lauren when become so severe that she was showing signs of she fi rst attended the school. Following success- depression, including frequent crying, loss of ful interactions with this peer (including attend- interest in playing her violin, and indicating sui- ing the peer’s birthday party), Lauren, the cidal ideation. therapist, and Lauren’s parents agreed to identify Lauren exhibited a number of symptoms of group activities in which Lauren could interact in social anxiety that were functionally related to a structured setting with peers with shared inter- her dif fi culties with social interactions. Behavioral ests. Lauren agreed to join the school orchestra to symptoms of Lauren’s social anxiety included a play the violin (no auditions were necessary). clear pattern of withdrawal and avoidance of During this time, Lauren’s mother began to resist social interactions, indicative of a generalized supporting Lauren’s behavioral avoidance by not subtype of social anxiety disorder. Although it excusing her from school and collaborating with was not possible to determine whether social the school nurse to limit the amount of time skills de fi cits preceded the social avoidance, it Lauren was allowed to stay in the clinic. was evident that Lauren lacked certain social Cognitive monitoring and restructuring was skills necessary for successful peer interaction used during each exposure activity. Strategies for (e.g., not accepting social interactions because cognitive restructuring included using scripted she did not know what to talk about with peers). self-statements prior to engaging in peer interac- Furthermore, her diffi culty interacting with peers tions and directly challenging maladaptive and 188 E.A. Voelkel et al. irrational beliefs related to fear of negative such as fear of negative evaluation and low social evaluations, social competence, and self-ef fi cacy. competence, and leading to an increase in social For example, self-statements included “I am a withdrawal and avoidance of social interactions. nice person and a good artist and have interesting In this chapter, we proposed a conceptual model things to talk about.” She also mentally reminded of social anxiety disorder, socialization, and social herself that only a minority of students in her experiences to explain these relationships. class were mean and engaged in bullying behav- Although relationships among individual compo- ior and many students had actually been friendly nents have been reported, research has not yet toward her. been conducted to empirically support the model Although bullying behavior did decrease per in its entirety. Future research should examine the Lauren’s report over the course of the school year appropriateness of the proposed model for explain- and as Lauren began to form friendships (though ing the link between social anxiety disorder and not yet close friendships) with individuals in the socialization in adolescence. In addition, although orchestra, Lauren and the therapist identifi ed cognitive-behavioral treatment approaches that appropriate coping strategies for when she was target the various components of the model exist, bullied. These included removing herself from randomized control trials need to continue to be the situation, using self-talk to remind herself of implemented to assess the ef fi cacy of comprehen- her positive attributes and positive peer interac- sive cognitive-behavioral therapy with adolescents tions, and engaging in enjoyable activities to with social anxiety. avoid rumination over the events. Lauren participated in weekly therapy sessions and completed therapy assignments when References not in sessions over the course of approximately 5 months. At discharge, Lauren continued to Albano, A. M., & DiBartolo, P. M. (2007). Cognitive- experience anxiety related to novel social situa- behavioral therapy for social phobia in adolescents: Stand up, speak out (therapist guide). New York, NY: tions and interacting in large groups of peers, Oxford University Press. though her avoidance of such situations had Albano, A. M., DiBartolo, P. M., Heimberg, R. G., & signifi cantly decreased. Lauren had formed Barlow, D. H. (1995). Children and adolescents: friendships with two peers, with whom she spent Assessment and treatment. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social time outside of school, and she had regular, posi- phobia: Diagnosis, assessment, and treatment (pp. tive interactions with students in the orchestra. 387Ð425). 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Tanya K. Murphy and Megan Toufexis

Pediatric Autoimmune Neuropsychiatric Disorder he postulated a potential cause of tics due to Associated with Streptococcus (PANDAS) is a infectious disease with three cases of new-onset clinical phenotype gaining more interest and tics and sinusitis (Selling, 1929 ) . Sometime later, research in the pediatric community. It is a syn- Kiessling and colleagues noted an increase in the drome consisting of new onset of neuropsychiat- prevalence of tics when group A streptococcal ric symptoms that are linked to a group A (GAS) infections were prevalent (Kiessling, streptococcal infection (GAS). This syndrome Marcotte, & Culpepper, 1993 ) . These observations consists of an abrupt onset of symptoms such as paralleled the clearly established relationship obsessive–compulsive features, tics, behavioral between GAS and Sydenham’s chorea (SC), a and mood changes, and neurologic abnormalities movement disorder associated with rheumatic which are episodic and drastic compared to the fever. Sydenham’s chorea, one of the major crite- child’s baseline functioning. PANDAS is not a ria for rheumatic fever, is characterized by rapid, contagious disease, but the infectious trigger GAS irregular, aimless involuntary movements of the is quite common and contagious in the pediatric arms and legs, trunk, and face. Historically, SC has population. Treatment is based on the child’s pre- been described to have many psychiatric manifes- sentation of symptoms and often involves treating tations as well, especially compulsive behaviors the underlying infectious process. Clinicians need (Grimshaw, 1964 ) . Further research with SC found to be aware of this infection-triggered neuropsy- as many as 70% of SC patients develop obsessive– chiatric disorder as PANDAS research grows and compulsive symptoms which are indistinguishable more evidence-based treatments evolve. from classic OCD (Swedo, 1994 ; Swedo et al., 1998 ) . It was from the observations related to this research that this immune subtype of OCD arose. Historical Background/Theory The phenomenon in which a person’s antibodies designed to attack foreign material, such as Many publications dating back to the 1920s have viruses and bacteria, attack one’s own body is supported the relationship between illness and termed “molecular mimicry.” This is a case of new-onset OCD and tics. One of the fi rst case “mistaken identity” in that some proteins on the reports was by an otolaryngologist in 1929 when wall of streptococcal bacteria are similar to those found on human tissues. For example, rheumatic fever (RF) is classi fi ed as an autoimmune illness T. K. Murphy , M.D. (*) • M. Toufexis , DO in which antibodies to the GAS attack a person’s Department of Psychiatry , University of South Florida , heart valve, joints, skin, and/or brain. Specifi cally, 800 6th Street South , Box 7523 , St. Petersburg , FL 33701 , USA the autoimmune process proposed for SC is e-mail: [email protected] thought to be due to antibodies to streptococcal

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 193 DOI 10.1007/978-1-4614-6458-7_13, © Springer Science+Business Media New York 2013 194 T.K. Murphy and M. Toufexis antigens associated with the M protein of GAS Table 13.1 Criteria for PANDAS as established by the that cross-react with the nervous system (Bronze National Institute on Mental Health & Dale, 1993 ) . One additional theory is that these Criteria for PANDAS as established by the National antibodies may bind to neuronal receptors to Institute on Mental Health release excitatory neurotransmitters in the brain 1. Presence of obsessive–compulsive disorder and/or a tic disorder and disrupt neuronal cell function (Kirvan, 2. Pediatric onset of symptoms (age 3 years to puberty) Swedo, Snider, & Cunningham, 2006 ) . 3. Episodic/dramatic course of symptom severity OCD, SC, and Tourette’s syndrome all have a 4. Association with group A beta-hemolytic streptococ- common anatomical link thought to be caused by cal infection (a positive throat culture for GAS or a dysfunction in the basal ganglia of the brain and history of scarlet fever) cortical and thalamic sites which suggests a com- 5. Association with neurological abnormalities mon genetic and immunologic vulnerability may (motoric hyperactivity, or adventitious movements, such as choreiform movements) exist in these patients (Murphy, Kurlan, & Leckman, 2010 ) . Neuroimaging has demonstrated structural changes with SC and PANDAS as volu- disorder presents differently in children, even metric MRI studies have demonstrated enlarge- those with identical genetics. Each identical sib- ment of the basal ganglia in both illnesses (Giedd ling in the family was exposed to very similar et al., 1995 ; Giedd, Rapoport, Leonard, Richter, & environments yet had very different symptoms, Swedo, 1996 ) . which suggests epigenetic factors and small variations in the environment may play a signi fi cant role in how the disorder manifests in each child Characteristics of PANDAS (Lewin et al., 2011 ). The association between a temporal relation- A practitioner should begin to suspect PANDAS ship of GAS and OCD remains controversial in when evaluating a child who was functioning the medical community but is gaining support well, but suddenly has a new dramatic onset or with more evidence-based research. The exact worsening of obsessions, compulsions, and prevalence of those with OCD with PANDAS movements that seem to develop over 1–2 days. subtype in the pediatric population is unknown. In addition to OCD, these children will develop a The course of OCD–PANDAS is different com- dramatic onset of other behavioral symptoms pared to classic OCD. With limited longitudinal such as rages, mood fl uctuations, separation anx- research, it is diffi cult to predict prognosis. iety, hyperactivity, and oppositional behaviors. Anecdotally, some children will become com- One or all of these symptoms can develop over- pletely asymptomatic and never have a future epi- night and continue to progress over a few days sode, while others will have frequent exacerbations (Swedo et al., 1998 ) . Symptoms of inattention, with or without full remission between episodes. new academic diffi culties, and worsening hand- Over time, some children may develop a course writing have also been reported. The child may that is indistinguishable from classic OCD. also begin to have frequent urination and/or nocturnal enuresis along with nightmares. In addition, there is a motor component to this illness as Immune Triggers many children will also have a new-onset tic disorder or severe worsening of a previous tic disor- GAS is the cause of 15–36% of pharyngitis among der. This dramatic change in functioning has a children in the United States, and many children, signi fi cant impact on the child’s social life, as high as 20%, are asymptomatic carriers of GAS academic performance, and family interactions (Pfoh, Wessels, Goldmann, & Lee, 2008 ) . If the ( Tables 13.1 and 13.2 ). child is infected with GAS, the onset of neuropsy- A recent case series of PANDAS in three sets chiatric symptoms is usually within a few days. If of identical siblings highlighted the fact that this a longer lag period is noted, it could be that the 13 PANDAS 195 PANDAS–OCD PANDAS–OCD 7 years or younger Not well studied but appears to have higher appears to have Not well studied but female-to-male ratio than tics and OCD in prepubertal population Dramatic onset; episodic or sawtooth course; Dramatic onset; episodic or sawtooth long-term prognosis unknown Proposed association with infection Academic decline, worsening handwriting, Academic decline, worsening ADHD, new-onset urinary frequency, instability; higher rates of comorbid affective tics 7 years 2:1 male-to-female ratio Peak severity at age 10; 50% of cases remit by Peak severity late teens Reported in some cases; cause uncertain ADHD, OCD, anxiety disorders, depression, ODD/conduct disorder OCD TS/tic disorders before age 15; female-to-male ratio increases after puberty some episodic cases reported ADHD, other anxiety disorders, hoarding, tics, depression Comparison of OCD, tics, and PANDAS characteristics characteristics Comparison of OCD, tics, and PANDAS Typical age of onset Typical Gender relatedness 10 years than girls in boys Slightly higher prevalence Course Insidious onset; typically unremitting, though GAS trigger Comorbidities Reported; cause uncertain Table 13.2 196 T.K. Murphy and M. Toufexis child has a subclinical infection which makes the A positive culture may occur in children without diagnosis of a preceding GAS infection even more symptoms of infection, and some of these chil- dif fi cult (Murphy et al., 2012 ). In addition to a dren are considered carriers of GAS. The role of sore throat, common symptoms of streptococcal the carrier state is thought to be benign in the risk pharyngitis are fever, swollen lymph glands, and for RF, but it is unclear if it may play a role of enlarged in fl amed tonsils. GAS is highly conta- increasing the risk for neuropsychiatric presenta- gious through respiratory secretions and has an tions (Murphy et al., 2007 ) . The NIH does not incubation period of 2–5 days. Some children may recommend children with PANDAS be treated not have the full clinical presentation of pharyngi- with a tonsillectomy (Table 13.3 ). tis but can lead to enough immune activation to Without a positive rapid strep or culture, ele- still cause neuropsychiatric symptoms (Murphy vated titers (antibodies to GAS) suggest a role for et al., 2004 ) . PANDAS presentations have also GAS infection as a trigger, but alone, titers are been associated with other infectious agents such not defi nitive proof of an inciting infection. as infl uenza; Mycoplasma pneumonia (Muller Elevated streptococcal titers are common in the et al., 2004 ) , which is commonly known as walk- pediatric population and indicate that the body ing pneumonia; and Borrelia burgdorferi (Riedel, has had previous infection or is fi ghting an infec- Straube, Schwarz, Wilske, & Muller, 1998 ) , which tion. The two streptococcal titers tested are anti- causes Lyme disease. As an example, in 1994, streptolysin O (ASO) and anti-deoxyribonuclease Swedo described a 9-year-old female who had a B (DNAse B). If one suspects PANDAS in a child dramatic change in her moods, new-onset anxiety, with very recent onset OCD, the child should compulsive hand washing, and ADHD which have rapid strep test or throat culture. Titers developed after an upper respiratory infection. She should be tested at the beginning of new-onset improved when treated with plasmapheresis and psychiatric symptoms and repeated 4–6 weeks penicillin (Swedo, 1994 ) . In 1995, four pediatric later to see if there has been a rise. It is important cases with new or worsening OCD and/or tics to see a fourfold increase in titer levels to help were proposed to have an infectious trigger such support the PANDAS diagnosis, but it has been as pharyngitis, sinusitis, or fl u-like symptoms, and reported that titers may remain elevated 6 months the acronym PITANDS (Pediatric Infection- to a year after infection (Murphy et al., 2004 ) . In Triggered Autoimmune Neuropsychiatric addition, there are many variables that will affect Disorders) was proposed (Allen, Leonard, & titer levels such as the time since infection when Swedo, 1995 ) . In this series, not all children had a the sample is drawn, the child’s immune status, GAS trigger, and as more cases of other infectious the use of antibiotics, and the age of the patient. triggers are described, it is likely that PANDAS Younger patients may not mount a suffi cient will be considered a subtype of PITANDS. immune response to reach laboratory threshold values and present with normal titers.

Evaluation Treatment A careful history is essential to understanding if new onset of neuropsychiatric symptoms has cor- There are no prevention strategies for PANDAS, responded to any changes in physical health. but limiting exposure to sick contacts, scheduled There is no test to conﬁ rm PANDAS as it is a vaccinations, and treatment compliance with preclinical diagnosis. Clinicians should ask about scribed antibiotics are recommended. Children illnesses and sick contacts as many children will diagnosed with PANDAS should be treated with have asymptomatic GAS infections or other ill- therapies shown to be bene ﬁ cial for OCD and tic nesses that can trigger such a response. There are disorders. The standard treatment for pediatric some tests that will aid with the diagnosis such as OCD is cognitive behavioral therapy (CBT) alone rapid strep test and a throat culture for GAS. or in conjunction with a SSRI (POTS, 2004 ) . 13 PANDAS 197

Table 13.3 Reference values: normal range ASO titer Anti-DNase B (Todd units/mL) Adult <160 Todd units/mL or <200 IU <85 Child (5–12 years) 170–330 Todd units/mL <170 Preschool-aged child 100–160 Todd units <60

With the use of Selective Serotonin Reuptake Snider, Lougee, Slattery, Grant, & Swedo, 2005 ) . Inhibitors (SSRIs) in a pediatric population, and However, prophylactic treatment is not without more specifi cally with a PANDAS population, risk due to the potential of increasing antibiotic- higher rates of behavior activation have been resistant organisms, allergic reactions, and gastro- associated with this class of medication, so lower intestinal side effects. If the child is having starting doses are advised (Murphy, Storch, & recurrent GAS infections, the family should be Strawser, 2006 ) . CBT is the treatment of choice tested to see if they are carriers and are a source of for mild to moderate severity OCD. Children chronic reexposure. with a PANDAS presentation should also bene fi t For severely ill children who have a clear diag- from the skills developed during CBT. In an open nosis of PANDAS and have not had symptoms trial of seven children, ages 9–14 years old, diag- resolve with appropriate antibiotic treatment, nosed with PANDAS, a 3-week intensive family- intravenous immunoglobulin (IVIG) or plasma- based CBT program was helpful for treating the pheresis has been shown in a small study to have OCD. It should be noted most of these children bene fi cial effects on obsessive–compulsive symp- were also on SSRI medication (Storch et al., toms, depression, anxiety, and global impairment 2006 ) . The tic component of PANDAS can be (Perlmutter et al., 1999 ) . IVIG is not a benign treated with standard pharmacologic interven- treatment and must be administered by a special- tions and habit reversal therapy. The skills devel- ized team of health-care professionals, and side oped in CBT and HRT should prove helpful to effects are common such as nausea, headaches, empower the patient and family in managing dizziness, and vomiting. This treatment has not symptoms in future recurrences. been shown to be helpful in those patients with For children presenting with OCD in the con- OCD without an infectious trigger, thus implying text of a documented infection, treatment consists that PANDAS has an immune-mediated process of antibiotic therapy targeted toward the identi fi ed (Nicolson et al., 2000) . Ideally, this type of treat- infectious agent. For con fi rmed GAS, the antibi- ment should be performed in a research setting otics typically used consist of penicillins, cepha- until risks and benefi ts are better clarifi ed (Snider losporins, and azithromycin and will need to be & Swedo, 2003 ) . The NIMH in 2011 began a trial prescribed by a physician. Some children will examining IVIG treatment for PANDAS to fur- have dramatic improvement with antibiotic treat- ther explore treatment implications. ment. The reported recurrence rate for PANDAS has been estimated to be close to 50% requiring children to have repeated treatment with antibiot- Case Study ics (Murphy & Pichichero, 2002 ) . There is con fl icting data as to if prophylaxis antibiotic Jake, a 7-year-old boy, presents to his pediatrician treatment is effective and safe in children with after his parents noticed he has begun to blink his suspected PANDAS, and this is a topic that is eyes, scrunch his nose, and clear his throat repeated being further investigated. A few studies have during the day and feel it could be allergies. These indicated that a possible bene fi t may exist for the new behaviors developed and worsened over a few use of prophylactic antibiotic treatment to decrease days along with many other behavioral changes. neuropsychiatric symptoms in patients with sus- The parents report that 1 week ago he began to wet pected PANDAS (Murphy & Pichichero, 2002 ; the bed again, which had not occurred since age 5. 198 T.K. Murphy and M. Toufexis

Jake also showed increased urinary frequency to the point he was going to the bathroom a few times Conclusion every hour. When he was in the bathroom, he felt compelled to wash his hands multiple times while Childhood OCD and tic disorders, along with the counting to the number ten. He also developed a multiple other neuropsychiatric symptoms asso- new severe separation anxiety from his family, and ciated with infections, are increasingly recog- it was a struggle to drop him off at school which he nized by pediatric providers. It is imperative that had previously enjoyed. To enter the school, he clinicians become aware of the diagnosis of required his mother and principal to escort him to PANDAS and investigate the infectious processes his classroom. His parents were confused as they associated with this disorder. Children with report until the prior week that their child was a PANDAS often have an acute and severe onset of very easygoing child who loved school and never neuropsychiatric symptoms that are impairing. had any of these odd fears and behaviors. They While standard therapies have shown to be help- reported he became a different child over a few ful such as psychopharmacological medications, days, and no form of discipline or reasoning with CBT, and habit reversal therapy, they will not him was effective. The parents reported to the pedi- address the identifi ed underlying infectious pro- atrician that Jake did have a sore throat but was cess, and medical treatment is warranted. Further eating and drinking well, had no fever, and no one research is needed for helping to clarify the in the home was ill. In the of fi ce, he tested positive PANDAS diagnosis and the bene fi t of prophylac- via rapid strep test. The pediatrician placed him on tic treatment for these children as recurrence is a 7-day course of amoxicillin, and within a few common. The PANDAS diagnosis requires clini- days, most of his symptoms remitted, and parents cians to take a thorough medical history in order felt that they had their “old Jake” back. to ensure that this subgroup of children is not Two months later Jake began to have compul- missed as they require a different evaluation and sive hand washing and needed to tap twice each close follow-up as recurrences are common. time he walked through a door. His handwriting Standard therapies are helpful adjuncts once the became very messy and large, and again, he began infectious process has been medically treated. to have eye blinking and separation anxiety from parents. His parents immediately took him to the pediatrician who again did a rapid strep test and References found him to be positive for GAS. At this time, the entire family tested for strep, and the older sister Allen, A. J., Leonard, H. L., & Swedo, S. E. (1995). Case was found to be rapid strep test positive but not study: A new infection-triggered, autoimmune subtype of pediatric OCD and Tourette’s syndrome. symptomatic. Both Jake and his sister were pre- Journal of the American Academy of Child and scribed amoxicillin, this time for a 10-day course, Adolescent Psychiatry, 34 (3), 307–311. and within 1 week, some of Jake’s behavior symp- Bronze, M. S., & Dale, J. B. (1993). Epitopes of strepto- toms remitted. Jake’s compulsive tapping and hand coccal M proteins that evoke antibodies that cross- react with human brain. Journal of Immunology, washing continued and was still problematic in the 151 (5), 2820–2828. morning when getting ready for school. At this time, Giedd, J. N., Rapoport, J. L., Kruesi, M. J., Parker, C., the pediatrician referred them to a child psychiatrist Schapiro, M. B., Allen, A. J., et al. (1995). Sydenham’s and psychologist for further treatment. He was eval- chorea: Magnetic resonance imaging of the basal ganglia. Neurology, 45 (12), 2199–2202. uated, and it was felt that a trial of CBT would be Giedd, J. N., Rapoport, J. L., Leonard, H. L., Richter, D., tried fi rst before starting an antidepressant. Jake & Swedo, S. E. (1996). Case study: Acute basal gan- went through ten sessions of CBT, and his compul- glia enlargement and obsessive-compulsive symptoms sions remitted. His parents were educated about in an adolescent boy. Journal of the American Academy of Child and Adolescent Psychiatry, 35 (7), 913–915. PANDAS and were told that at the fi rst sign of psy- Grimshaw, L. (1964). Obsessional disorder and neuro- chiatric symptoms they have to bring him to the logical illness. Journal of Neurology, Neurosurgery, physician to be checked for an infectious cause. and Psychiatry, 27 , 229–231. 13 PANDAS 199

Kiessling, L. S., Marcotte, A. C., & Culpepper, L. (1993). Nicolson, R., Swedo, S. E., Lenane, M., Bedwell, J., Antineuronal antibodies in movement disorders. Wudarsky, M., Gochman, P., et al. (2000). An open Pediatrics, 92 (1), 39–43. trial of plasma exchange in childhood-onset obsessive- Kirvan, C. A., Swedo, S. E., Snider, L. A., & Cunningham, compulsive disorder without poststreptococcal M. W. (2006). Antibody-mediated neuronal cell sig- exacerbations. Journal of the American Academy of naling in behavior and movement disorders. Journal of Child and Adolescent Psychiatry, 39 (10), 1313–1315. Neuroimmunology, 179 (1–2), 173–179. Perlmutter, S. J., Leitman, S. F., Garvey, M. A., Hamburger, Lewin, A. B., Storch, E. A., & Murphy, T. K. (2011). S., Feldman, E., Leonard, H. L., et al. (1999). Therapeutic Pediatric autoimmune neuropsychiatric disorders plasma exchange and intravenous immunoglobulin for associated with Streptococcus in identical siblings. obsessive-compulsive disorder and tic disorders in Journal of Child and Adolescent Psychopharmacology, childhood. Lancet, 354 (9185), 1153–1158. 21, 177–182. Pfoh, E., Wessels, M. R., Goldmann, D., & Lee, G. M. Muller, N., Riedel, M., Blendinger, C., Oberle, K., Jacobs, (2008). Burden and economic cost of group A strepto- E., & Abele-Horn, M. (2004). Mycoplasma pneumo- coccal pharyngitis. Pediatrics, 121 (2), 229–234. niae infection and Tourette’s syndrome. Psychiatry POTS. (2004). Cognitive-behavior therapy, sertraline, and Research, 129 (2), 119–125. their combination for children and adolescents with Murphy, T. K., Kurlan, R., & Leckman, J. (2010). The obsessive-compulsive disorder: The Pediatric OCD immunobiology of Tourette’s disorder, pediatric auto- Treatment Study (POTS) randomized controlled trial. immune neuropsychiatric disorders associated with Journal of the American Medical Association, 292 (16), Streptococcus, and related disorders: A way forward. 1969–1976. Journal of Child and Adolescent Psychopharmacology, Riedel, M., Straube, A., Schwarz, M. J., Wilske, B., & 20 (4), 317–331. Muller, N. (1998). Lyme disease presenting as Murphy, M. L., & Pichichero, M. E. (2002). Prospective Tourette’s syndrome. Lancet, 351 (9100), 418–419. identiﬁ cation and treatment of children with pediatric Selling, L. (1929). The role of infection in the etiology of autoimmune neuropsychiatric disorder associated with tics. Archives of Neurology and Psychiatry, 22 , group A streptococcal infection (PANDAS). Archives of 1163–1171. Pediatrics & Adolescent Medicine, 156(4), 356–361. Snider, L. A., Lougee, L., Slattery, M., Grant, P., & Swedo, Murphy, T. K., Sajid, M., Soto, O., Shapira, N., Edge, P., S. E. (2005). Antibiotic prophylaxis with azithromy- Yang, M., et al. (2004). Detecting pediatric autoim- cin or penicillin for childhood-onset neuropsychiatric mune neuropsychiatric disorders associated with disorders. Biological Psychiatry, 57 (7), 788–792. streptococcus in children with obsessive-compulsive Snider, L. A., & Swedo, S. E. (2003). Post-streptococcal disorder and tics. Biological Psychiatry, 55 (1), 61–68. autoimmune disorders of the central nervous system. Murphy, T. K., Snider, L. A., Mutch, P. J., Harden, E., Current Opinion in Neurology, 16 (3), 359–365. Zaytoun, A., Edge, P. J., et al. (2007). Relationship of Storch, E. A., Murphy, T. K., Geffken, G. R., Mann, G., movements and behaviors to Group A Streptococcus Adkins, J., Merlo, L. J., et al. (2006). Cognitive- infections in elementary school children. Biological behavioral therapy for PANDAS-related obsessive- Psychiatry, 61 (3), 279–284. compulsive disorder: Findings from a preliminary Murphy, T. K., Storch, E. A., Lewin, A. B., Edge, P. J., & waitlist controlled open trial. Journal of the American Goodman, W. K. (2012). Clinical factors associated Academy of Child and Adolescent Psychiatry, 45 (10), with pediatric autoimmune neuropsychiatric disorders 1171–1178. associated with streptococcal infections. Journal of Swedo, S. E. (1994). Sydenham’s chorea. A model for Pediatrics, 160(2), 314–319. childhood autoimmune neuropsychiatric disorders. Murphy, T. K., Storch, E. A., & Strawser, M. S. (2006). Journal of the American Medical Association, 272 (22), Case Report: Selective serotonin reuptake inhibitor- 1788–1791. induced behavioral activation in the PANDAS sub- Swedo, S. E., Leonard, H. L., Garvey, M., Mittleman, B., type. Primary Psychiatry, 13 (8), 87–89. Allen, A. J., Perlmutter, S., et al. (1998). Pediatric Murphy, T. K., & Yokum, K. (2011). Immune and endo- autoimmune neuropsychiatric disorders associated crine function in child and adolescent obsessive com- with streptococcal infections: Clinical description of pulsive disorder (1st ed.). New York: Springer-Verlag the ﬁ rst 50 cases. The American Journal of Psychiatry, New York Inc. 155 (2), 264–271. Part III

Complexities in Adult Anxiety Disorders Treatment of Posttraumatic Stress Disorder and Comorbid Borderline 1 4 Personality Disorder

Melanie S. Harned

Borderline personality disorder (BPD) is a meeting criteria for both BPD and PTSD. Next, severe and complex psychological disorder an integrated BPD and PTSD treatment that characterized by pervasive dysregulation of combines Dialectical Behavior Therapy (DBT; emotion, behavior, and cognition. Individuals Linehan, 1993a, 1993b ) with Prolonged who meet criteria for BPD are the quintessential Exposure therapy (PE; Foa, Hembree, & multiproblem clients, often presenting to treat- Rothbaum, 2007) will be described. Finally, a ment with multiple comorbid Axis I and II diag- case example will be presented along with sug- noses, numerous dysfunctional behaviors, and gestions for future research. generally chaotic lives. Of the many complex problems exhibited by individuals with BPD, co-occurring posttraumatic stress disorder The Nature of the Problem (PTSD) is among the most common. However, the clinical challenges encountered in the treat- The comorbidity between BPD and PTSD is ment of individuals with BPD can make it well documented and some have even pro- dif ﬁ cult to implement PTSD treatments in this posed that BPD is better conceptualized as a population. Indeed, clients with BPD, particu- trauma-related condition known as “complex larly those with a severe level of disorder, are PTSD” (e.g., Herman, 1992 ) . However, this generally viewed as inappropriate for PTSD view has been contested on both theoretical treatments. Conversely, BPD treatments include and empirical grounds (e.g., Gunderson & clients with a range of severity but do not typi- Sabo, 1993 ) , and the current diagnostic system cally target their PTSD. Thus, efforts to develop considers BPD and PTSD to be distinct though treatments that can safely and effectively often co-occurring disorders (American address PTSD in this complex client population Psychiatric Association [APA], 2000 ) . are clearly needed. The present chapter will Epidemiologic research has indicated that begin by reviewing the prevalence, phenome- 30.2% of individuals with BPD are also diag- nology, and clinical complexities of individuals nosed with PTSD, whereas 24.2% of individuals with PTSD also have BPD (Pagura et al., 2010 ) . Within clinical samples, the rate of comorbidity is even higher with approximately 50% of BPD inpatients and outpatients also * M. S. Harned , Ph.D. ( ) meeting criteria for PTSD (e.g., Harned, Rizvi, Department of Psychology , University of Washington , Box 355915 , Seattle , WA 98195-5915 , USA & Linehan, 2010 ; Zanarini, Frankenburg, e-mail: [email protected] Hennen, Reich, & Silk, 2004 ) . Research

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 203 DOI 10.1007/978-1-4614-6458-7_14, © Springer Science+Business Media New York 2013 204 M.S. Harned comparing individuals with BPD and PTSD to those with either disorder alone has shown that Factors That Contribute to Complexity those with both disorders report more extensive trauma histories and are more impaired in Clients with both BPD and PTSD often present to terms of global psychological distress, Axis I treatment with multiple severe problems that may comorbidity, emotion dysregulation, and phys- create signifi cant obstacles to the successful imple- ical health (e.g., Bolton, Mueser, & Rosenberg, mentation of PTSD treatments. In this section, sev- 2006 ; Connor et al., 2006; Harned, Rizvi, eral factors that may increase complexity and et al., 2010 ; Pagura et al., 2010 ; Rusch et al., decrease treatment response among BPD clients 2007 ) . Moreover, BPD clients with PTSD seeking PTSD treatment are proposed. Although engage in more frequent non-suicidal self- these complicating factors are likely to interfere with injury (NSSI) than those without PTSD any type of PTSD treatment, emphasis will be placed (Harned, Rizvi, et al., 2010 ; Rusch et al., on PE (Foa et al., 2007 ) , the treatment program that 2007 ) , and PTSD increases the risk of suicide has received the most empirical support and is rec- attempts in community samples of individuals ommended as a frontline treatment for PTSD (Foa, with BPD (e.g., Pagura et al., 2010 ) . Given Keane, Friedman, & Cohen, 2009 ) . PE involves these fi ndings, it is not surprising that the pres- imaginal exposure to the trauma memory followed ence of PTSD predicts a lower likelihood of by processing of the client’s experience during the remitting from BPD over 10 years of prospec- imaginal exposure and in vivo exposure to feared tive follow-up (Zanarini, Frankenburg, Hennen, but non-dangerous situations. Both types of expo- Reich, & Silk, 2006 ) . sure are designed to promote extinction of maladap- Several theories have been proposed to account tive emotions by discon fi rming erroneous perceptions for the high comorbidity between BPD and PTSD. that maintain PTSD (e.g., the world is extremely The biosocial theory of the etiology of BPD dangerous and the self is extremely incompetent). (Linehan, 1993a ) highlights the role of the PE is based on Emotional Processing Theory (Foa & invalidating environment, which may include Cahill, 2001; Foa & Kozak, 1986 ) that specifi es that childhood abuse and trauma, in the develop- effective treatments for anxiety disorders including ment of BPD. In addition, individuals with PTSD involve activating the pathological fear struc- BPD may possess certain vulnerability factors ture underlying the target disorder and presenting that increase their risk of trauma exposure as information that is incompatible with the pathologi- adults. For example, childhood sexual abuse cal elements of the structure. In other words, clients and childhood emotional withdrawal by a care- are repeatedly exposed to the situations or memories taker have both been found to increase the risk that elicit anxiety or distress in the absence of their of adult trauma among individuals with BPD anticipated negative consequences so that they can (Zanarini et al., 1999 ) . Many individuals with learn that they do not need to avoid these situations BPD also possess a variety of known risk fac- or be distressed by them. Thus, anything that inter- tors for PTSD, such as low social support, poor feres with the ability to experience and tolerate dis- psychological adjustment, and childhood abuse tress so that corrective information can be learned (Brewin, Andrews, & Valentine, 2000; Ozer, will likely reduce the effi cacy of PE and exposure- Best, Lipsey, & Weiss, 2003) that may make based treatments more generally. them particularly vulnerable to developing PTSD in response to traumatic events. Finally, trauma and PTSD may maintain or exacerbate Intentional Self-Injury BPD by, for example, further intensifying the emotion dysregulation that is central to BPD Suicidal behavior and NSSI, together referred to as and increasing the frequency of impulsive, intentional self-injury, are considered hallmark fea- self-destructive behaviors such as NSSI tures of BPD. Among inpatients with BPD, more (Harned, Rizvi, et al., 2010 ) . than 70% report a lifetime history of multiple 14 PTSD and BPD 205 episodes and methods of NSSI and 60% report Other Co-occurring Problems multiple suicide attempts (Zanarini et al., 2008 ) . The rate of death by suicide among individuals In addition to the high rate of intentional self- with BPD is estimated at 8Ð10% (Linehan, Rizvi, injury, many BPD clients with PTSD exhibit a Shaw-Welch, & Page, 2000; Pompili, Girardi, variety of other co-occurring psychological, social, Ruberto, & Tatarelli, 2005 ) . Among individuals and functional problems. For example, it is not with BPD, intentional self-injury most often func- uncommon for clients with both BPD and PTSD tions to provide relief from tension and unpleasant to present to treatment with multiple other Axis I emotions, punish oneself, get away or escape, and II disorders, a variety of impulsive behaviors infl uence others, and generate feelings (Brown, (e.g., shoplifting, gambling), chaotic or nonexis- Comtois, & Linehan, 2002 ; Kleindienst et al., tent relationships, no or limited source of income 2008 ) . The increased risk of intentional self-injury beyond psychiatric disability, unstable housing, among BPD clients with PTSD may be due to a and several chronic and disabling medical condi- functional relationship between PTSD symptoms tions. Faced with a client who reports a multitude and intentional self-injury. Clients with BPD and of serious problems, it can be diffi cult for thera- PTSD are more likely than those without PTSD to pists to decide how and in what order these many report a variety of trauma-related cues for inten- problems should be targeted. Further adding to tional self-injury, including fl ashbacks, nightmares, this complexity is the fact that many of these co- and intrusive thoughts about sexual abuse or rape occurring problems, such as dissociation, sub- (Harned, Rizvi, et al., 2010 ) . These fi ndings are stance use, and ongoing trauma, are likely to consistent with research showing that the relation- interfere with the ef fi cacy of PTSD treatments. ship between childhood sexual abuse and NSSI is mediated by the PTSD symptom clusters of reex- Dissociation. The rate of Axis I dissociative dis- periencing and avoidance/numbing (Weierich & orders among individuals with BPD is quite high Nock, 2008 ) . Taken together, these fi ndings sug- (55Ð72%; Foote, Smolin, Neft, & Lipschitz, 2008 ; gest that the higher rate of intentional self-injury Sar, Akyuz, Kugu, Ozturk, & Ertem-Vehid, 2006 ) among individuals with both BPD and PTSD may and 68% of inpatients with BPD report moderate be due to the use of intentional self-injury as a way to high levels of dissociative experiences (Zanarini, to cope with the intense negative affect and cogni- Ruser, Frankenburg, & Hennen, 2000 ) . Among tions associated with PTSD and trauma. individuals with BPD, those with high levels of The high rate of intentional self-injury among dissociation report more PTSD symptoms, trau- BPD clients with PTSD may both add complexity matic experiences (particularly childhood trauma), and cause anxiety for therapists implementing and more severe impairment in a variety of other PTSD treatments in this population. Given that areas (e.g., Brodsky, Cloitre, & Dulit, 1995 ; Sar treatments for PTSD often elicit intense emotions et al., 2006 ) . In addition, the presence of a disso- and can cause a temporary increase in PTSD ciative disorder has been found to enormously symptoms before they eventually improve (Nishith, increase the odds of having a history of multiple Resick, & Griffi n, 2002) , it is understandable that suicide attempts (odds ratio = 15.09), even after both therapists and BPD clients may be anxious controlling for the effects of BPD, PTSD, and about the potential risk of intentional self-injury alcohol abuse (Foote et al., 2008) . Similarly, dis- during PTSD treatment. This fear of intentional sociation predicts an increased likelihood of NSSI self-injury may make both therapists and clients among individuals with BPD over 10 years of wary of allowing trauma-related emotions to be prospective follow-up (Zanarini, Laudate, experienced in their full intensity. Alternatively, if Frankenburg, Reich, & Fitzmaurice, 2011 ) . clients engage in intentional self-injury as a way to Dissociation can pose a signi fi cant challenge to the escape from intense emotions elicited by exposure, successful implementation of exposure therapy then the opportunity for corrective learning (e.g., for PTSD because it functions to escape intense that intense emotions can be tolerated) is emotions and is likely to interfere with informa- decreased. tion processing. Several laboratory-based studies 206 M.S. Harned have shown that, compared to BPD clients low in 90% report a history of abuse in adulthood and state dissociation, BPD clients with high state dis- 47Ð60% report new abusive experiences at each sociation exhibit reduced emotional reactivity 2-year interval over 6 years of prospective fol- during a startle response task (Ebner-Priemer low-up (Zanarini, Frankenburg, Reich, Hennen, et al., 2005 ) and diminished emotional learning & Silk, 2005) . In addition, case descriptions of during an aversive differential delay conditioning two clients with BPD and PTSD who received procedure (Ebner-Priemer et al., 2009 ) . In addi- the combined DBT and modifi ed PE treatment tion, clients with PTSD who are high in trait dis- indicate that both women experienced new trau- sociation are more likely than those who are low mas during treatment (Harned & Linehan, 2008 ) . in trait dissociation to continue to meet criteria for These fi ndings suggest that new or ongoing PTSD following PE (69% vs. 10%; Hagenaars, trauma is likely to complicate PTSD treatment in van Minnen, & Hoogduin, 2010 ) . this population.

Substance use. Approximately 60% of clients with BPD also meet criteria for a substance use disorder Emotion Dysregulation (SUD; Trull, Sher, Minks-Brown, Durbin, & Burr, 2000 ) , and individuals with both BPD and PTSD The biosocial theory of BPD proposes that it is the are even more likely to meet criteria for a lifetime transaction between an emotionally vulnerable SUD than those with BPD alone (Pagura et al., biology and an invalidating environment (includ- 2010) . Like intentional self-injury, substance use ing childhood abuse and trauma) that leads to the often functions as a way to regulate negative emo- pervasive disruption of the emotion regulation tions and cognitions, including those speci fi cally system that is central to BPD (Linehan, 1993a ) . In associated with PTSD. Indeed, individuals with this theory, emotional vulnerability is defi ned as BPD are more likely than those without BPD to having a heightened sensitivity to emotional cues, report using illicit drugs or misusing prescribed increased emotional reactivity, and a slow return medications to control PTSD symptoms (Leeies, to emotional baseline, and research has generally Pagura, Sareen, & Bolton, 2010 ) . Recent research con fi rmed the presence of these emotional char- has shown that treatments for co-occurring SUD acteristics among individuals with BPD (see and PTSD that incorporate exposure procedures Rosenthal et al., 2008 for a review). The emotion signifi cantly reduce PTSD without exacerbating dysregulation exhibited by individuals with BPD SUD (e.g., Brady, Dansky, Back, Foa, & Carroll, is further intensi fi ed by the presence of PTSD 2001 ; Mills et al., 2012 ) . However, substance use, (Harned, Rizvi, et al., 2010 ) and can complicate particularly when it occurs during or immediately PTSD treatment in several ways. following exposure tasks, is likely to interfere with corrective learning by inhibiting emotional engage- Over-engagement. In PE, the term “over-engagement and/or preventing a complete test of problem- ment” refers to excessive emotional distress that atic expectancies. This is supported by research renders clients unable to process and incorporate indicating that daily use of benzodiazepines corrective information that is present during expo- decreases the ef fi cacy of exposure therapy for sure (Foa et al., 2007 ) . Foa et al. ( 2007 ) identify PTSD (van Minnen, Arntz, & Keijsers, 2002 ) . two types of over-engaged clients: dissociative Of note, clients with both BPD and PTSD are (e.g., losing the distinction between a memory more likely to be prescribed benzodiazepines than that occurred in the past and being in the present clients with PTSD alone (59.3% vs. 10.8%; Connor moment, having body memories or fl ashbacks) et al., 2006 ) . and emotionally overwhelmed (e.g., sobbing or crying throughout imaginal exposure to the trauma Ongoing trauma. Ongoing abuse and trauma is memory across multiple sessions). Foa et al. present in the lives of many clients with BPD and ( 2007) report that in their extensive clinical expe- is commonly used as an exclusion criterion for rience using PE they have encountered relatively PTSD treatment. Among inpatients with BPD, few clients who manifest severe over-engagement. 14 PTSD and BPD 207

However, our clinical experience suggests that such cases, shame is often accompanied by intense both types of over-engagement occur with some self-hatred as well as rigidly held beliefs of being regularity during exposure with clients with severe inherently bad, disgusting, and unlovable. BPD BPD, and this is likely due to the heightened emo- clients with high levels of shame often exhibit a tion dysregulation and dissociative tendencies variety of avoidance behaviors that are likely to found in this client population. reduce the ef fi cacy of exposure, such as avoiding eye contact and leaving out the most shame-elicit- Under-engagement. At the other end of the spec- ing details from the trauma narrative. trum, the PE manual de fi nes “under-engagement” as dif fi culty accessing the emotional components of the trauma memory (Foa et al., 2007 ) . During Trauma Memory Characteristics exposure, under-engaged clients may report feeling numb or detached, and distress or anxiety The treatment of PTSD among clients with BPD levels are typically low (Foa et al., 2007 ). Under- is often complicated by both the quantity and engagement re fl ects a lack of activation of the quality of their trauma memories. emotional structure which, according to Emotional Processing Theory, is a necessary Large quantity of trauma memories. While many condition for incorporating the corrective infor- individuals with PTSD report multiple traumas, mation that leads to reduction of maladaptive individuals with BPD often report particularly emotions. Indeed, activation (emotional engage- extensive trauma histories. Indeed, repeated abu- ment) is associated with better outcomes during sive experiences, multiple types of abusive expe- PE (e.g., Jaycox, Foa, & Morral, 1998 ) . Under- riences, multiple perpetrators of abuse, and early engagement is also common in clients with BPD age of onset of abuse in childhood have been and can refl ect a general unwillingness to experi- found to distinguish BPD from other diagnostic ence intense emotions. For example, clients with groups (Herman, Perry, & van der Kolk, 1989 ; BPD are less willing than clients without a Ogata et al., 1990 ; Zanarini et al., 1997 ) , and the personality disorder to tolerate distress in order majority of individuals with BPD continue to to pursue desired goals or to approach a poten- experience traumatic events as adults (e.g., tially distressing situation (Gratz, Rosenthal, Zanarini et al., 2005 ) . In addition, nearly all cli- Tull, Lejuez, & Gunderson, 2006 ) found, both of ents with BPD report experiences of neglect, which are critical to the success of exposure- emotional and verbal abuse, emotional with- based PTSD treatments. Of note, it is not unusual drawal by a caretaker, and/or chronic invalidation for a client with BPD to vacillate between being (Zanarini et al., 1997 ) , which, despite not consti- over- and under-engaged within and across expo- tuting “trauma” according to Criterion A of the sure sessions. For example, under-engagement PTSD diagnosis (APA, 2000 ) , are often reported may follow an experience of over-engagement by clients with BPD to be among their most dis- and refl ect an intentional effort to suppress emo- tressing experiences. The sheer number of trau- tions due to fear of becoming over-engaged. matic events experienced by clients with BPD is likely to complicate PTSD treatment. Intense non-fear emotions. Consistent with the conceptualization of PTSD as an anxiety disorder, Poor quality of trauma memories. To complete PTSD is primarily viewed as a disorder associated imaginal exposure for PTSD, individuals must with maladaptive fear. However, BPD clients often remember at least some details of a traumatic report multiple emotions about their traumatic event. While many individuals with PTSD have experiences and fear may or may not be primary. elaborated memories, some have only short or Shame is a particularly common and persistent fragmented memories, particularly those whose emotion in BPD (Rizvi, Brown, Bohus, & Linehan, PTSD is related to childhood abuse. Many clients 2011 ) and is sometimes the primary emotional with BPD are not able to remember enough response to trauma among severe BPD clients. In details about their trauma(s) to create an elabo- 208 M.S. Harned rated narrative, and some have only fragmented Hendriks, & Olff, 2010 ) . In addition, although memories or brief images of certain events. not supported by empirical data, many therapists The degraded memory quality reported by many believe that exposure therapy for PTSD is con- clients with BPD is likely explained by a number traindicated for more complex clients and is of factors, such as the early age of trauma onset, likely to cause increases in suicidality, self- peritraumatic dissociation, and autobiographical injury, dissociation, substance abuse, PTSD memory overgenerality (e.g., Crane & Duggan, symptoms, and dropout (Becker et al., 2004 ; van 2009 ; Eisen & Lynn, 2001 ) . Importantly, these Minnen et al., 2010 ) . Given these common types of brief memories and images often cause beliefs, many therapists are likely to be hesitant signifi cant distress and are frequently reexperi- or even unwilling to implement exposure therapy enced as intrusive memories, fl ashbacks, and for PTSD with BPD clients. Thus, providing nightmares. The treatment of individuals with therapists with the training and support neces- very fragmented trauma memories is often chal- sary to feel confi dent in deciding when and how lenging in part due to concerns about the possi- to implement exposure therapy for PTSD with bility of reifying “false memories” (see McNally, clients with BPD is critical. 2003 for a review of this topic).

Summary Treatment Noncompliance In sum, treating PTSD among clients with BPD, Clients with BPD are often noncompliant with particularly those with a severe level of disorder, treatment, frequently missing or arriving late to is likely to be both complex and challenging. sessions, failing to complete homework, and Treatments for this population not only need to dropping out of treatment prematurely (e.g., be able to address the multiple problems beyond Gunderson et al., 1989 ) . The risk of treatment PTSD that are common among clients with BPD dropout among clients with BPD may be par- but also to provide a clear method for determin- ticularly high during exposure-based PTSD ing when and how to address PTSD in the con- treatments (McDonagh et al., 2005 ; Zayfert text of a plethora of potential treatment targets. et al., 2005 ) , although one study did not fi nd a Some problems may be a higher priority than relationship between borderline characteristics treating PTSD due to safety concerns (e.g., inten- and treatment dropout (Clarke, Rizvi, & Resick, tional self-injury, ongoing trauma) or because, if 2008) . Given research indicating that inconsis- untreated, they are likely to interfere with the tent treatment attendance is the best predictor successful implementation of PTSD treatment of poor outcome in PTSD treatment (Tarrier, (e.g., severe dissociation, substance use, or treat- Sommer fi eld, Pilgrim, & Faragher, 2000 ) , BPD ment noncompliance). Further, several compli- clients with treatment compliance problems cating factors are likely to arise during exposure are unlikely to benefi t from PTSD treatment. therapy with severe BPD clients (e.g., intense shame, over-engagement), which may interfere with the corrective learning that is necessary for Therapist Factors the treatment to work. In addition, strategies for addressing multiple and sometimes fragmented Just as clients with BPD may possess character- trauma memories, including traumatic non-Criterion istics that can interfere with the successful imple- A events, are needed in this population. Finally, mentation of PTSD treatments, so too can their therapists may not have received training in expo- therapists. Relatively few practicing therapists, sure therapy for PTSD and/or may have concerns including trauma experts, have been trained in or about the safety and tolerability of this treatment use exposure procedures for PTSD (Becker, that make them unable or unwilling to implement Zayfert, & Anderson, 2004; van Minnen, it with BPD clients. 14 PTSD and BPD 209

characteristics (BPC) show similar rates of A Review of Existing Treatment improvement in PTSD symptoms (i.e., slopes) Approaches during CBT for PTSD as clients without BPD/ BPC (Clarke et al., 2008; Feeny, Zoellner, & Foa, Few approaches exist for treating PTSD among 2002; Mueser et al., 2008 ) , and one study found clients with BPD, particularly those with recent mixed results across two BPD case studies intentional self-injury. Indeed, the most common (Hendriks, de Kleine, van Rees, Bult, & van approach is not to treat their PTSD by either exclud- Minnen, 2010 ) . Also, one study found that clients ing them from PTSD treatments or including them with BPD (11%) were less likely than those within BPD treatments that do not typically target PTSD. out BPD (51%) to achieve good end-state functioning, which was de fi ned as being below clinical cutoffs on measures of PTSD, depression, and PTSD Treatments anxiety (Feeny et al., 2002 ) . In addition, a feasibility study of narrative exposure therapy for women Historically, it was not uncommon to exclude cli- with BPD and PTSD (n=10) found a signi fi cant ents with BPD from PTSD treatments altogether pre-post reduction in PTSD severity (Pabst et al., due to clinical lore suggesting that they would be 2012 ) . Three studies did not report outcome results unlikely to benefi t and may even decompensate specifi c to the BPD clients in the sample (Ehlers, as a result of these treatments. Indeed, the fi rst Clark, Hackmann, McManus, & Fennell, 2005 ; formal attempt at de fi ning decision-making McDonagh et al., 2005 ; Sachsse, Vogel, & guidelines for the use of exposure therapy for Leichsenring, 2006 ) . Four of the eight studies PTSD included BPD as a condition thought to specifi ed the exclusion criteria that were used, contraindicate the use of exposure (Litz, Blake, which included many BPD-relevant behaviors Gerardi, & Keane, 1990 ) . Although it has become such as recent and/or active suicidality (n = 4, less common to exclude clients with BPD from 100%), substance abuse/dependence (n = 4; 100%), PTSD treatments, this still occurs in some more ongoing abuse or trauma (n = 3, 75%), and recent recent studies (e.g., Speckens, Ehlers, Hackmann, and/or active NSSI (n = 2, 50%). Thus, the general- & Clark, 2006) . It remains a common practice, izability of these results to more severe BPD cli- however, to exclude clients that exhibit certain ents is not known. behaviors that frequently co-occur with severe BPD. For example, a meta-analysis found that Sequential treatments. Three studies evaluating PTSD treatment outcome studies frequently sequential treatments for childhood abuse-related exclude participants due to suicide risk (46%), PTSD have reported including individuals with substance abuse/dependence (62%), and “serious BPD. These treatments each use modifi ed ver- comorbidity” (62%), resulting in a combination sions of DBT to increase behavioral skills prior of exclusion criteria that is likely to exclude most to and/or after exposure therapy for PTSD clients with BPD from PTSD treatment (Bradley, (Bohus, Kruger, Dyer, Priebe, & Steil, 2011 ; Greene, Russ, Dutra, & Westen, 2005 ) . Thus, the Cloitre et al., 2010 ; Steil, Dyer, Priebe, research data on PTSD treatment among clients Kleindienst, & Bohus, 2011 ) . Two of these stud- with BPD is limited both in the number of studies ies (Cloitre et al., 2010; Steil et al., 2011 ) did not available and the generalizability of the fi ndings report results specifi c to clients with BPD (24% to severe BPD clients. of each sample). The third study found that clients with BPD (42% of the sample) showed a Single-diagnosis treatments. Eight PTSD treat- comparable rate of improvement in PTSD symp- ment studies were located that reported including toms as those without BPD (Bohus et al., 2011 ) . clients with BPD (10Ð100% of the total samples), All three studies excluded clients with recent but focused only on treating PTSD (i.e., single- acute suicidality thereby limiting their diagnosis treatments). Three of these studies found generalizability. that clients with BPD or borderline personality 210 M.S. Harned

BPD Treatments Summary

In contrast to PTSD treatments, BPD treat- In sum, the few studies that have examined PTSD ments have often included the most severe treatments among clients with BPD uniformly BPD clients but have not speci fi cally targeted exclude clients with suicidal behaviors and some their PTSD. DBT (Linehan, 1993a, 1993b) is use a variety of additional exclusion criteria that the most empirically supported treatment limit the generalizability of the fi ndings. The available for BPD, and a recent meta-analysis PTSD treatments that have utilized the broadest of 16 DBT studies found a low dropout rate inclusion criteria (e.g., allowing actively self- (27.3%) and moderate effect sizes for DBT in injuring clients to receive treatment) have also terms of global improvement and reductions in used more restrictive treatment settings, includ- intentional self-injury (Kliem, Kröger, & ing inpatient (Sachsse et al., 2006 ) , residential Kosfelder, 2010 ) . DBT is a comprehensive, (Bohus et al., 2011 ; Steil et al., 2011 ) , or inten- principle-based treatment that allows for sive outpatient programs (Hendriks et al., 2010 ) . simultaneous targeting of multiple disorders Thus, no standard outpatient treatments exist that and includes a number of protocols specifying specifi cally target PTSD among severe BPD cli- how to target common problems in BPD (e.g., ents, particularly those with recent intentional suicide crisis protocol, hospitalization proto- self-injury. In addition, although the current state col). Although the DBT manual recommends of the art for treating comorbid disorders is inte- the use of exposure to treat PTSD, it does not grated treatment that allows for simultaneous and include a protocol specifying when or how to fl exible targeting of both disorders by one pro- do this. In addition, the DBT manual warns vider, the existing PTSD treatments that have therapists to be particularly cautious about been examined with BPD clients are either single treating PTSD and suggests that PTSD treat- diagnosis or sequential treatments. Finally, the ment is likely to increase suicide risk and effects of BPD treatments on PTSD are either wreak havoc in the lives of individuals with minimal or unknown. BPD. Thus, although DBT has been shown to be effective in reducing behavioral dyscontrol among clients with both BPD and PTSD An Integrated BPD and PTSD (Harned, Jackson, Comtois, & Linehan, 2010 ) , Treatment: DBT with the DBT it has not routinely targeted PTSD itself. In a PE Protocol study of DBT for suicidal and self-injuring BPD women in which PTSD was not routinely The DBT PE protocol provides a structured targeted, few clients (13%) remitted from method for targeting PTSD within the larger PTSD during 1 year of treatment (Harned context of standard DBT and differs from exist- et al., 2008 ) . Similarly, an effectiveness trial ing treatments by (1) providing integrated, con- of DBT for individuals with Cluster B person- current treatment for both BPD and PTSD; (2) ality disorders found that DBT resulted in only focusing speci fi cally on clients with severe a small reduction in PTSD symptom severity BPD, particularly those with recent intentional compared to treatment as usual (Feigenbaum self-injury; (3) administering treatment in an et al., 2011 ) . Other BPD treatments that have outpatient (i.e., least restrictive) setting; and (4) been evaluated in randomized controlled trials implementing standard DBT (instead of (RCTs) have not included PTSD as an out- modifi ed DBT treatments) in combination with come and their impact on PTSD is therefore PE for PTSD. In addition, the DBT PE protocol unknown (Bateman & Fonagy, 1999 ; Blum incorporates DBT strategies and procedures into et al., 2008 ; Clarkin, Levy, Lenzenweger, & PE to address the complexities that are likely to Kernberg, 2007 ; Giesen-Bloo et al., 2006 ) . arise when treating PTSD in a severe BPD 14 PTSD and BPD 211 client population. Initial case studies (Harned intervention, and relationship repair. Finally, & Linehan, 2008 ) and an open trial (Harned, therapists attend a structured weekly consulta- Korslund, Linehan, & Foa, 2012 ) have been pub- tion meeting to assist each other in the imple- lished, and a pilot RCT is currently underway. mentation of the treatment. Results from the open trial ( n = 13) indicate that Within the DBT target hierarchy, PTSD is this treatment is feasible to administer, highly considered a quality-of-life-interfering behavior acceptable to clients, can be implemented safely and is not targeted until life-threatening and (e.g., no clients exhibited worsening of inten- therapy-interfering behaviors are suf fi ciently tional self-injury), and shows considerable controlled. During the pretreatment phase of promise as an effective intervention for PTSD. DBT, clients’ treatment goals are assessed, At posttreatment, the majority of clients no lon- and those clients who express interest in treat- ger met criteria for PTSD (71.4% of DBT PE ing their PTSD are explicitly told that PTSD protocol completers, 60.0% of the intent-to-treat will not be targeted until all forms of life-threat- [ITT] sample), and these remission rates are ening behavior are stopped. Clarifying this comparable to those found in a meta-analysis of contingency early in treatment has proven to exposure treatments for PTSD (68% of treat- be an effective strategy for increasing commitment completers, 53% of the ITT sample; ment to stop intentional self-injury, particu- Bradley et al., 2005 ) . However, it is important larly for clients who are motivated to receive to note that the DBT PE protocol is still actively PTSD treatment. Treatment then begins with being developed, and some of the procedures standard DBT that focuses on helping clients described below may change as they continue gain control over higher-priority behaviors to be evaluated. and acquire the skills necessary to begin the DBT PE protocol. The speci fi c criteria that are used to determine readiness to begin the DBT Standard DBT PE protocol are the following: (1) not at imminent risk of suicide, (2) no recent (past 2 Standard DBT (Linehan, 1993a, 1993b ) forms months) life-threatening behavior (i.e., suicide the foundation of the treatment and is imple- attempts or NSSI), (3) ability to control life- mented without modi fi cation across four treat- threatening behaviors when in the presence of ment modes: (1) weekly individual DBT cues for those behaviors, (4) no serious ther- psychotherapy (1 h/week), (2) group DBT skills apy-interfering behaviors, (5) PTSD is the training (2.5 h/week), (3) telephone consulta- highest priority target (for the client), and (6) tion (as needed), and (4) therapist consultation ability and willingness to experience intense team (1 h/week). Individual DBT session agen- emotions without escaping. Once these crite- das are determined by a target hierarchy, with ria are met, the DBT PE protocol is begun and life-threatening behavior (e.g., suicidal behav- occurs concurrently with ongoing individual ior and NSSI) as the top priority, followed by DBT therapy, group DBT skills training, and therapy-interfering behaviors (e.g., noncompli- telephone consultation. In addition, the DBT ance, non-collaboration), and serious quality- therapist consultation team functions to proof-life-interfering behaviors (e.g., severe Axis I vide support and training to therapists and to disorders, homelessness, unemployment, rela- address any therapist factors that may inter- tionship problems). Group DBT skills training fere with the implementation of the DBT PE is didactically focused and includes four skill protocol. After the DBT PE protocol is com- modules: (1) mindfulness, (2) interpersonal plete (and assuming time remains in the effectiveness, (3) emotion regulation, and (4) agreed-upon treatment period), standard DBT distress tolerance. Brief telephone contact continues with the focus of treatment deter- between sessions is used for problem-solving mined by the client’s remaining treatment and coaching in generalization of skills, crisis goals, which often include working to improve 212 M.S. Harned existing and develop new relationships. This ner violence by ex-husband) and identify the general treatment structure is compatible with most distressing memory within each category. theories proposing that trauma recovery occurs The potential advantages and disadvantages of in three stages, including establishing safety starting with each of the three identifi ed traumas and stability, remembering and mourning past are discussed, and consistent with PE, clients are trauma, and reconnecting with the world encouraged to start with the most distressing (Herman, 1992 ) . trauma unless there are clinical reasons to believe that this would not be appropriate. The decision about which trauma to target fi rst is ultimately The DBT PE Protocol left to the client. Once this decision is made, additional information speci fi c to the selected The DBT PE protocol is based on PE for PTSD target trauma is collected. Next, DBT strategies (Foa et al., 2007 ) and incorporates DBT strate- for obtaining, strengthening, and troubleshooting gies and procedures into PE to address the par- commitments are used, and clients are asked to ticular complexities of severe BPD clients. commit to (1) not engaging in intentional self- During the implementation of the DBT PE pro- injury during the DBT PE protocol, (2) actively tocol, clients receive either one combined indi- participating in the treatment (including com- vidual therapy session per week (90 min of the pleting homework), and (3) controlling any other DBT PE protocol and 30 min of DBT) or two problem behaviors (e.g., dissociation, substance separate individual therapy sessions per week use) that are likely to interfere with exposure. delivered by the same therapist (one DBT PE In addition, a Post-Exposure Skills Plan is cre- protocol session (90 min) and one DBT session ated that includes DBT skills that can be used to (1 h)). The choice of one or two individual ses- manage increased urges to engage in intentional sions is at the discretion of the client and the self-injury or other distress that may be present therapist and is typically determined by the num- after exposure tasks. In addition to the regular ber of additional (non-PTSD) treatment targets PE Session 1 homework, clients are asked to as well as logistical considerations. Identical to fi nalize this Post-Exposure Skills Plan, share it PE, the DBT PE protocol includes three treat- with primary support people (if any), and prac- ment phases: pre-exposure, exposure, and termi- tice skills from the plan at least once per day. nation/consolidation. Session 2 begins with reviewing homework and providing clients with didactic information Pre-exposure sessions . As in PE, Session 1 on common reactions to trauma, including reac- begins with an overview of the treatment, an ori- tions that are more common in severe BPD entation to the rationale for exposure, and an clients (e.g., dissociation, self-injury, increased assessment of the client’s trauma history. sexual behavior). As in standard PE, the therapist Consistent with PE, the DBT PE protocol can be then orients clients to the rationale for in vivo used to treat one or more traumatic events, and exposure, introduces the Subjective Units of the norm in this client population is to target Distress (SUDs) scale, and works with the client multiple traumatic events. During the trauma to construct the in vivo exposure hierarchy. assessment, clients are therefore asked to iden- Consistent with the DBT skill of opposite action tify the three traumas that are most distressing for shame (Rizvi & Linehan, 2005 ) , in vivo expo- and/or most related to current problems, and sure is also used to confront situations that elicit these can include non-Criterion A events as well unjusti fi ed shame (e.g., saying “no” to sex with a as fragmented memories and images. One strat- partner, sharing aspects of their trauma history egy for narrowing down the large number of with supportive family and friends). Standard PE potential events is to group trauma memories homework tasks are assigned, including instruct- into different categories by trauma type and per- ing clients to complete their fi rst in vivo expo- petrator (e.g., childhood sexual abuse by father, sures and scheduling an optional phone check-in childhood sexual abuse by brother, intimate part- following completion of the fi rst in vivo exposure 14 PTSD and BPD 213 task. In addition, clients are asked to continue Imaginal exposure adheres to the procedures daily practice of skills from the Post-Exposure outlined in the PE manual with the addition of Skills Plan. methods for monitoring problematic urges or An optional third pre-exposure session may emotions that may arise as a result of exposure. be conducted with the client and one or more This is accomplished via a modi fi ed version of support people (e.g., a partner, friend, or parent). the Exposure Recording Form that clients com- The goals of this session are to orient relevant plete before and after all exposure tasks. In family members and friends to the plan to begin addition to recording the standard SUDs ratings, the DBT PE protocol, prepare them for the likeli- clients also report pre-, peak, and post-exposure hood that the treatment will be challenging, and urges to commit suicide, self-injure, quit therapy, enlist their help and support. This session is con- and use substances as well as levels of state ducted in accord with standard DBT strategies dissociation. Clients also provide pre-/post-ratings for joint or family sessions. For example, the for seven specifi c emotions, which are intended DBT strategy of consultation to the client is used to increase clients’ ability to identify and label such that therapists generally do not speak for emotions (a DBT skill) and to allow therapists clients and instead encourage clients to speak for to monitor whether intense non-fear emotions themselves. Clients are also coached to use are present (and perhaps interfering). Clients speci fi c DBT skills while interacting with the also rate the degree to which they radically support person (e.g., using the “DEARMAN” accept that the trauma occurred. Radical accep- skill to ask their partner to provide support in tance is a DBT skill that focuses on letting go of specifi c ways). The timing of this session is fi ghting reality and is particularly relevant to fl exible, but typically takes place prior to Session practice in regard to past trauma. Finally, to aid 1 or between Sessions 1 and 2. If clients do not in monitoring whether corrective learning is have people in their lives that are likely to be occurring, clients provide pre-/post-estimates of effective supports, or they would prefer not to the likelihood and severity of feared outcomes involve such people in the treatment process, this of exposure. session can be skipped. Imaginal exposure begins with the trauma memory the client selected. Consistent with stan- Exposure sessions. In PE, exposure sessions are dard PE, non-Criterion A events are targeted for structured to include time to review homework, treatment when they constitute highly distressing present the session agenda, conduct imaginal events for the client, and this happens routinely exposure, process the imaginal exposure, and with BPD clients. For example, imaginal expo- assign in vivo and imaginal exposure homework. sure is often used to address specifi c episodes of This general session structure is followed with severe invalidation or verbal abuse by a parent as two modi fi cations. First, the session begins with well as relationship breakups that were experi- a brief review of the DBT diary card to ensure enced as traumatic. Similarly, fragmented trauma that no behaviors (e.g., intentional self-injury) memories are routinely targeted during imaginal have occurred that would require the DBT PE exposure with BPD clients given that many of protocol to be stopped. Second, if one 2-h indi- these clients have only partial memories or vidual therapy session is being held per week, the images of some traumatic events. As in standard standard 90-min PE session is augmented by an PE, the following precautions are taken to mini- additional 30 min of DBT. The DBT portion of mize the risk of suggestibility when targeting the session can occur at the beginning (e.g., for these types of fragmented memories. First, cli- clients who tend to be too exhausted at the end of ents are clearly told that the goal of imaginal exposure to engage in additional treatment tasks) exposure is to make whatever memories and or after the exposure (e.g., as an additional images they do have less distressing—not to try strategy to help clients regulate emotions before to remember more details. Although many clients leaving the therapy of fi ce). do naturally remember more trauma details as 214 M.S. Harned they stop avoiding the memories, this is not the therapist strategies is particularly prominent dur- goal of imaginal exposure, and therapists do not ing the processing portion of exposure sessions. make any effort to “uncover” new memories. For example, in standard PE therapists are encour- Second, clients are asked to describe anything aged not to tell the client how she should view the they can remember in as much detail as possible trauma or how the therapist views it and to instead while also being sure not to fi ll in the memory rely on Socratic questioning to help the client gaps with things they do not actually remember. develop these new beliefs for herself. In DBT, Importantly, traumatic events for which the client cognitive modi fi cation strategies include directly has no clear image or memory are not targeted challenging maladaptive styles of thinking and (e.g., when clients report only a vague sense that suggesting more adaptive cognitions. This more “something happened”). directive approach re fl ects the fact that many During imaginal exposure, standard PE strate- clients with BPD have experienced such pervasive gies for managing over-engagement are used as invalidation that they are not able to generate more needed to decrease emotional intensity (e.g., adaptive beliefs on their own. For example, many recounting the trauma narrative with eyes open clients with BPD simply cannot conceive of the and in the past tense, writing out the trauma possibility that they may not have been to blame memory instead of verbally recounting it). In for their abuse. Thus, during the DBT PE protocol, addition, clients are coached to use speci fi c DBT therapists may initially suggest or model more skills to downregulate emotions, such as skills to validating ways of conceptualizing their traumatic reduce emotional intensity (e.g., opposite action), experiences. As these adaptive cognitions become decrease physiological arousal (e.g., progressive more believable, clients are asked to generate muscle relaxation), and tolerate distress (e.g., these self-validating beliefs on their own. Other self-soothe, distraction). Speci fi c DBT strategies examples of DBT therapist strategies that are com- for managing dissociation are also used, includ- monly utilized during processing include the coming using skills designed to provide intense sen- munication strategy of irreverence (e.g., saying sory input to ground clients in the present moment something unorthodox to get clients “unstuck” (e.g., holding ice packs, eating sour candy, stand- from a rigidly held belief) as well as dialectical ing on a balance board, doing wall squats) and strategies (e.g., highlighting polarized thinking implementing contingency management strate- styles and searching for a synthesis). gies to reinforce non-dissociative behavior (e.g., Throughout DBT PE protocol sessions, DBT praise, increase warmth) and punish dissociative procedures are used when needed to address behavior (e.g., withdraw warmth, express irrita- problems that arise from or interfere with expo- tion). Under-engagement is addressed via stan- sure. As described above, clients are coached to dard PE strategies such as prompting clients to use specifi c DBT skills to address problems with include additional details, validating clients’ con- emotional engagement during imaginal exposure. cerns about experiencing emotions, and reorient- In addition, standard DBT protocols are used to ing clients to the rationale for exposure. In target problems that occur during DBT PE proto- addition, clients are coached to use speci fi c DBT col sessions. For example, if a client reports that skills to upregulate emotions, such as mindful- she did not complete her homework, the therapist ness observe and describe skills, mindfulness of would implement the DBT therapy-interfering current emotions and thoughts, willingness, turn- behavior protocol to assess and solve the problem ing the mind, and radical acceptance. and get a commitment to complete homework in Standard DBT therapist strategies (e.g., dialec- the future. Similarly, if a client reports high urges tical, communication, problem-solving, and vali- to commit suicide or self-injure after completing dation strategies) are used throughout the DBT PE an imaginal exposure task, the therapist would protocol to increase compatibility with the larger utilize the DBT life-threatening behavior protocol DBT treatment framework and address the partic- to assess risk, generate solutions, obtain a com- ular emotional, behavioral, and cognitive charac- mitment to a behavioral plan, and troubleshoot teristics of severe BPD clients. The use of DBT the plan. Other DBT protocols (e.g., DBT suicide 14 PTSD and BPD 215 crisis and quality-of-life-interfering behavior pro- Procedures for treating higher-priority behaviors. tocols) are used as needed. The overall goal is to The DBT PE protocol also includes specifi ed pro- utilize DBT to increase the likelihood that expo- cedures for addressing any higher-priority behav- sure will be successful with severe BPD clients iors that may occur. Consistent with the DBT and to decrease the need to stop or postpone target hierarchy, these behaviors would include PTSD treatment once it has been started. life-threatening behaviors, serious therapy-interfering behaviors, or other quality-of-life targets Termination and consolidation. The duration of the that require priority treatment over PTSD. There DBT PE protocol, including the number of trauma is a “zero tolerance” policy for all forms of life- memories that are targeted, is not predetermined threatening behavior (e.g., suicide attempts, NSSI, and is instead based on continuous assessment of suicide threats, suicide preparation behaviors), the client’s PTSD symptoms and treatment goals. and the DBT PE protocol is immediately stopped Once one memory has been suffi ciently processed if these behaviors occur or if there is reason to (e.g., the memory elicits mild to moderate dis- believe the client is at imminent risk of engaging tress), other trauma memories are reassessed to in these behaviors. This rule aims to decrease determine which, if any, continue to elicit high safety concerns and also functions as a contin- levels of distress. Of note, targeting the most dis- gency management strategy to decrease the likeli- tressing memory from a larger category of recur- hood that these behaviors will occur (given that rent trauma is often suf fi cient to relieve distress prematurely stopping the DBT PE protocol is associated with the entire trauma category. experienced as aversive for nearly all clients). As However, if more work is needed on memories in standard PE, the decision to stop the DBT PE from the same or different trauma categories, protocol due to therapy-interfering or quality-of- therapists may gather information about the next life behaviors is at the discretion of the therapist memory and then proceed with imaginal expo- (in consultation with the DBT treatment team). sure. Ultimately, it is up to the client to decide This decision is based on whether (1) stopping the when she has made suf fi cient progress and is DBT PE protocol would effectively punish the ready to end targeted PTSD treatment. To date, behavior, (2) the DBT PE protocol is unlikely to the DBT PE protocol has been conducted in an be effective in the presence of the behavior (e.g., average of 13 sessions and clients have targeted severe dissociation during exposure, signi fi cant approximately 3 trauma memories during this homework noncompliance), and (3) the behavior time (Harned et al., 2012 ) . Once the decision to must be treated now and cannot be effectively or end the DBT PE protocol is made, the fi nal ses- suffi ciently treated while continuing the DBT PE sion follows the same general procedures out- protocol (e.g., active psychosis, threats of vio- lined in standard PE, including conducting a brief lence to others). While the DBT PE protocol is imaginal exposure, reviewing progress, and dis- stopped, standard DBT strategies and protocols cussing relapse prevention strategies. In addition, are used to target the higher-priority behavior(s) the DBT PE protocol includes a set of structured with the goal of resuming PTSD treatment as worksheets on relapse prevention strategies. soon as possible. The DBT PE protocol is not These strategies include creating speci fi c plans resumed until the following conditions have been for continued self-directed exposure practice, met: (1) the behavior that triggered the stopping is learning skills to promote an “exposure lifestyle,” no longer present (if life-threatening) or is planning and rehearsing DBT skills to manage suf fi ciently controlled so as not to interfere with high-risk situations, and identifying DBT skills PTSD treatment (if therapy-interfering or quality- to use in the event of a future increase in PTSD. of-life), (2) the circumstances that contributed to The DBT PE protocol emphasizes relapse pre- the behavior have been altered or addressed, (3) vention given that many severe BPD clients are the therapist and client believe that the client can likely to experience additional trauma as well as prevent further occurrences of the behavior, and periods of high stress and crisis that may increase (4) when appropriate, the client has made their risk of future relapse. suffi cient repairs to those individuals (including 216 M.S. Harned possibly the therapist) who were negatively which she would suddenly fall to the fl oor and impacted by the behavior. As a general rule, the become catatonic for up to 30 min. Both the length of time that the DBT PE protocol is stopped “switching” and the conversion episodes were should match the severity of the behavior that triggered by exposure to trauma-related cues. She triggered the stopping. Of note, in the open trial also engaged in NSSI (hitting her hand against such higher-priority behaviors occurred infre- objects and cutting) about once per month, quently during the DBT PE protocol and these and these episodes always occurred while she procedures were therefore rarely implemented. was dissociated. She met criteria for BPD, PTSD, DID, major depression, panic disorder with agoraphobia, marijuana abuse, ADHD, Case Example of DBT with the DBT PE and obsessive-compulsive personality disorder. Protocol At intake, she was taking Xanax, Klonopin, Effexor, Abilify, and Ritalin. Identifying Information and Relevant History Treatment Process and Complexities “Jody” was a 33-year-old, married, Caucasian woman who lived with her husband and three Standard DBT. Jody reported that her primary young children. Her parents divorced shortly treatment goals were to treat her PTSD and after she was born, and she grew up with her become “one integrated person” (i.e., no longer mother and stepfather, both of whom she have DID). Given these treatment goals, the early described as being very strict and emotionally stage of DBT focused on helping her to gain con- distant. After graduating from high school, Jody trol over life-threatening behaviors and other joined the Army where she had her fi rst “episode” behaviors that would likely interfere with PTSD in which she suddenly fell to the fl oor screaming treatment. This was primarily achieved through while covering her genitals. She saw a military contingency management and skills training strat- counselor after that for 6 months, but no further egies. Namely, Jody was told that the DBT PE episodes occurred. She was honorably discharged protocol would not be implemented until she from the Army after 7 years of service and met stopped self-injuring for a period of at least 2 and married her husband shortly thereafter. She months and demonstrated the ability to control worked full time in a variety of jobs for the next her dissociation, particularly during therapy ses- 6 years and reported always excelling at her work. sions. In addition, she was taught DBT skills to Two years prior to her intake, however, she help prevent and manage urges to self-injure and reported having an “emotional breakdown” after dissociate. These treatment strategies were effec- she began to have intrusive, vivid images of tive in helping Jody to immediately stop self-in- severe childhood sexual abuse for the fi rst time in juring and to increasingly prevent dissociation her life. She became unable to work at that time (including switching) during therapy sessions. and was placed on psychiatric disability. In the She and her therapist also discussed the possibil- past 2 years she had been psychiatrically hospi- ity that her use of benzodiazepines and marijuana talized three times, attended a partial hospital may interfere with the effectiveness of PTSD program for 1 month, and had been in treatment treatment. As a result, Jody decided to taper off with a supportive counselor. During her fi rst hos- her benzodiazepines under the supervision of her pitalization, she was diagnosed with Dissociative prescriber and to rely instead on DBT skills to Identity Disorder (DID) and her dissociation had manage anxiety. However, she was unwilling to gotten progressively worse since that time. At decrease her marijuana use (4Ð5 days per week), intake, she reported having four alters that she as she did not view it as problematic. Because switched to about four times per week as well as there was no evidence that her marijuana use was conversion episodes 2Ð3 times per month during causing signifi cant impairment or interfering with 14 PTSD and BPD 217 treatment, her therapist agreed that the DBT PE open while using anti-dissociation skills as protocol would not need to be delayed because of needed. After Session 3, she became quite it. Given her success at quickly gaining control depressed and had diffi culty functioning (e.g., over higher-priority behaviors, Jody and her ther- stayed in bed most of the day and was unable to apist decided that she was ready to start the DBT care for her children). This lasted for 3 days, after PE protocol after 8 weeks of DBT. It was also which she returned to her regular level of func- decided that the treatment would be implemented tioning. As a result of this experience, in Session in one 2-h session per week due to the limited 4 she intentionally suppressed her emotions due availability of childcare for Jody’s children. to fear that she would become depressed and unable to function again. This under-engagement The DBT PE protocol. In preparation for beginning was addressed by validating her urges to suppress the DBT PE protocol, a session was conducted emotions while also reorienting her to the impor- with Jody’s husband to orient him to the plan to tance of allowing herself to feel emotions in their begin the PTSD treatment and to identify ways in full intensity. Although she then became more which he could provide support (e.g., being avail- willing to experience her emotions, she remained able after exposure sessions as needed). During under-engaged in Session 5. Further assessment Session 1, it became clear that Jody’s memories indicated that this under-engagement was due to of her sexual abuse were very fragmented and the fact that, in an effort to make her trauma nar- that many were only fl ashbulb images. She rative more coherent, she had included details in became very distressed while describing these the imaginal exposure that were things she did trauma memories during the trauma assessment not actually remember. This had the effect of and nearly switched to an alter during this portion decreasing the intensity of the memory by mak- of the session. With coaching from her therapist, ing it less “real.” To address this, Jody was she succeeded in using a number of anti-dissoci- instructed to only describe details that she could ation skills to prevent this (e.g., holding an ice actually remember and was assured that it was pack, standing on a balance board). She ulti- fi ne if the narrative remained fragmented. She mately decided to begin imaginal exposure with was then effectively emotionally engaged in her most distressing memory—a violent child- Sessions 6 and 7, including feeling intense anger hood sexual abuse episode during which she was and disgust toward the perpetrator for the fi rst threatened with a knife. Commitments to no sui- time. By Session 8, her peak SUDs during imagi- cide, self-injury, switching to alters, or dissociat- nal exposure was a 30 and it was decided that she ing during the PTSD treatment were re-obtained was ready to move to another trauma memory. and strengthened. In addition, she committed to Sessions 9Ð14 then focused on addressing her coming to all sessions and completing all expo- second and third most distressing memories (dif- sure homework while not under the infl uence of ferent incidents of sexual abuse by the same per- marijuana and to not using marijuana for at least petrator). Because these two memories were 2 h after completing any exposure task. Session 2 fl ashbulb images and only took several minutes to progressed smoothly, after which she success- recount, she completed imaginal exposure by fully completed her fi rst in vivo exposure task describing them one after the other and then involving sitting in a position that was associated repeating. In Session 10, Jody switched to an alter with her abuse. for the fi rst time during a session, and the expo- Sessions 3Ð8 focused on imaginal exposure to sure had to be stopped for 20 min to get her reori- her most distressing memory, and she experi- ented. She then resumed the exposure and enced several dif fi culties during these sessions. effectively completed two more repetitions of the During her fi rst imaginal exposure in Session 3, narrative in that session. Although she had previ- she experienced three fl ashbacks and was moder- ously been very compliant with homework, ately dissociated. To address the dissociation, she between Sessions 11 and 12, she did not complete completed the imaginal exposure with her eyes any of her imaginal or in vivo exposure homework. 218 M.S. Harned

This increased avoidance was due to her desire to mental health services said, “I haven’t had a chance be “normal,” which included not having to deal to tell my story and am derailed by it. I feel like a with dif fi cult trauma memories. She reengaged in hamster running in circles because I haven’t been treatment with validation from her therapist and able to talk about it.” Thus, treatments that can review of her goals and by Session 15 she no lon- safely and effectively treat PTSD among severe ger met criteria for PTSD and was satisfi ed with BPD clients are critically needed, and the combined the progress she had made. In this fi nal session, DBT and DBT PE protocol treatment described she reported that she had “found peace” with her here has been developed specifi cally to address the past abuse. She had also radically accepted that needs of this complex client population. Although she may never remember all the details about her initial results of this integrated BPD and PTSD abuse and she no longer felt it was important to do treatment are promising, additional research is so. She had stopped avoiding all trauma-related clearly needed to evaluate its ef fi cacy and inform cues, rarely dissociated or switched to alters, had ongoing treatment development. not had a conversion episode for 3 months, and had decreased her marijuana use to approximately Acknowledgements This work was supported by grant once per week. She also reported that her relation- R34MH082143 from the National Institute of Mental Health. ships with her children had greatly improved and I would like to thank the clients, therapists, assessors, and staff at the Behavioral Research and Therapy Clinics for their that she felt much more skillful and able to cope contributions to this research. I am also extremely apprecia- with stressors. tive for the mentorship and guidance provided by Dr. Marsha Linehan and Dr. Edna Foa. Dr. Harned is a trainer and con- Treatment after the DBT PE protocol. The sultant for Behavioral Tech, LLC. remaining 6 months of treatment consisted of standard DBT focused on Jody’s remaining treatment goals, including (1) continuing to experi- References ence and discuss sadness and anger related to her American Psychiatric Association. (2000). Diagnostic abuse, (2) addressing shame and guilt related to and statistical manual of mental disorders (revised 4th having initiated sexual behavior with a cousin on ed.). Washington, DC: American Psychiatric several occasions as a child, and (3) improving Association. her relationship with her husband. She succeeded Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline per- at reaching all of these additional goals, while sonality disorder: A randomized controlled trial. The also maintaining the gains she had already made American Journal of Psychiatry, 156 , 1563Ð1569. in terms of her PTSD, DID, and self-injury. Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42 , 277Ð292. Conclusions and Future Directions Blum, N., St. John, D., Pfohl, B., Stuart, S., McCormick, B., Allen, J., et al. (2008). Systems Training for Emotional Over the past several decades, a number of empiri- Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: A random- cally supported PTSD treatments have been devel- ized controlled trial and 1-year follow-up. The American oped and evaluated among increasingly Journal of Psychiatry, 165 , 468Ð478. representative samples of clients with PTSD. Bohus, M., Kruger, A., Dyer, A., Priebe, K., & Steil, R. However, these highly effective treatments remain (2011, April). Residential DBT program for patients with borderline personality disorder and PTSD after largely inaccessible to clients with severe BPD childhood sexual abuse: A controlled randomized who are typically viewed as unsuitable candidates trial. Presented at the 8th Annual NIMH Conference for PTSD treatment. As a result, these clients often of the National Education Alliance for Borderline suffer tremendously under the burden of chronic Personality Disorder, Seattle, WA. Bolton, E. E., Mueser, K. T., & Rosenberg, S. D. (2006). PTSD, a co-occurring condition that frequently Symptom correlates of posttraumatic stress disorder in underlies or exacerbates BPD-related problems. clients with borderline personality disorder. As one of our BPD clients, a 25-year utilizer of Comprehensive Psychiatry, 47 , 357Ð361. 14 PTSD and BPD 219

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A pilot study of ‘opposite action’. Cognitive and Weierich, M. R., & Nock, M. K. (2008). Posttraumatic Behavioral Practice, 12 , 437Ð447. stress symptoms mediate the relation between child- Rosenthal, M. Z., Gratz, K. L., Kosson, D. S., Cheavens, hood sexual abuse and nonsuicidal self-injury. J. S., Lejuez, C. W., & Lynch, T. R. (2008). Borderline Journal of Consulting and Clinical Psychology, 76 , personality disorder and emotional responding: A 39Ð44. review of the research literature. Clinical Psychology Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. Review, 28 , 75Ð91. B., & Silk, K. R. (2004). Axis I comorbidity in patients Rusch, N., Corrigan, P. W., Bohus, M., Kuhler, T., Jacob, with borderline personality disorder: 6-year follow-up G. A., & Lieb, K. (2007). The impact of posttraumatic and prediction of time to remission. The American stress disorder on dysfunctional implicit and explicit Journal of Psychiatry, 161 , 2108Ð2114. emotions among women with borderline personality Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. disorder. The Journal of Nervous and Mental Disease, B., & Silk, K. R. (2006). Prediction of the 10-year 195 , 537Ð539. course of borderline personality disorder. The Sachsse, U., Vogel, C., & Leichsenring, F. (2006). Results American Journal of Psychiatry, 163 , 827Ð832. of psychodynamically oriented trauma-focused inpa- Zanarini, M. C., Frankenburg, F. R., Marino, M. F., tient treatment for women with complex posttraumatic Reich, D. B., Haynes, M. C., & Gunderson, J. G. stress disorder (PTSD) and borderline personality (1999). Violence in the lives of adult borderline cli- disorder (BPD). Bulletin of the Menninger Clinic, 70 , ents. The Journal of Nervous and Mental Disease, 125Ð144. 187, 65Ð71. Sar, V., Akyuz, G., Kugu, N., Ozturk, E., & Ertem-Vehid, H. Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Fitzmaurice, (2006). Axis I dissociative disorder comorbidity in border- G., Weinberg, I., & Gunderson, J. G. (2008). The 10-year line personality disorder and reports of childhood trauma. course of physically self-destructive acts reported by bor- The Journal of Clinical Psychiatry, 67 , 1583Ð1590. derline patients and axis II comparison subjects. Acta Speckens, A. E. M., Ehlers, A., Hackmann, A., & Clark, Psychiatrica Scandinavica, 117 , 177Ð184. D. M. (2006). Changes in intrusive memories associated Zanarini, M. C., Frankenburg, F. R., Reich, B., Hennen, with imaginal reliving in posttraumatic stress disorder. J., & Silk, K. R. (2005). Adult experiences of abuse Journal of Anxiety Disorders, 20 , 328Ð341. reported by borderline patients and Axis II compari- Steil, R., Dyer, A., Priebe, K., Kleindienst, N., & Bohus, son subjects over six years of prospective follow-up. M. (2011). Dialectical Behavior Therapy for posttrau- The Journal of Nervous and Mental Disease, 193 , matic stress disorder related to childhood sexual abuse: 412Ð416. A pilot study of an intensive residential treatment pro- Zanarini, M. C., Laudate, C. S., Frankenburg, F. R., Reich, gram. Journal of Traumatic Stress, 24 , 102Ð106. D. B., & Fitzmaurice, G. (2011). Predictors of self- Tarrier, N., Sommer ﬁ eld, C., Pilgrim, H., & Faragher, B. mutilation in patients with borderline personality dis- (2000). Factors associated with outcome of cognitive-be- order: A 10-year follow-up study. Journal of havioural treatment of chronic post-traumatic stress dis- Psychiatric Research, 45 , 823Ð828. order. Behaviour Research and Therapy, 38 , 191Ð202. Zanarini, M. C., Ruser, T., Frankenburg, F. R., & Hennen, Trull, T. J., Sher, K. J., Minks-Brown, C., Durbin, J., & J. H. (2000). The dissociative experiences of borderline Burr, R. (2000). Borderline personality disorder and patients. Comprehensive Psychiatry, 41, 223Ð227. substance use disorders: A review and integration. Zanarini, M. C., Williams, A. A., Lewis, R. E., Reich, R. Clinical Psychology Review, 20 , 235Ð253. B., Vera, S. C., Marino, M. F., et al. (1997). Reported van Minnen, A., Arntz, A., & Keijsers, G. P. J. (2002). pathological childhood experiences associated with the Prolonged exposure in patients with chronic PTSD: development of borderline personality disorder. The Predictors of treatment outcome and dropout. American Journal of Psychiatry, 154 , 1101Ð1106. Behaviour Research and Therapy, 40 , 439Ð457. Zayfert, C., DeViva, J. C., Becker, C. B., Pike, J. L., van Minnen, A., Hendriks, L., & Olff, M. (2010). When do Gillock, K. L., & Hayes, S. A. (2005). Exposure utili- trauma experts choose exposure therapy for PTSD zation and completion of cognitive behavioral therapy patients? A controlled study of therapist and patient fac- for PTSD in a “real world” clinical practice. Journal of tors. Behaviour Research and Therapy, 48 , 312Ð320. Traumatic Stress, 18 , 637Ð645. Treatment of Anxiety and Comorbid Cluster A Personality Disorders 1 5

Han-Joo Lee and Jennifer E. Turkel

avoidant PD are considered to lie on a continuum Overview (Holt, Heimberg, & Hope, 1992 ; Turner, Beidel, & Townsley, 1992 ) . Having comorbid conditions represents the norm In contrast to Cluster C PDs, there is a paucity rather than the exception among individuals with of empirical research on Cluster A PDs in the anxiety disorders (Brown & Barlow, 1995 ; context of anxiety disorders, although there is Brown, Campbell, Lehman, Grisham, & Mancill, some evidence that suggests important phenom- 2001 ) . There is convincing evidence that person- enological and theoretical linkage between anxiety ality disorders (PDs) frequently co-occur with disorders and these odd and eccentric PDs. anxiety disorders. For example, in an early study Further, this rarely reported but clinically based on a large outpatient sample with a primary signiﬁ cant co-occurrence of Cluster A PDs is diagnosis of anxiety disorder, 35% of the patients suspected to pose numerous challenges to the presented with at least one diagnosable PD treatment for anxiety disorders. In order to dis- (Sanderson, Wetzler, Beck, & Betz, 1994 ) . One cuss the complexity of such comorbidity, this of the highest comorbidity rates was reported by chapter presents the following: (a) a brief review Skodol, Oldham, Hyler, and Stein (1995 ) ; 62% of of Cluster A PDs in DSM-IV-TR, (b) research patients with anxiety disorders were diagnosed evidence that supports the phenomenological with a comorbid PD. It should be noted that this linkage between Cluster A PDs and anxiety dis- line of research has consistently shown that anxi- orders, (c) clinical complications that may arise ety disorders are strongly associated with Cluster from Cluster A PDs comorbid with anxiety disor- C PDs (i.e., avoidant, dependent, and obsessive- ders, (d) therapeutic strategies to address compli- compulsive PDs). This is understandable, because cations and challenges of such comorbidity cases, the fearful and anxious PDs in Cluster C share and (e) a clinical case that illustrates how to numerous similarities with anxiety disorders in understand and treat an individual presenting their core clinical manifestations such as fearful with complex anxiety problems mixed with emotional reactions, marked avoidance, and pas- comorbid Cluster A PD. sivity, as well as in their diagnostic criteria (American Psychiatric Association (APA), 2000 ) . For instance, generalized social phobia and Cluster A Personality Disorders

The DSM-IV-TR de ﬁ nes a PD as “an enduring * H. -J. Lee ( ) ¥ J. E. Turkel pattern of inner experience that deviates mark- Department of Psychology , University of Wisconsin- Milwaukee , Milwaukee , WI 53211 , USA edly from the expectations of the individual’s e-mail: [email protected] culture, is pervasive and inﬂ exible, and had an

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 223 DOI 10.1007/978-1-4614-6458-7_15, © Springer Science+Business Media New York 2013 224 H.-J. Lee and J.E. Turkel onset in adolescence or early adulthood, is stable individual displays a flattened emotional response over time and leads to distress or impairment” to what others might respond with joy, anger, or (APA, 2000) . The DSM-IV-TR subdivides PDs sorrow. Due to the lack of adaptive social skills, into three clusters. For the purposes of this chap- an individual with schizoid PD communicates dis- ter, we will be focusing on Cluster A, the odd and interest and further withdraws from the social eccentric pattern of personality, which is com- world, resulting in increased social isolation. prised of paranoid, schizotypal, and schizoid Prevalence estimates for schizoid PD are believed PDs. A hallmark feature of Cluster A PDs is to be around 1.7% (Torgersen et al., 2001 ) . severe distortion in interpreting other people’s behavior and resulting social isolation. Paranoid PD is characterized by a pattern of Phenomenological Linkage Between distrust and suspiciousness of others and affects Cluster A PDs and Anxiety Disorders 2.4% of the general population (Torgersen, Kringlen, & Cramer, 2001 ) and an even greater The DSM-IV criteria indicate that fear and anxi- proportion in inpatient psychiatric populations, ety are likely to contribute to clinical manifesta- in the range of 10Ð30% (APA, 2000 ) . People with tions of Cluster A PDs. Similar to social phobia, paranoid PD are constantly on guard and ready to schizotypal PD is characterized by excessive detect threats in their environment. This preoc- social anxiety, although its core threat is centered cupation with monitoring ones surroundings on paranoid suspiciousness rather than negative leads paranoid individuals to appear on edge, evaluation about the self. Likewise, paranoid unable to relax, and hypersensitive. Once they PD’s diagnostic criteria describe unwarranted perceive a threat, whether the threat is real or fear about the malicious use of one’s own infor- imagined, the individual is likely to respond in an mation and concerns (doubts) about the trustwor- aggressive manner that further elicits a hostile thiness of friends or associates, which may be response in return. Individuals with paranoid PD similar to the qualities often evidenced by patho- are wary of entering into close relationships logical worrying or obsessional rumination. because they are mistrustful and believe others Evidence from well-controlled longitudinal are capable and motivated to use any information studies also provides support for the close link- obtained in a manipulative or deceitful manner. age between Cluster A PDs and anxiety disor- Individuals with schizotypal PD experience ders. Adolescent anxiety disorders signi fi cantly discomfort in social relationships in addition to predicted schizotypal , schizoid , borderline, clear disturbances in cognition and perception. avoidant, and dependent personality traits mea- Prevalence of schizotypal PD in the general pop- sured in early adulthood, even after controlling ulation has been estimated to be approximately for the Axis I diagnostic status in adolescence 3%; more males than females are affected (APA, (Lewinsohn, Rohde, Seeley, & Klein, 1997 ) . 2000 ) . Some individuals with schizotypal PD Johnson et al. (1999 ) also found that adolescent believe they have the ability to read others’ minds PDs were signifi cantly associated with elevated and control others’ behavior. Additionally, many risk for developing anxiety disorders during early individuals with schizotypal PD exhibit supersti- adulthood. In this analysis, Cluster A PDs tious or magical thinking and display inappropri- revealed a higher odd ratio (OR = 3.83), relative ate or constricted affect. They often lack proper to Cluster B (OR = 2.64) and Cluster C (OR = 3.32) hygiene or have a disheveled appearance. PDs. Moreover, the association between Cluster A person with schizoid PD exhibits social and A PDs in adolescence and anxiety disorders in emotional detachment as indicated by a lack of desire early adulthood remained signifi cant even after for friendships as well as romantic and familial controlling for Axis I conditions and co-occurring relationships. They have a preference for engaging PDs in adolescence (Johnson et al., 1999 ) . Overall, in solitary activities and are likely to experience a the causal pattern of interplay between Cluster A lack of pleasure in daily activities. The schizoid PDs and anxiety disorders on developmental tra- 15 Treatment of Anxiety and Comorbid Cluster A Personality Disorders 225 jectory is not clear, but these fi ndings certainly out, or fail to respond to existing treatments provide important empirical data supporting their (Moritz et al., 2004 ) . Thus, many researchers have close phenomenological linkage. made efforts to examine putative treatment mod- As reviewed here, there is reason to suspect erators for OCD in order to improve the overall that coexistence of anxiety disorders and Cluster treatment response rates for this debilitating anxi- A PDs is not as uncommon as usually thought. ety disorder. Among several candidates, schizo- However, there is a remarkable lack of research typal PD has received much attention as a negative concerning the impact of comorbid Cluster A PDs prognostic factor in treatment for OCD. Jenike, on treatment of anxiety disorders. The most sus- Baer, Minichiello, Schwartz, and Carey (1986 ) pected culprit for the profound lack of available examined 43 patients with treatment-resistant data on this important topic is clinical characteris- OCD and showed that 26 out of 29 OCD patients tics of Cluster A PDs themselves. Individuals with without schizotypal PD (90%) improved at least paranoid and schizotypal PDs are characterized moderately, whereas 13 of 14 OCD patients with by enormous dif fi culties in con fi ding in others and schizotypal PD (93%) failed to show improve- hypervigilance and suspiciousness in interper- ment. Minichiello, Baer, and Jenike (1987 ) , using sonal contexts. Schizoid PD is characterized by a sample of 29 patients with OCD, found that of indifference and aloofness. Thus, it is highly 19 patients without schizotypal PD, 16 (84%) unlikely for individuals with Cluster A PDs to showed at least a moderate level of improvement spontaneously seek relevant treatment resources in response to exposure and response prevention or participate in clinical research activities. Not (ERP) alone or a combined ERP and pharmaco- surprisingly, Cluster A PDs have not been studied therapy. In contrast, of 10 OCD patients with as thoroughly as Cluster B and C PDs, which may comorbid schizotypal PD, only 1 (10%) improved again be attributed to the dif fi culty in recruiting in response to the same treatments. Similarly, participants with Cluster A PDs. To date, there Baer et al. (1992 ) found that in patients with OCD seems to be no randomized clinical trial research who were treated by clomipramine over a 10-week conducted for Cluster A PDs. period, schizotypal, borderline, and avoidant PDs Likewise, very little is known about how each were signi fi cantly associated with poorer treat- of the Cluster A PDs is linked to anxiety disorders ment outcome. in terms of its impact on clinical manifestations These fi ndings were further elaborated by and therapy processes. Despite defi cient empirical some evidence showing that only a certain aspect data, we have identifi ed a few relevant topics that of schizotypal features is responsible for treat- have repeatedly appeared in the literature, which ment failure in OCD (Moritz et al., 2004 ) . This may assist in understanding the nature of this study showed that positive schizotypal symptoms comorbidity: (a) schizotypal PD as a negative such as perceptual aberrations, magical thinking, prognostic factor in treatment for obsessive-com- and sensory irritation were associated with pulsive disorder (OCD), (b) schizotypy (schizo- increased risk for poorer treatment outcomes, typal personality features) and its close linkage to whereas negative schizotypal symptoms were OCD, and (c) paranoid PD frequently co-occurring not. However, it should be mentioned that some with panic disorder. authors failed to fi nd a signi fi cant association between poor treatment outcome in OCD and PDs (e.g., Dreessen, Hoekstra, & Arntz, 1997 ; Comorbid Schizotypal PD and Its Fricke et al., 2006 ) . Other studies found alternate Negative Impact on Treatment types of PDs to be negative treatment predictors Outcome for OCD for OCD such as borderline, avoidant, and passive-aggressive PDs (Baer et al., 1992 ; Hermesh, Empirically supported pharmacological and Shahar, & Munitz, 1987; Steketee, 1990 ) . behavioral interventions exist for OCD, but almost Nevertheless, there is considerable evidence that half of patients with OCD seem to refuse, drop demonstrates the negative impact of schizotypal 226 H.-J. Lee and J.E. Turkel

PD on treatment outcome in OCD. Further signifi cantly greater schizotypal features, relative research is warranted on this topic due to its direct to a mixed group of patients with other anxiety relevance for enhancing overall treatment disorders (Enright, Claridge, Beech, & Kemp- response in OCD. Wheeler, 1993 ) . Sobin et al. ( 2000 ) proposed that there is a schizotypy subtype in OCD based on the fi ndings that mild to severe levels of positive Elevated Schizotypy in Individuals schizotypy signs such as magical ideation and with OCD ideas of reference (IOR) were displayed in approximately half the study sample consisting A closely related line of research has investigated of OCD patients. Moreover, OCD patients were the association between OCD and schizotypy. found to show as high self-report schizotypy Although OCD and schizophrenia are easily dis- scores as schizophrenic or bipolar patients, tinguished, there is a growing line of research whereas all three groups showed higher schizo- that has demonstrated a signi fi cant linkage typy scores than unipolar depressive patients between OCD and schizotypy. Schizotypy is (Rossi & Daneluzzo, 2002 ) . In addition, Lee and defi ned as personality traits that are similar to Telch ( 2005 ) showed that mental intrusions char- symptoms of schizophrenia but are manifested in acterized by sexual, aggressive, and religious an attenuated form (Meehl, 1962 ) . From this obsessions are signi fi cantly associated with posi- point of view, schizotypy is regarded as tive schizotypy such as magical thinking and nonspecifi c psychosis-proneness (Claridge et al., unusual perceptual experiences among nonclinical 1996 ) , or a liability to schizophrenia (Lenzenweger students. Poyurovsky and colleagues (2008 ) & Kor fi ne, 1995 ) . In the literature, schizotypy study found that OCD patients showed poorer and schizotypal personality traits are treated as insight, more negative symptoms, overall lower interchangeable terms that refl ect dimensional functioning, greater need for antipsychotic aug- characteristics varying on a continuous spectrum. mentation, as well as more schizophrenia-spec- Currently, there are two diverging views on the trum conditions among fi rst-degree relatives, nature of the schizotypy continuum (Asai, when they had comorbid schizotypal PD. Some Sugimori, Bando, & Tanno, 2011 ) : (a) a fully authors have suggested that at least a subgroup of dimensional view suggesting that schizotypy is a OCD patients may be linked to the schizophrenic general personality trait evidenced by all people spectrum along a multidimensionality of schizo- to a varying degree, and (b) a quasi-dimensional typy (Pallanti, 2000 ) . view conceptualizing that schizotypy is a predis- However, these data are mostly cross-sec- position to schizophrenia that is shown only by tional, and no conclusions can be drawn about those with schizophrenic genes . Regardless of the pathogenetic mechanisms underlying the where the lower-end limit of the schizotypy spec- coexistence of OCD and schizotypy. This line of trum exists, the majority of authors (e.g., Calkins, research also takes a dimensional view of Curtis, Grove, & Iacono, 2004 ; Kerns, 2006 ) sug- schizotypy, and thus elevated schizotypy scores gest schizotypy is a multidimensional construct do not necessarily indicate the presence of that encompasses (a) positive schizotypy (cogni- DSM-IV schizotypal PD. Nevertheless, these tive dyscontrol such as magical thinking and fi ndings contribute to revealing the linkage unusual perceptual experiences), (b) negative between OCD and schizotypy and are also con- schizotypy (social anhedonia and interpersonal sistent with the well-known fact that OCD is suspiciousness), and (c) disorganized schizotypy commonly associated with magical beliefs (disorganized speech and behavior tendencies). (Einstein & Menzies, 2004 ; Tibbo, Kroetsch, There is compelling evidence for elevated Chue, & Warneke, 2000 ). One way for OCD to schizotypy scores (schizotypal personality traits) link to Cluster A PD appears to be through the in OCD. Patients with OCD were found to show shared schizotypy features. 15 Treatment of Anxiety and Comorbid Cluster A Personality Disorders 227

Panic Disorder and Paranoid and schizoid PDs were also found to be strongly Personality Features associated with the prevalence of panic disorder with agoraphobia (OR = 12.4, 13.1), social pho- Another line of empirical data that reveals the bia (OR = 10.0, 10.4), and GAD (OR = 10.9, 8.2). linkage between anxiety disorders and Cluster A Taken together, this study revealed that Cluster A PDs concerns the elevated paranoid personality PDs were signi fi cantly associated with current features in panic disorder. Overall, panic disor- anxiety disorders, particularly panic disorder. der, along with social phobia and GAD, tends to Marchesi, Cantoni, Fontò, Giannelli, and show highest rates of comorbid PDs among anxi- Maggini (2005 ) conducted a longitudinal study, in ety disorders (Grant et al., 2005 ; Sanderson et al., which patients with panic disorder were treated 1994 ) . However, in light of clinical features of with pharmacotherapy and PDs were assessed panic disorder, it is somewhat puzzling to see using the structured diagnostic interview for elevated paranoid PD in individuals with panic DSM-IV personality disorders (SIDP) before and disorder. after the treatment. At baseline, 60% of the Reich and Braginsky ( 1994 ) reported that patients with panic disorder showed comorbid among 28 patients with panic disorder who were PDs, whereas only 8% of normal matched con- presented to a community mental health center, trols showed PDs. The most frequent PDs included 54% of them showed paranoid PD, as assessed by obsessive-compulsive (18.3%), dependent the Personality Diagnostic Questionnaire-Revised (13.3%), narcissistic (13.3%), avoidant (11.6%), (PDQ-R; Hyler et al., 1988 ) . The patients dis- and paranoid PDs (11.6%). After treatment, the playing elevated paranoid personality features overall comorbidity rate was diminished to 43%, also revealed an earlier age of onset, longer dura- and the reduction of panic symptoms was found tion of illness, and overall greater psychopatho- to be associated with the reduction in paranoid, logical symptoms. In a recent study involving avoidant, and dependent traits. 122 adult patients with panic disorder (Ozkan & Taken together, although paranoia is not con- Altindag, 2005 ) , 33.9% who showed at least one sidered an obvious clinical feature of panic disor- comorbid PD were found to show earlier ages of der, several studies have reported signifi cantly onset, more severe anxiety, depression, and ago- elevated paranoid PD from the Cluster A family raphobic symptoms and overall lower levels of among individuals with panic disorder. The rea- functioning. Particularly, comorbid paranoid PD son for this unexpected but frequently observed was found to be a signifi cant predictor of suicide association is not clear, but one possible explana- attempts, along with borderline PD. A more tion is that some aspects of the way individuals recent study examined the prevalence and asso- experience panic disorder seem to have some ciations between DSM-IV mood and anxiety dis- parallels with experiences of individuals suffer- orders and PDs using the National Institute on ing from paranoid PD (Noyes, Reich, Suelzer, & Alcohol Abuse and Alcoholism’s 2001Ð2002 Christiansen, 1991 ) . Individuals with panic dis- national epidemiologic survey data (NESARC; order tend to be hypervigilant and have diffi culty Grant et al., 2005 ) . The wave 1 data assessed 7 relaxing. They also have trouble having others PDs (i.e., avoidant, dependent, obsessive- accept their illness and show heightened interper- compulsive, paranoid, schizoid, histrionic, and sonal sensitivity. Moreover, those with panic dis- antisocial). Overall, avoidant and dependent PDs order with agoraphobia generally perceive people were more strongly associated with current anxi- around them to be unhelpful in the event of a ety disorders than any other PDs assessed in the panic attack, which may suggest the possibility study. The odd ratios (ORs) of having avoidant that they have a low level of interpersonal trust. and dependent PDs were 21.0 and 37.2 times Additionally, given fi ndings that show a greater among those with panic disorder with signi fi cant reduction of paranoid personality fea- agoraphobia, relative to the odds of those who tures in panic disorder after pharmacotherapy did not have current anxiety disorders. Paranoid (Marchesi et al., 2005 ; Noyes et al., 1991 ) , 228 H.-J. Lee and J.E. Turkel comorbid paranoia may be a state-like alterable Comorbid Cluster A PDs May Dampen personality feature. Further research is warranted the Motivation for Treatment to explore the nature of the association between panic disorder and paranoid PD. There is a notable shortage of empirical data on treatment of Cluster A PDs. Clinical observations suggest that one hardly encounters patients who Factors of Cluster A PDs That present Cluster A PDs as their chief complaints Contribute to the Complexity in clinical settings. We believe that this lack of of Anxiety Disorders empirical data at least in part re fl ects the serious motivational issue linked to Cluster A PDs that A comprehensive review by Dreessen and Arntz impedes spontaneous treatment seeking. Overall, (1998 ) including only high-quality clinical trials more than 90% of all treatment outcome studies (which assessed PDs using a structured diagnos- are focused on borderline PD, and this is the only tic interview in a prospective research design) group for which suf fi cient information exists to concluded that the overall evidence for negative formulate treatment guidelines (APA, 2001 ) . impact of comorbid PDs on treatments of anxiety There is some research evidence that clearly indi- disorders is weak. Nevertheless, there are several cates the low treatment-seeking tendency associ- studies that suggest the negative effects of schizo- ated with Cluster A PDs. Tyrer, Mitchard, typal and paranoid PDs on treatment of anxiety Methuen, and Ranger ( 2003 ) proposed a disorders. Long-standing clinical observations classi fi cation scheme for PDs based on their willing- also speak to the increased dif fi culty in treating ness to seek treatment: treatment seekers (type S) individuals with anxiety disorders when comor- and treatment rejectors (type R). Type R is char- bid Cluster A PDs are present. Considering the acterized by their unwillingness and reluctance to characteristics of the odd and eccentric PDs, irre- present with personality issues as part of treat- spective of the resulting ef fi cacy of existing clini- ment problems, engage in psychological assess- cal interventions when treating anxiety disorders ment and treatment, take drug treatments, accept combined with Cluster A PDs, therapeutic pro- diagnosis of PD, and change to at least some cesses would become more challenging when degree. In their study using 68 patients with PDs, such personality features are present in addition patients with Cluster C PDs were signifi cantly to anxiety problems. There are at least fi ve impor- more likely to be type S, whereas patients with tant clinical features of Cluster A PDs that would paranoid and schizoid PDs were signi fi cantly render the treatment of anxiety disorders highly more likely to be type R. Only 3 out of 25 patients complicated (see Fig. 15.1 ). with paranoid PD (11%) and 1 out of 17 patients

Anxiety

1. Lower Motivation Disorders 5. Extremely Poor for Treatment Social Functioning

2. Increase Difficulty Cluster A PDs 4. Increase Illogical Establishing Rapport Thinking & Perception

3. Worsen Information Processing Deficits

Fig. 15.1 Complexity in treating anxiety disorders with comorbid Cluster A PDs 15 Treatment of Anxiety and Comorbid Cluster A Personality Disorders 229 with schizoid PD (6%) were classi fi ed as type S are core interpersonal features of paranoid and (Tyrer et al., 2003 ). schizotypal PDs. Similarly, schizoid PD is also Given these fi ndings and common clinical characterized by extremely level of interpersonal observations (i.e., a remarkable lack of patients aloofness and lack of desire and need for close presenting with Cluster A PDs), it is conceivable relationship (APA, 2000 ) . Even if an individual that comorbid Cluster A PDs may adversely affect with comorbid Cluster A PD manages to come the individual’s willingness to seek treatment for into therapy, the formation and maintenance of a anxiety disorders, as compared with the cases of trustworthy and confi ding relationship with the pure anxiety disorders with no Axis II comorbid- therapist would be a challenging task. ity. Likewise, comorbid Cluster A PD may hinder As a general therapeutic factor, sound the patient’s overall efforts during treatment, therapeutic alliance is instrumental in promoting reduce overall compliance with treatment proce- positive treatment outcomes in psychological dures such as homework, and increase the chance treatments (Martin, Garske, & Davis, 2000 ) . of early termination of therapy, resulting in over- Particularly, in the treatment of anxiety disorder, all suboptimal treatment outcomes for anxiety many therapeutic techniques require the patients disorders. Considering that receptivity to treat- to be courageous and fully committed to highly ment rationale and procedures (e.g., homework) intense and distressing procedures (e.g., in vivo or signifi cantly predicts CBT outcomes (Addis & imaginal exposure to intense fear-provoking Jacobson, 2000 ; Burns & Spangler, 2000 ) , comor- objects, events, or situations) and directly confront bid Cluster A PDs may likely serve as an obstacle the aversive stimuli that they have striven to avoid for favorable treatment outcome by dampening for months or years. Oftentimes, self-guided expo- overall willingness, adherence, and commitment sure or behavioral experiments are an essential to the treatment for anxiety disorders. part of homework that is critical in generalizing De fi cient motivation and willingness for in-session therapeutic gains to day-to-day life and change associated with Cluster A PDs may mani- also in collecting further data to disconfi rm errone- fest differently among individuals whose present- ous beliefs about the feared objects or situations. ing problems are anxiety disorders. Alternatively, Thus, from theoretical and clinical standpoints, it the negative infl uence of Cluster A PDs on is believed that good therapeutic alliance is needed patients’ motivation may be overridden by will- as a prerequisite for behavioral treatment of anxi- ingness to change the acute distress caused by ety disorders (Langhoff, Baer, Zubraegel, & primary anxiety disorders. Hence, efforts to col- Linden, 2008 ) . Collaboration is a key philosophy lect empirical data should be made to elucidate in any psychological interventions for anxiety dis- this important issue. orders, whereas a fragile and mistrustful relationship with the therapist is highly likely to impede effective implementation of therapeutic proce- Cluster A PDs Likely Cause Signi fi cant dures and restrict the patient’s ability to gain ade- Dif fi culty in Establishing Rapport quate bene fi ts from treatment. In this regard, comorbid Cluster A PD is suspected to present a Another complicating factor of comorbid Cluster signi fi cant challenge in treating individuals with A PDs is the individual’s dif fi culty in forming anxiety disorders, although their mistrustful, trustworthy and intimate relationships, which hypervigilant, or distant interpersonal qualities would contribute to the diffi culty in establishing may not be highlighted as the primary agenda in good rapport (Bender, 2005 ) . Interpersonally, session unless they become a roadblock in making Cluster A PDs are associated with remarkable progress. Considering the critical importance of diffi culty in trusting people, lack of warmth, initial therapy sessions for therapeutic alliance guardedness and defensiveness, and indifference (Horvath & Luborsky, 1993 ; Horvath & Symonds, to or avoidance of intimate relationships. The 1991 ) , this is one of the most important areas that pervasive sense of mistrust and suspiciousness deserve special attention in treatment. 230 H.-J. Lee and J.E. Turkel

Information-Processing Defi cits Trower, 1997 ) ; and (c) misperception of emotional cues as anger or disgust (Peer, Rothmann, Cognitive theories of anxiety disorders (e.g., Beck, Penrod, Penn, & Spaulding, 2004 ; Smari, Emery, & Greenberg, 1985 ) propose that patho- Stefansson, & Thorgilsson, 1994 ) . Moreover, logical anxiety problems are caused and main- individuals with paranoid PD are overly confi dent tained by distorted information processing, by in selectively fi ltered evidence in support of their which the meaning and consequences of the event biased beliefs and suspicions, while effectively are misperceived or exaggerated. Thus, treat- disregarding discon fi rming evidence. ments based on this perspective highlight the Thus, comorbid Cluster A PDs might adversely importance of identifying and altering distorted affect patients’ abilities to benefi t from standard information processing. For example, individuals cognitive interventions for anxiety disorders by with social phobia have a markedly biased pat- diminishing their overall cognitive capabilities to tern of perceiving and interpreting social situa- effectively and objectively select, interpret, and tions in a way that boost their pathological fears integrate data in modifying cognitive biases asso- about being negatively evaluated by others or ciated with their emotional distress. De fi cits in humiliating themselves in front of others (Rapee selective attention are also problematic in treat- & Heimberg, 1997) . Over the past few decades, ment for anxiety, considering there is some evi- there has been an explosive growth in experimen- dence that anxiety reduction can be best achieved tal psychopathology research that has illuminated when attention is consistently sustained to the the nature of information-processing biases feared objects (Rodriguez & Craske, 1993 ) . underlying anxiety problems. Paranoid suspicion often takes the form of unwar- From these considerations, another potential ranted convictions about the malevolent motives noteworthy complication in treating such comor- of others, which would be a very tough complica- bid anxiety cases is information-processing tion in the context of treating social phobia. Given defi cits that may be worsened by the presence of that every interpersonal situation contains ambi- Cluster A PDs. Particularly, individuals with guity to a degree, such information-processing heightened schizotypal personality traits show defi cits would make the threat disconfi rmation information-processing defi cits across multiple and habituation of anxiety more dif fi cult. domains, which are often shown to be as impaired Additionally, such information-processing as those demonstrated by patients with schizo- defi cits, which heavily tap memory processes, phrenia: impaired working memory (e.g., are likely to make it a challenge for the therapist Mitropoulou et al., 2005 ) ; impaired executive to glean reliable data about the history related to functioning, including cognitive inhibition defi cits emotional distress when the patient is the only (e.g., Laurent et al., 2000 ; Moritz & Mass, 1997 ) ; informant. In this manner, the accuracy of infor- and impaired selective attention and sustained mation regarding the patient’s social interactions attention (e.g., Bergida & Lenzenweger, 2006 ) . may be easily lowered when comorbid Cluster A Despite the lack of empirical data for paranoid PD discolors his social information processing. PD, paranoid symptoms in general (mostly in schizophrenia) have been associated with numerous cognitive de fi cits and biases: (a) cognitive Cluster A PD May Induce Overvalued rigidity as shown by perseverative errors on cog- Ideas, Magical Thinking, and Ideas nitive tasks such as the Wisconsin Card Sorting of Reference Task (Spaulding, Fleming, Reed, Sullivan, & Storzbach, 1999 ) and the tendency to jump to It is not uncommon for individuals with anxiety conclusions (Mujica-Parodi, Malaspina, & disorders to report illogical or unrealistic experi- Sackeim, 2000 ) ; (b) extreme self-serving bias, in ences such as overvalued ideas, magical beliefs, which positive events are attributed to self while superstitious behaviors, and dissociation, as the negative events to other people (Chadwick & core threat of their anxiety symptoms. Patients 15 Treatment of Anxiety and Comorbid Cluster A Personality Disorders 231 with OCD in particular often display magical and chronic and pervasive social withdrawal and ideation and superstitious behaviors as their core avoidance (Ahmed, Green, Buckley, & symptom presentations (Einstein & Menzies, McFarland, 2012 ; Calkins et al., 2004 ; Martens, 2004 ; Tolin, Abramowitz, Kozak, & Foa, 2001 ) . 2010 ; Peer et al., 2004 ; Schmidt, Lerew, & Overvalued ideas have been conceptualized and Trakowski, 1997 ; Waldeck & Miller, 2000 ) . found to predict poor treatment outcomes in These interpersonal features present numerous OCD (e.g., Basoglu, Lax, Kasvikis, & Marks, challenges in implementing exposure-based ther- 1988 ; Neziroglu, Pinto, Yaryura-Tobias, & McKay, apy procedures for anxiety disorders, particularly 2004 ) . when the core target of exposure encompasses Considering the biased cognitive processing public or social situations (e.g., various social and elevated schizotypy in Cluster A PDs, this phobic symptoms, agoraphobia, worries focused comorbidity may increase the likelihood that on interpersonal relationships, OCD symptoms individuals with anxiety disorders develop illogi- that involve social interactions). First, the extreme cal and idiosyncratic accounts about their own level of vigilance in social situations may dis- experiences (particularly, by making connections courage them from making efforts to carry out between irrelevant events/situations). Relatedly, behavioral treatment regimens. Given that many Lee, Cougle, and Telch ( 2005 ) showed that a type of the anxiety symptoms need to be reexperi- of magical thinking such as likelihood thought- enced and processed in a therapeutic context (Foa action fusion (i.e., merely having this thought & Kozak, 1986 ) , this reluctance to be exposed to will increase the likelihood of the event), which public situations could be a signi fi cant obstacle is often elevated in OCD, is signifi cantly associ- in treatment for various anxiety problems. ated with schizotypal personality traits, after con- Second, social skills de fi cits (along with other trolling for the in fl uence of general emotional odd and eccentric features of Cluster A PDs) may distress. increase the risk for the individuals to indeed Discon fi rming exaggerated fears in cognitive- evoke unfavorable reactions from others, which behavioral treatments essentially entails accurate would eventually corroborate their extremely perception of the threat objects/situations and negative views of others and interaction with realistic evidence-based reevaluation of their them. Thus, the therapist should be cautious in value, meaning, probability, and consequence. designing self-administered exposure work for Thus, the presence of schizotypal thinking, par- these patients, taking into account the patient’s ticularly cognitive disorganization symptoms current ability to adequately perform the required such as magical ideation and aberrational percep- social activities. Third, due to their hypervigi- tion, may render the individuals more resistant to lance coupled with social information-processing cognitive changes, which would result in increased de fi cits, patients with comorbid Cluster A PDs diffi culty in reality monitoring and threat may be quick to perceive and magnify any nega- disconfi rmation. This may also explain why tive aspects of such social interactions that occur patients with OCD show poorer treatment out- during the exposure work. Distorted social- come when comorbid schizotypal PD is present. cognitive information processing would also confi rm their aversive view of social interactions, thereby strengthening their oversensitivity and Comorbid Cluster A PDs May hypervigilance. Exacerbate Social Skills De fi cits Severe de fi cits in social skills may re fl ect the and Hypervigilance consequence of chronic social withdrawal and avoidance but may also directly contribute to Individuals with Cluster A PDs show very poor maintaining or strengthening distorted social social functioning characterized by social skills cognitions and hypervigilance in a self-perpetu- de fi cits, extreme sensitivity in interpersonal con- ating way. The relationship with the therapist is texts, tendency to perceive malevolent motives, an example of a social context, in which individuals 232 H.-J. Lee and J.E. Turkel with Cluster A PD would reveal their maladaptive treatment. However, we expect our suggestions pattern of relating to others. The dif fi culty in to be relevant for other types of psychological establishing rapport may be largely attributed to interventions or pharmacological treatments the challenges caused by these interpersonal since our emphasis is on overcoming various de fi cits and biases characterized by extreme lev- hurdles in establishing and maintaining therapeu- els of vigilance, guardedness, distorted social tic relationships. perception, and social withdrawal.

Enhancing Motivation for Change Treatment Approaches to Address Complexity of the Comorbidity As discussed earlier, one of the most important tasks in treating anxiety problems comorbid with Overall, cognitive-behavioral treatments with a Cluster A PDs would be to enhance the patient’s strong emphasis on exposure procedures and motivation and willingness to adhere to treatment selective serotonin reuptake inhibitor (SSRI)- regimens given its direct relevance for treatment based antidepressant medications are most empir- outcome. One promising approach to address this ically supported and widely used clinical challenge is motivational interviewing (MI; interventions for anxiety disorders (see Baldwin Miller & Rollnick, 2002 ) , which has started to be et al., 2005 ; Butler, Chapman, Forman, & Beck, applied to anxiety disorders in conjunction with 2006; Hofmann & Smits, 2008 ; Olatunji, Cisler, CBT (Westra & Dozois, 2008 ) . In addition to & Tolin, 2010 , for a review). However, there are potentially distressing procedures of exposure, no known speci fi c guidelines developed for treat- Cluster A PDs are also expected to generate ing anxiety disorders concomitant with Cluster A strong ambivalence about initiating, maintaining, PDs. On a positive note, a recent meta-analytic and committing oneself to treatment. MI concep- review on the ef fi cacy of existing psychological tualizes what is typically considered resistance or and pharmacological treatments for anxiety disor- noncompliance as a re fl ection of ambivalence for ders showed that comorbidity was generally not change and offers effective methods to identify, related to the effect sizes at posttreatment and clarify, and resolve the patient’s ambivalence. follow-up (Olatunji et al. 2010 ). Likewise, another Core components of MI include (a) expressing review (Dreessen & Arntz, 1998 ) concluded that empathic understanding of the patient from his there is no clear evidence that comorbid PDs neg- own point of view, (b) refl ecting and amplifying atively affect treatment outcome for anxiety disor- the discrepancies between desired goals/values ders. Given these fi ndings, it may be that we are and one’s current behavior, (c) respecting patient’s currently equipped with therapeutic interventions autonomy and rolling with resistance to diffuse it that can specifi cally address the target anxiety rather than directly confronting it, and (d) sup- problems regardless of their complicated comor- porting self-ef fi cacy and guiding the patient to bidity picture. However, apart from the relation- generate “change talk,” make his own decision, ship between comorbid schizotypal PD and poor and develop a change plan. treatment outcome in OCD, very little is known as MI has shown promising therapeutic outcomes to whether the demonstrated effi cacy of existing as an adjunct to CBT for anxiety disorders treatments for anxiety disorders would still hold through controlled case studies with CBT nonre- when the comorbid conditions are Cluster A PDs. sponders (e.g., Arkowitz & Westra, 2004 ) . The Much research is needed in this area. spirit of MI is also consistent with Beck, Freeman, In this section, we suggest some therapeutic Davis, and Associates’ cognitive therapy ( 2004 ) approaches that would be useful in addressing for paranoid PD that primarily aims to enhance complex clinical issues arising from the presence patient’s sense of self-effi cacy rather than directly of comorbid Cluster A PDs in anxiety disorders, addressing maladaptive interpersonal function- mostly from the perspective of cognitive-behavioral ing. Moreover, given that ambivalence is considered 15 Treatment of Anxiety and Comorbid Cluster A Personality Disorders 233 a strong emotional component of schizotypy in setting session agenda, goals, and (Mann, Vaughn, Barrantes-Vidal, Raulin, & homework. Kwapil, 2008 ) , MI is expected to signi fi cantly ¥ Reduce unpredictability while increasing the enhance adherence to treatment and commitment transparency of the sessions by providing for change. proper overviews in advance to help the patient gain a sense of control over the course of treatment. Enhancing the Therapeutic Relationship Additionally, although paranoid ideation or suspiciousness is not the main focus of the treat- Collaborative empiricism is the ideal context for ment in addressing the main anxiety symptoms, conducting effective CBT, and this is particularly the therapist is recommended to address this important in establishing rapport with individuals relationship issue as soon as it starts to impede presenting with comorbid Cluster A PDs given therapy progress or in-session relationship. In their characteristic mistrust, hostility, and guard- this regard, we have found it very useful to teach edness. In this regard, therapeutic interventions paranoid patients how subtle and powerful self- developed for Cluster A PDs and schizo-spectrum fulfi lling prophecies could be in molding social conditions provide useful guidance to design interaction in a certain anticipated way. Self- effective communication strategies to prevent or ful fi lling prophecy (Merton, 1948 ) explains how address potential relationship problems (Beck a perceiver’s (false) beliefs contribute to shaping et al., 2004 ; Beck, Rector, Stolar, & Grant, 2009 ) . the target’s future behavior. It is helpful for the Incorporating the existing work, we suggest the patient to learn that his own unfavorable belief following therapeutic approaches: can indeed contribute to the occurrence of per- ¥ Maintain consistently warm, respectful, and ceived malevolence in people, thereby creating a nonjudgmental stance throughout treatment. self-perpetuating cycle of suspiciousness and ¥ Monitor a shift in mood and explore any vigilance. Further, the discussion on self- potential relationship issues in session that ful fi lling process can be used to improve the may prevent the successful implementation of patient’s sense of control over interpersonal con- potentially aversive and effortful procedures texts by emphasizing that he can indeed in fl uence such as exposure. what seems to be an uncontrollable social inter- ¥ Avoid jargon and use very plain and straight- action through the power of balanced evidence- forward language; frequently provide sum- based thinking, in addition to commanding a mary to help patient clearly understand the better understanding of interpersonal dynamics. procedures and rationale of the in-session The therapy relationship usually provides easily activities and homework; a written summary accessible examples for illustrating the operation of the previous session could help. of self-fulfi lling process, and this effort can also ¥ Offer a dimensional, as opposed to diagnostic, provide a useful channel for communicating framework along with normalization in about relationship problems taking place in ther- explaining anxiety and relevant personality apy session. problems (i.e., “anxiety and mistrust in interpersonal contexts could be adaptive and protective to some extent, but too much could be Make New Information as Manageable counterproductive”) in order to improve self- as Possible esteem, promote understanding of psychological problems, and reduce stigma. Considering the numerous information-processing ¥ Grant as much control to the patient as possi- defi cits associated with Cluster A PDs (particu- ble within the allowable range of the speci fi c larly impairment in working memory and selec- treatment strategies employed for the main tive/sustained attention), procedural aspects of anxiety problem—collaborate with the patient the standard CBT protocols for anxiety disorders 234 H.-J. Lee and J.E. Turkel may need to be modifi ed to help patients incorpo- organization strategies in order to improve gen- rate materials more ef fi ciently. First, use visual eral executive processing capabilities (see McKay aids to explain complex concepts or procedures. & McKiernan, 2005 ) . For example, in order to explain the maladaptive self-sustaining role of rituals in OCD, the patient may be presented with a diagram depicting a Addressing Illogical Thinking and vicious cycle linking obsessional triggers, mental Unusual Perceptual Experiences intrusions, resulting distress, rituals, and temporary fear reduction that eventually reinforces the Comorbid Cluster A PDs (particularly schizo- OCD symptoms. Second, provide written review typy) may add odd and eccentric features to clini- sheets to assist the patient in consolidating mate- cal manifestations of anxiety disorders, mostly rials learned from the sessions. For example, through magical thinking and aberrational per- patients with marked defi cits in working memory ception. For example, the patient with social pho- and attentional processing may benefi t from bia in our case study complained of IOR added reviewing printouts of educational materials on to his excessive social fears such that he about anxiety disorders, instructions for home- believed that even total strangers in the street work assignments, and procedures of therapeutic somehow knew about him and spoke ill of him. techniques that patients should continue to prac- In such cases, cognitive restructuring work in the tice at home (e.g., relaxation training, diaphrag- form of empirical hypothesis testing conducted matic breathing exercise). Relatedly, it would through exposure-based behavioral experiment is also be useful for the patient to review the session expected to be more effective in modifying para- by listening to an audio recording of the session. noid beliefs rather than relying solely on cogni- Third, the fear hierarchy should be designed to tive reappraisal (Chadwick & Lowe, 1990 ) . include more exposure steps with a shorter dura- In general, to the extent that these cognitive tion than usual, as well as allowing a very con- anomalies are part of the main anxiety problem, crete prediction to be tested, because individuals existing cognitive interventions developed for with signifi cant defi cits in fundamental informa- paranoid and schizotypal ideation (Beck et al., tion-processing abilities (e.g., working memory, 2004 ) may be integrated into the main CBT sustained attention, and integrative/abstractive protocols for anxiety problems. Incorporating reasoning) are likely to fi nd it diffi cult to properly the existing work, we offer the following conduct lengthy therapy procedures with full suggestions: attention or adequately understand and integrate ¥ Communicate empathic understanding of the the implications of the results. Fourth, consider- distress associated with such cognitive anom- ing cognitive rigidity associated with Cluster A alies, but avoid validating the beliefs. PDs, it would be particularly important to guide ¥ Collaborate with the patient to generate the the patient to practice generating numerous alter- evidence for and against such beliefs. native interpretations in response to ambiguous ¥ Generate alternative interpretations of such social situations. Considering that most interper- beliefs. sonal contexts contain some level of ambiguity ¥ Discuss how to distinguish vague feelings/ that is open to multiple interpretations, improved suspicions from observed facts relying on cognitive fl exibility may help weaken the ten- empirical evidence-based examination. dency to develop paranoid ideation and ¥ Discuss the impact of maintaining such beliefs suspiciousness. on the current anxiety symptoms. Additionally, in the event of marked cognitive ¥ Discuss the pros and cons of holding onto the de fi cits associated with schizotypy, the ef fi cacy beliefs vs. alternative beliefs in terms of proof exposure-based treatment work may be moting positive changes in the main anxiety enhanced by providing cognitive rehabilitation symptoms. designed to teach speci fi c memory strategies and 15 Treatment of Anxiety and Comorbid Cluster A Personality Disorders 235

¥ Discuss the pros and cons of abandoning the no simple task when social phobia is complicated belief (or ignoring the unusual experiences). by severe and chronic social skills de fi cits or ¥ Discuss how such beliefs contribute to main- excessive vigilance. Despite a wide variation, taining the current anxiety symptoms. most social skills training includes common strat- ¥ If needed, in order to reduce emotional dis- egies such as role modeling, rehearsal, positive tress and potential stigma, provide informa- reinforcement, corrective feedback, and home- tion to help normalize the experience, work (Kurtz & Mueser, 2008 ) . In assisting including the commonness of paranoid and patients with comorbid anxiety disorders and hallucinatory experiences in the general popu- Cluster A PDs to get prepared for exposure work lation and potential utility of certain unusual that involves social interactions, in-session mod- experiences (Kingdon & Turkington, 1994 ; eling and rehearsal are expected to provide quite McCreery & Claridge, 2002 ) . practical guidance. ¥ Bring patient’s attention to common cognitive Therapy sessions can serve as a relatively safe distortions (Beck et al., 2004 ) that are often interpersonal context for the patient to learn and observed in PDs. Particularly, paranoid ide- rehearse basic social skills that are necessary for ation, magical thinking, and IOR may be pro- conducting therapeutic procedures for anxiety moted by fi ltering (i.e., exclusive focus on problems. For these individuals, unprepared negative details), jumping to conclusions (i.e., social interactions may produce negative conse- unfounded and hasty conclusion), overgener- quences, which would reinforce their excessive alizing (i.e., broadly apply negative outcomes social fear, suspiciousness, and vigilance. limited to a certain situation), and magnifying/ Relatedly, patients with Cluster A PDs may minimizing (i.e., amplify negative details benefi t from learning skills to accurately perceive while minimizing positive details). and label emotions in the self, as well as others, ¥ Self-serving bias and fundamental attribution to facilitate social interactions, given their defi cits error (Ross, 1977 ) are useful educational in processing emotional cues accurately. materials to help reduce paranoid ideation. Additionally, with respect to SSRI-based pharmacotherapy for anxiety disorders, the pres- Case Study ence of strong Cluster A personality features (particularly schizotypal personality features) Background Information may be a useful indicator for augmentative antipsychotic medications in the presence of partial or Jeffrey, a 27-year old male, had been seen by a nonresponse (e.g., Bogetto, Bellino, Vaschetto, & psychiatrist and was prescribed antidepressant Ziero, 2000 ; Keuneman, Pokos, Weerasundera, medication for 3 years until he was referred to & Castle, 2005 ; McDougle et al., 1990 ) . our clinic. Our intake phone-interviewer indicated his primary problems as “some complex and unusual obsessive-compulsive symptoms Social Skills Training and interpersonal diffi culties” on the record sheet. When he visited our clinic for the fi rst In the event that patients with comorbid Cluster time, he was rather poorly dressed and groomed. A PDs (particularly schizoid and schizotypal He looked quite tense and nervous while sitting PDs) show diffi culty following through with in the waiting room. He maintained a rigidly treatment procedures that involve interpersonal upright posture with his back and neck straight- contexts, social skills training may be added to ened and often looked around vigilantly. In the provide necessary guidance for their successful initial assessment session, he reported his primary implementation. Exposure work involving social problem as “OCD.” Our comprehensive assess- interactions (e.g., conversation with a stranger, ment and ongoing clinical observation revealed public speaking, speaking with a boss) would be that he met criteria for multiple conditions: 236 H.-J. Lee and J.E. Turkel

OCD and social phobia in Axis I and schizotypal or behavior because he thought they would easily PD in Axis II. fi nd out about it (by reading his mind) and be upset with him. Due to his excessive social fears that were complicated by these magical ideas, he Clinical Presentations had become socially withdrawn, maintaining only minimal social relationships with his family OCD. Jeffrey presented a peculiar constellation of members. OCD symptoms that seemed diffi cult to be expressed in everyday language. His primary Schizotypal Personality Features . His speech often obsession occurred in the form of strong urges to became vague and circumstantial, and his attention clean his body by releasing “bad mental energy” often needed to be redirected to the topic at hand. that he perceived as being frequently accumulated He also showed quite eccentric and bizarre fanta- inside his body. He reported intense distress due sies. When the topic in session was focused on his to these frequent urges, although he was not able hobbies as part of the effort to establish rapport and to clarify what negative consequences he antici- explore his social resources, he volunteered to pated in the event of holding the mental energy bring in his sketchbook to show his drawings. His inside. He had developed several bizarre rituals to drawings were full of unrealistic fantasies that emit the mental energy, including overstretching mingled nudity, evil spirits, monsters, human, and his body to straighten his back and limb, standing grotesque patterns. However, despite numerous frozen in a very rigid posture for about 30Ð60 s, peculiarities and eccentricities in his clinical pre- yawning in a very unnatural and exaggerated way, sentations, none of them seemed delusional or and repeating behaviors he was engaging in when actively psychotic. He was clearly distressed by the urge occurred until he felt right about it. These OCD and social anxiety symptoms that were com- rituals granted him a temporary relief from intense plicated and intensifi ed by schizotypal features distress, but over the past few years, he continued but maintained an adequate level of insight. to expand his repertoire of bizarre rituals by adding new items. Moreover, he suffered severe back pains because of the rigid and tense body posture Case Conceptualization he assumed repeatedly throughout the day. He reported not being clear as to what speci fi c situa- In many aspects, the clinical presentations of tions usually triggered his mental intrusions about Jeffrey closely fi t the anxiety-Cluster A PD the mental energy but said he could physically comorbidity case discussed in this chapter. feel the fl ow of the annoying energy. Evidently, the comorbid schizotypal PD rendered his overall clinical manifestations highly odd and Social Anxiety . Jeffrey appeared very tense, intro- eccentric. Nevertheless, his primary OCD and verted, inhibited, shy, timid, and oversensitive social phobia symptoms appeared to be main- early in session. He displayed severe anxiety tained in a way that is consistent with current about being negatively judged by other people cognitive-behavioral formulations. That is, he and reported having scrambled to avoid social engaged in numerous rituals, safety behaviors, interactions. His social anxiety turned out to be and avoidant strategies to minimize his emotional complicated by IOR. He believed that people distress, which indeed strengthened and main- around him, including total strangers in the street, tained his maladaptive fears and behaviors. His often knew him well and spoke about him. OCD and social phobia were interconnected in Although at some level he thought this may not the sense that his urges for relieving mental be true, his emotional reactions appeared to energy usually occurred when he became keenly accept that as a quite realistic situation. Moreover, conscious of other people in either reality or fan- he was worried about intentionally or unwittingly tasy. This case was further complicated because making judgment about other people’s appearance by-products of his schizotypal thinking (e.g., IOR 15 Treatment of Anxiety and Comorbid Cluster A Personality Disorders 237 and magical thinking) seemed to directly contrib- as well as anticipated outcomes, was an essential ute to triggering the intrusions of obsessional part of behavioral experiments. For example, one urges, which are related to almost hallucinatory task was to intentionally judge someone’s appear- perception of the mental energy and odd beliefs ance while sitting close to her in a lounge in order of its harmfulness, and amplifying the intensity to test if she showed any signs of having read his of socially threatening cues (i.e., IOR and para- mind and being upset about his negative judgment. noid suspiciousness contributed to increasing his IOR was revisited throughout the course of fears of negative evaluation and idea that other treatment when it was indicated that Jeffrey’s people may be able to read his mind). anxiety symptoms were negatively infl uenced by his fl uctuating level of such illogical ideation. To encourage him to openly bring up his trouble Treatment Approaches with IOR rather than concealing such symptoms, his IOR was labeled as “mental noise” as part of Jeffrey was treated by weekly CBT sessions over normalizing efforts. Cognitive restructuring was the course of a full year. There were three main aimed at helping him learn (a) anyone could components of the treatment. First, using the ERP experience such mental noise particularly under paradigm, he was exposed to various situations stress, and having it in mind does not mean any- that triggered his perception of mental energy thing; (b) everyone has the inherent ability to get and subsequent urges to release it (e.g., being at a used to such noise and even forget about its pres- restaurant, walking down a crowded street, hear- ence; (c) struggling with the noise (e.g., trying to ing unclear human voice from the next room, suppress, prove, or dispute) is counterproductive; imagining people speaking about him, tolerating (d) its content is meaningless because it is merely certain physical sensations that increase the urge noise with no evidence; and (e) even in the for rituals) while being inhibited from perform- extremely unlikely event that they indeed speak ing his odd rituals. As he started to make progress about you, it does not affect you in any practical in tolerance of the urges related to mental energy, way if you simply ignore it. This approach was his odd belief about the existence of mental very helpful for him to openly acknowledge the energy was examined. The potential bene fi ts and emergence/presence of IOR and engage in con- risks of disregarding the vague physical sensation structive discussion on how (not) to respond to of mental energy were also discussed. Over time, such “mental noise” in session. he showed improved abilities to tolerate the dis- Overall, the treatment was successful in reduc- tress related to mental energy, and the overall fre- ing OCD and social anxiety symptoms below the quency of rituals dropped. clinical cutoff level (Y-BOCS total score = 9, Second, exposure-based behavioral experi- LSAS total score = 35). His schizotypal thinking ments were repeatedly conducted to improve his and unusual perceptual experience persisted in a social anxiety. Because his social anxiety was diminished form and sometimes worsened as a interwoven with schizotypal thinking (e.g., IOR function of his stress level. However, he seemed and magical beliefs about mind reading), each to have learned how to prevent his schizotypal exposure task was conducted in the form of factors from deteriorating his anxiety problems. behavioral experiments by incorporating cognitive intervention focused on collaborative empirical hypothesis testing. However, he was easily Summary distracted and showed dif fi culty sustaining attention on the topic in question. Thus, for each We have discussed how Cluster A PDs can com- behavioral experiment, the rationale and purpose plicate the clinical features of anxiety disorders of the experiment needed to be explained to him and their therapeutic approaches. This issue is repeatedly using slide presentation on a computer crucial because comorbid Cluster A PDs may monitor. Collaboratively generating hypotheses, interfere with the implementation and outcome 238 H.-J. Lee and J.E. Turkel of existing treatments for anxiety disorders. As in 55 patients with obsessiveÐcompulsive disorder. discussed in this chapter, a variety of factors chal- Archives of General Psychiatry, 49 , 862Ð866. Baldwin, D. S., Anderson, I. M., Nutt, D. J., Bandelow, lenge the treatment process for anxiety disorders B., Bond, A. A., Davidson, J. T., et al. (2005). when working with individuals who present with Evidence-based guidelines for the pharmacological comorbid Cluster A PD: motivational issues, bar- treatment of anxiety disorders: Recommendations riers to establishing a strong therapeutic alliance, from the British Association for Psychopharmacology. 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Fixity of belief, perceptual aberration, and 15 Treatment of Anxiety and Comorbid Cluster A Personality Disorders 241

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Jonathan S. Abramowitz and Lauren Landy

Anxiety disorders are not only among the most com- ety disorders with comorbid depression. In this chapter, mon complaints seen by mental health clinicians; we discuss the nature of the relationship between they are also very often associated with comorbidity anxiety disorders and depression, review evidence in the form of depression (American Psychiatric suggesting that depression attenuates the effects of Association [APA], 2000 ) . This should not be sur- psychological treatment, offer some hypotheses as prising to readers who are familiar with anxiety dis- to why this is so, and outline and illustrate a promis- orders as these syndromes are, simply put, ing psychological treatment approach that addresses depressing . The anxious rumination, personal dis- this complicated clinical picture. tress, and functional interference resulting from fear and avoidance can be devastating. Consider a man with social phobia who, fearful of most social inter- Nature of the Problem actions, spends most of the time alone or a woman with obsessive-compulsive disorder (OCD) whose Overview of Depressive Symptoms days are dominated by senseless distressing obsessive thoughts and repeating compulsive rituals that Depression is a psychological state characterized by a never seem to be done to perfection. Posttraumatic chronically sad mood (e.g., feeling empty or hope- stress disorder and generalized anxiety disorder less) that is often associated with a diminished inter- (GAD) include depressive symptoms in their very est or pleasure in activities that were once enjoyed. diagnostic criteria, and individuals with panic often The following other signs and symptoms are also end up rearranging their lives to accommodate their often present: reduced appetite or weight loss, insom- fears of unexpected anxiety attacks. Nondepressed nia or hypersomnia, psychomotor agitation or retar- anxious individuals end up being the exception, and dation, fatigue, feelings of guilt and worthlessness, yet relatively little attention has been paid to the diminished ability to concentrate, and recurrent development and evaluation of treatments for anxi- thoughts of death or suicide. Although depression is observed within the context of many psychological syndromes, as well as in nonclinical individuals, a J. S. Abramowitz , Ph.D. (*) Department of Psychology , University of North person meets the criteria for a major depressive epi- Carolina at Chapel Hill , Campus Box 3270 , sode if the aforementioned symptoms persist for at Chapel Hill , NC 27599 , USA least a 2-week period and interfere with daily func- e-mail: [email protected] tioning (APA, 2000 ) . Major depressive disorder L. Landy , B.A. (MDD) is deﬁ ned by the occurrence of one or more Department of Psychology , University of Colorado major depressive episodes (APA). Dysthymia, a less at Boulder , 345 UCB Muenzinger, Boulder , CO 80309-0345 , USA severe form of depression, involves a chronically

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 243 DOI 10.1007/978-1-4614-6458-7_16, © Springer Science+Business Media New York 2013 244 J.S. Abramowitz and L. Landy depressed mood and reduced interest but does not disorder diagnosis with subthreshold depressive grossly disable the person’s daily functioning (APA). symptoms, (b) a principal MDD diagnosis with subthreshold anxiety symptoms, (c) coprincipal diagnoses of MDD and an anxiety disorder, and Co-occurrence of Depression (d) subthreshold presentations of both disorders and Anxiety (Hirschfeld, 2001 ) . There is, however, disagreement over the nature and mechanisms underlying Depressive symptoms are prevalent across psy- the relationship between anxiety and depression. chological disorders, yet appear to be most Some theories attribute comorbidity to an overlap closely related with anxiety disorders. Research in diagnostic criteria, while others highlight com- indicates that anxiety is the single best predictor mon putative underlying genetic and neurobiolog- of the development of clinically severe depres- ical substrates (Bremner & Charney, 2010 ) . Still sive symptoms (Hirschfeld, 2001 ; Hranov, others propose that the distress and disruption in 2007 ) . Depression also ranks as the single most functioning associated with having an anxiety dis- commonly co-occurring problem among anxi- order leads to the development of depression ety diagnoses, affecting up to 90% of people (Mineka, Watson, & Clark, 1998 ; Newman, with anxiety disorders (Gorman, 1996 ) . Przeworski, Fisher, & Borkovec, 2010 ) .

Comorbidity Rates . The rate of comorbid depres- Is Depression the “Chicken ” or the “Egg ”? As in sion varies across the anxiety disorders, with panic the folk riddle which asks which came fi rst , the disorder (with or without agoraphobia) being chicken or the egg? There are reasons to consider among the most likely to be accompanied by that anxiety could lead to depression and depres- depression—comorbidity rates between 32 and sion to anxiety. Anxiety disorders, for example, 70% have been reported (Bystritsky et al., 2010 ; typically impair functioning and are personally dis- Roy-Byrne, 2000; Weissman, Bland, & Canino, tressing, which can lead to social isolation, hope- 1997 ) . Among individuals with PTSD, rates of lessness, and depressed mood. Depression, on the MDD similarly range from 21 to 94% (e.g., Frayne other hand, is associated with ruminative thinking et al., 2005 ; Ginzburg, 2007 ; Mollica et al., 1999 ; and negative intrusive thoughts that are reminiscent Salcioglu, Basoglu, & Livanou, 2003; Sundquist, of anxiety symptoms such as obsessions. It is Johansson, DeMarinis, & Johansson, 2005 ) . important to note, however, that despite the clear Between a quarter and a third of people with OCD overlaps in the signs and symptoms of anxiety and meet criteria for MDD (e.g., Antony, Downie, & depression (Davis, Barlow, & Smith, 2010 ) , clear Swinson, 1998 ; Nestadt et al., 2001 ; Yaryuba- distinctions can be found. For example, there are Tobias et al., 1996) , and rates of MDD among cognitive differences: the tendency toward help- individuals with social phobia are less consistent, lessness in anxiety and hopelessness in depression. ranging from 19.5 to 45% (Moitra, Herbert, & Differences in neurological and psychophysiologi- Forman, 2008 ; Ohayon & Schatzberg, 2010 ) . cal reactivity have also been observed: hyperarousal Among patients with specifi c phobias, 25.4% met dominates in anxiety versus anhedonia in depres- criteria for MDD in one study (Marom, Gilboa- sion (American Psychiatric Association, 2000 ) . Schechtman, Aderka, Weizman, & Hermesh, Probably the best way to determine whether 2009 ) , and a large epidemiological study in Hong anxiety precedes depression, or vice versa, is to Kong found a somewhat higher rate of 38.5% examine the temporal nature of these two symp- (Chou, 2009) . Approximately 39% of individuals tom constellations. Accordingly, consistent with GAD also meet criteria for MDD (Bruce, fi ndings demonstrate that among patients with Machan, Dyck, & Keller, 2001 ) . this comorbidity pattern, the onset of anxiety Research and clinical observations also suggest disorders is more likely to temporally precede four clinical presentations of comorbid anxiety that of mood disorders (e.g., Alloy, Kelly, and depressive disorders: (a) a principal anxiety Mineka, & Clements, 1990 ; Lepine, Wittchen, & 16 Comorbid Depression 245

Essau, 1993 ) . In a large study, for example, 59% In an investigation of comorbid social phobia of individuals with comorbid mood and anxiety and MDD, Moitra et al. (2008 ) found that behav- disorders experienced their fi rst anxiety disor- ioral avoidance mediated the relationship between der at least a year before the onset of their mood these two disorders. Research with OCD patients disorder, while only 15% had experienced a found that depression is associated with more mood disorder fi rst, and 26% experienced the severe obsessions, but not compulsive rituals onset of both a mood and anxiety disorder within (Ricciardi & McNally, 1995), and particularly the same year (Lepine et al.). These data vary with the presence of obsessional intrusions con- across the different anxiety disorders, yet the cerning sexual and religious themes (Hassler, general trend holds. For instance, in two studies, et al., 2005 ). Moreover, relative to nondepressed the majority of individuals with OCD and OCD patients, those with MDD evince more comorbid depression experienced the onset of severe cognitive distortions (i.e., the tendency to their obsessive-compulsive symptoms before misinterpret the signi fi cance of obsessional their depressive symptoms began (Bellodi, thoughts) and poorer insight into the senseless- Scioto, Diaferia, Ronchi, & Smiraldi, 1992 ; ness of obsessions and rituals. Thus, the presence Demal, Lenz, Mayrhofer, Zapotoczky, & Zitterl, of depression is not only associated with greater 1993 ) . Temporal examination of the onset of overall OCD symptom severity, but also with cer- comorbid social phobia and MDD also indicate tain presentations of this highly heterogeneous that in the majority of cases, social phobia devel- condition. In similar fashion, patients with GAD ops fi rst (e.g., Schneier, Johnson, Hornig, & with comorbid MDD report more severe anxiety Liebowitz, 1992). Indeed, the avoidance, isola- symptoms than do GAD patients without MDD tion, and social anxiety that characterize social (Newman et al., 2010 ) . phobia often leave sufferers without opportunities for interpersonal interactions, which are at the foundation of many enjoyable activities, Factors That Contribute to Complexity thereby perhaps creating vulnerability to depression. Although these studies are primarily based Clinical Picture on retrospective self-report data, the general pattern of results suggests that the direction of Clinical observations and research fi ndings indi- the causal arrow involves anxiety disorder cate that the presence of comorbid depressive symptoms leading to the secondary development symptoms and MDD complicates the clinical of depression. picture and treatment of anxiety disorders (Abramowitz & Foa, 2000 ; Angst & Dobler-Mikola, Predictors of Depressive Symptoms in Anxiety 1985 ; Stavrakaki & Vargo, 1986 ). Anxiety disor- Patients . Why do some anxious patients, but not der patients with depression might become demor- others, develop comorbid depression? A number alized, giving in to their fear and avoidance patterns of researchers have sought to elucidate variables and subsequently becoming more impaired than that predict the presence of depression among less depressed anxiety patients. Their risk of suicide patients with anxiety disorders. de Graaf, Bijl, might also be greater than nondepressed patients. ten Have, Beekman, and Vollebergh ( 2004 ) , for Finally, the physical signs which accompany example, found that physical disability and stress- depression (sleep disturbance, weight loss or ful life circumstances (past and present) were the gain, and psychomotor retardation) may directly strongest predictors of MDD among individuals exacerbate the symptoms of various anxiety dis- with anxiety problems. Eison ( 1990 ) found data orders. Indeed, one study found that patients with consistent with the view that the prolonged GAD and with panic disorder with agoraphobia, central nervous system arousal involved in anxiety who also had comorbid MDD, were half as disorders depletes forebrain neurotransmitters, likely to recover from these anxiety disorders as leading to depression. compared to individuals with GAD and panic 246 J.S. Abramowitz and L. Landy patients without MDD (Bruce et al., 2005 ) . In this successful exposure therapy requires practicing study, comorbid MDD was also associated with a prolonged and repeated confrontation with twofold increase in the risk of long-term recur- feared stimuli, and depressed individuals might rence of the anxiety disorder. Other investigations comply with these demanding instructions. con fi rm the clinical observations that individuals Indeed, noncompliance is related to attenuated suffering from anxiety disorders complicated by treatment response. It is also possible that depressive disorders (e.g., MDD) experience more depressed anxious patients perceive themselves severe and lasting psychological symptoms, a as more helpless (Seligman, 1975 ) or less greater risk for suicide, higher relapse rates, and ef fi cacious (Bandura, 1977 ) than nondepressed greater functional impairment when compared to ones, resulting in lower expectations of improve- nondepressed anxious individuals (Belzer & ment, thus interfering with treatment gains. Schneier, 2004 ; Davis et al., 2010; Goldenberg Perhaps depressed patients attribute any limited et al., 1996 ; Hecht, Von Zerssen, & Wittchen, gains in treatment to external sources and there- 1990 ; Huppert, Simpson, Nissenson, Liebowitz, & fore evidence less improvement and more Foa, 2009 ) . relapses than nondepressed patients. In the remainder of this chapter, we discuss approaches to the psychological treatment of Treatment Response anxiety disorders with comorbid depression.

Effective psychological treatment for anxiety disorders involves cognitive-behavioral interven- Treatment Approaches to Address tions such as exposure therapy and cognitive Comorbid Depression restructuring (e.g., Abramowitz, Deacon, & Whiteside, 2011 ) . Yet, these techniques require When the negative impact of depression on the the patient to work hard to learn and practice effects of CBT for anxiety is considered along skills, some of which involve facing their fears with high prevalence rates of comorbid depression and deliberately provoking anxiety and distress. among people with anxiety disorders, one recog- Depressed patients often lack the motivation and nizes the importance of developing treatments for willpower to do this diffi cult work and may even patients with this pattern of comorbidity. For the fall prey to dysfunctional beliefs that they don’t most part, research on the treatment of anxiety has deserve to get better. Whereas cognitive-behavioral focused on more or less “straightforward” or therapy (CBT) can be highly effective in reduc- “clean” presentations of anxiety disorders (e.g., ing the symptoms of anxiety disorders, for the Foa et al., 2005) . Less attention has been paid to reasons mentioned above, the presence of unman- complex cases such as those involving comorbid aged depression often hinders the effects of this disorders. Yet ironically, the majority of individu- treatment. For example, in separate studies, als with anxiety present with complexities of one Abramowitz and Foa ( 2000 ) and Steketee, sort or another—comorbid depression being Chambless, and Tran (2001 ) found that OCD among the most common presentations. patients with comorbid MDD fared worse with As mentioned, exposure—repeated and pro- exposure-based CBT relative to nondepressed longed confrontation with feared stimuli—along OCD patients. Similar results were found with with help refraining from subtle and overt avoid- depressed and nondepressed panic disorder ance and safety-seeking behaviors (i.e., response patients (Steketee et al.). prevention) is the centerpiece of CBT for most anx- There are several potential explanations for iety disorders (Abramowitz et al., 2011 ) . Someone why depression negatively impacts the outcome with social phobia, for example, is helped to of CBT for anxiety. For example, decreased confront situations in which he or she might become compliance with treatment demands among the center of attention (e.g., speaking in a group, depressed individuals. As mentioned previously, dropping a handful of coins on the fl oor of a crowded 16 Comorbid Depression 247 mall) while simultaneously refraining from any a few possible ways in which CBT could be avoidance or anxiety-reducing behavior (e.g., exces- implemented to address comorbid depression. sive rehearsal, going shopping at off-peak hours). These are described below, along with the theo- Exposure-based CBT is a highly effective therapy retical and practical considerations relevant to for anxiety disorders, producing an average of each. We then present a case study illustrating 60Ð70% reduction in fear, avoidance, and the use of what we believe is the most useful approach. safety behaviors (Abramowitz et al., 2011 ). A draw- back of this approach, however, is that patients must confront their fear-evoking stimuli and resist urges Adding Antidepressant Medication to immediately reduce anxiety via escape or avoid- to CBT ance. Because exposure therapy requires compliance with these somewhat demanding procedures, Antidepressant medications, such as the serotonin approximately 25% of patients either refuse this reuptake inhibitors (SRIs), are the most widely form of therapy or terminate prematurely. Moreover, used treatments for both depression and anxiety exposure therapy is highly focused on alleviating disorders. Thus, intuitively, the use of these agents anxiety and fear and does not directly address should improve outcome for anxiety patients with comorbid problems such as depression. comorbid depression. Very few studies, however, Cognitive conceptualizations of anxiety dis- have addressed whether antidepressants offer an orders have led to the inclusion of cognitive advantage over exposure-based CBT, speci fi cally therapy (CT) strategies along with exposure in for comorbid samples, and the existing studies many treatment protocols (e.g., Beck & Emery, have numerous methodological dif fi culties which 1985 ; Wells, 1997 ) . In CT, a number of verbal limit the conclusions that can be drawn. The OCD and skill development techniques are used to (a) literature provides the best examples of such stud- educate patients about the nature of anxiety and ies. In one investigation with OCD patients, Marks how pathological anxiety is maintained and (b) et al. (1980 ) found that clomipramine (CMI) help patients correct dysfunctional beliefs and helped severe depression and OCD symptoms automatic thoughts that lead directly to anxiety more than did placebo. However, the comparison and fear (e.g., exaggerated estimates of proba- included only fi ve patients on CMI and fi ve on bility and severity of catastrophes). For exam- placebo, and the statistical analysis was conducted ple, someone who experiences recurrent panic at the 4-week point in treatment, which may not attacks would be helped to recognize that the have been enough time for CMI to yield full symptoms of panic are nothing more than the bene fi t in all patients. harmless sensations associated with anxious In another study, Foa, Kozak, Steketee, and arousal ( fi ght-or- fl ight), and as such, panic McCarthy (1992) examined whether using imip- attacks will not lead to physical or mental harm. ramine (IMI) prior to CBT would facilitate In addition to verbally challenging dysfunc- improvement in OCD symptoms once CBT tional thinking patterns, patients test out the began. In their prospective study, mildly and validity of these (and corrected) beliefs using severely depressed OCD patients received either real-life “experiments” (that are similar to expo- pill placebo or IMI for 6 weeks prior to CBT. sure exercises), such as trying to “bring on” a Results indicated that although IMI improved the panic attack. The effi cacy of CT is suggested by symptoms of depression, it did not potentiate the numerous outcome studies, yet CT does not effects of CBT on OCD symptoms. Abramowitz appear to be quite as effective as exposure-based et al. (2000 ) also included a comparison between therapy for anxiety (Abramowitz et al., 2011 ) . severely depressed OCD patients who either were Treatment protocols developed for anxiety or were not using SRI medications during CBT. disorders have not routinely addressed the com- No difference between groups were reported, mon comorbid depressive symptoms that are although the small size of the severely depressed known to present challenges. There are, however, group in that study (n = 11) limits the generaliz- 248 J.S. Abramowitz and L. Landy ability of this fi nding. To date, there is little com- Another reason CT is a good choice to use in pelling evidence that medication potentiates the the treatment of anxiety disorder patients with effects of CBT with severely depressed anxiety comorbid depression is ef fi ciency: that is, the patients. conceptual approach and implementation of CT One explanation for the above conclusion is as used for depression (e.g., identifying and chal- that because SRI medications are the most widely lenging beliefs) are largely similar to those used used therapy for anxiety, patients with anxiety in CT for anxiety disorders—although the con- disorders have often already tried these agents tent of the dysfunctional beliefs that are targeted before presenting for psychological treatment. is different. For example, cognitive restructuring Thus, many depressed anxiety disorder patients can be used to modify dysfunctional cognitions in treatment studies might have been “medication relevant to panic attacks (e.g., “too much panic resistant,” thus putting a ceiling on the effects of will lead to a heart attack”) as well as those rel- medications. Nevertheless, since the average evant to depression (e.g., “I am a total failure as improvement with SRI medication is somewhat a human being and can’t do anything right”). modest (about 20Ð40% on average), there is a Thus, patients could learn to make use of the need to consider non-medication strategies for same skills to reduce both anxiety and depressive augmenting psychological treatment for symptoms. depressed anxiety disorder patients. Engaging in CT to reduce depressive symptoms prior to beginning exposure techniques might alleviate some depressive symptoms and Adding Cognitive Therapy help the patient increase motivation and compli- for Depression ance with diffi cult exposure therapy assignments, thereby enhancing reductions in anxiety symp- Cognitive therapy is a useful intervention for toms. Unfortunately, however, no systematic anxiety disorders and can also be applied in the evaluations of such treatment programs have treatment of depression. Indeed, CT yields high been conducted, although we are currently con- responder rates, few adverse effects, and good ducting a small study involving a series of patients durability of gains in depressed patients (e.g., with OCD and comorbid depression. The follow- Elkin et al., 1989 ) . Cognitive therapy for depres- ing case report describes the details of how we sion involves identifying and challenging overly have implemented this treatment approach with negative beliefs about oneself, world, and the one such patient. future that lead to overly negative and biased interpretations of events, giving rise to feelings of extreme hopelessness, helplessness, and personal Case Study failure. It also includes the use of behavioral activation in which the patient increases his or her Patient Background and Assessment engagement in activities he or she fi nds enjoyable. This helps positively reinforce behavior that “Elaine” was a 26-year-old woman from the is the opposite of depressive behavior (e.g., sleep- southeastern United States who came to our out- ing, social isolation). Numerous studies report patient clinic seeking treatment for “depression signifi cant and lasting improvement in dysphoric and obsessive thoughts.” She stated that her mood and other MDD symptoms following CT obsessive thoughts about her new baby were (Dobson, 1989 ) . Typically, 50Ð70% of MDD “ruining her life.” Elaine and her husband of 3 patients who complete CT no longer meet criteria years, Joe, had recently given birth to their fi rst for MDD at posttreatment, and only 20Ð30% child, a son named Ryan. But Elaine was avoiding show signifi cant relapse at follow-up (Craighead, interacting with Ryan, especially if Joe was not Evans, & Robins, 1992 ) . around to “supervise.” This was because Elaine was having thoughts that she might sexually 16 Comorbid Depression 249 molest the baby when no one was looking. She and response prevention) would help her achieve was unable to bathe Ryan, change his diaper, or relief from her symptoms even if it meant “invest- breastfeed him. ing anxiety up front in a calmer future.” After Assessment using the Yale-Brown Obsessive some discussion with her family, Elaine opted to Compulsive Scale (Y-BOCS) and Symptom enter our program. Checklist (Goodman et al., 1989a, 1989b ) indicated prominent sexual obsessions, mental rituals (e.g., praying), and rituals involving asking for Conceptualization and Treatment reassurances from her mother and husband that she would “never do such a thing.” Specifi c Treatment involved 16 90-min twice-weekly obsessional thoughts included unwanted images sessions over the course of about 2 months of the baby’s penis and impulses to touch his (8 weeks). During the fi rst two treatment ses- genitals. Elaine was very religious and spent sions, the therapist continued to collect informa- hours praying that she wouldn’t act on her tion about Elaine’s depressive symptoms, and unwanted thoughts (i.e., mental rituals). She also she was introduced to the cognitive model of repeatedly asked others questions such as “Do emotional disorders wherein negative emotions you think I will molest the baby?” and “What are considered to be evoked by dysfunctional does it mean that I think about doing such evil interpretations of situations. It became clear that things?” Elaine’s pretreatment score on the Elaine’s depression was secondary to her OCD Y-BOCS severity scale was 27, indicating fairly symptoms; she described feeling guilty, worth- severe OCD symptoms. less, and like a “bad mother” as a result of her A diagnostic interview con fi rmed both a diag- unwanted sexual obsessions. Like many individ- nosis of OCD and of major depression. Elaine uals with OCD, Elaine overinterpreted the occur- had experienced some minor OCD symptoms as rence and signifi cance of her senseless obsessional a teenager, but her anxiety got noticeably worse thoughts. She believed that deep down, she was during her pregnancy, and her symptoms spiked becoming a sexual predator and that it was only a after Ryan was born. For the last few months, matter of time before she eventually gave in and Elaine reported feeling down, having decreased ended up sexually assaulting her own child. energy, decreased interest in activities or hobbies, Elaine attributed her problems to demonic pos- and feelings of worthlessness, hopelessness, and session and often berated herself for not being a passive suicidal thinking. Her Beck Depression good enough servant of God. Cognitive therapy Inventory (BDI) score was 29, and her Hamilton for depression was begun, and the therapist taught Depression Rating Scale score was 20, suggest- Elaine to recognize cognitive errors including ing clinical depression of moderate severity. “overgeneralizing,” “catastrophizing,” and “dis- Elaine had never received treatment for OCD counting the positive” (Greenberger & Padesky, or depression except to speak with the pastor at 1995) . Elaine was helped to generate more realis- her church. After several sessions with the pastor, tic appraisals of herself and her future. For exam- she saw the advertisement for our clinic and ple, “I am a terrible mother” was modifi ed to “I decided to contact us. After an assessment and want what’s best for my baby, but am having discussion of treatment options, Elaine was quite problems with OCD that make me have thoughts ambivalent about beginning therapy, primarily about strange things.” because she feared engaging in exposure exer- Elaine was instructed in how to use daily cises. Her therapist explained how treatment thought diaries to practice identifying and modi- would indeed be a challenge but would progress fying dysfunctional thoughts on her own. She at a level Elaine was comfortable with and that also worked with her therapist to develop a she would never be forced into doing exposure routine of activities that she enjoyed (behavioral practices. Instead, it would be the therapist’s job activation), such as watching the Comedy Central to help Elaine to see how trying CBT (exposure TV network, renting movies she liked, and ice 250 J.S. Abramowitz and L. Landy skating. It became clear that Elaine felt that how nitive restructuring and behavioral activation for others perceived her as a parent was very impor- her depressive symptoms during and between tant. Thus, she was encouraged to get involved in these treatment sessions. During her fi fth visit, playgroups and “Mommy and Me” classes where however, she reported that her mood was she and Ryan would interact with other mother- improved, that she felt a good deal of con fi dence child dyads. Numerous cognitive therapy work- in her therapist, and that she was hopeful of sheets were dedicated to thoughts regarding the improving with continued therapy. importance of what others thought of her and her Exposure began with confronting objects such ability to be a good parent. Thus, Elaine was as diapers and pictures of babies from magazines. helped to reduce the emphasis she placed on what Elaine was instructed to allow unwanted sexual she thought others might be thinking of her. thoughts to enter her mind and just “hang out” Sessions 3 and 4 involved learning to apply there. She was also told to allow herself to worry the cognitive model (and cognitive therapy) to about molesting Ryan; she needed to confront, OCD symptoms. In particular, Elaine was taught rather than avoid, these thoughts and ideas. that distressing intrusive thoughts—even those Although Elaine had some dif fi culty refraining about unwanted or taboo subjects—are normal from compulsive praying rituals at fi rst, by the experiences for most people, and that such seventh treatment session, she had cut her prayer thoughts do not mean anything signi fi cant or to acceptable levels, such as before bedtime, and threatening about the thinker. A model of OCD in was not asking Joe for reassurance about her which normal obsessional thoughts get misinter- unwanted thoughts. Joe had attended an early preted as overly signifi cant, leading to anxiety, exposure session and had been instructed by the was outlined. Anxiety then leads to urges to avoid therapist in how to offer supportive reinforce- Ryan, engage in compulsive prayer, and ask for ment for successful exposure practice, rather excessive reassurance from her family. These than giving reassurance that “everything would avoidance behaviors and rituals, which reduce be OK.” At the eighth session, a mid-treatment anxiety and provide reassurance in the short term, evaluation revealed a Y-BOCS score of 20, BDI paradoxically reinforce obsessional anxiety in score of 13, and a Hamilton Depression Rating the long run because they lead to greater preoc- Scale score of 10. cupation with the unwanted thoughts and the Sessions 9 through 16 included reviewing sense that the thoughts are “out of control.” Elaine exposure and cognitive therapy homework assign- understood the conceptual model, and it came as ments as well as conducting in-session exposure a relief to learn that others also experience strange practice with gradually more dif fi cult situations. intrusive thoughts from time to time (her thera- With some reluctance, Elaine was able to con- pist self-disclosed many of his own). She under- front most items on her exposure hierarchy stood that once she realized her sexual thoughts including changing Ryan, playing with him while about Ryan were not dangerous, her urges to he was naked, giving him a bath, and putting engage in avoidance, excessive prayer, and reas- lotion on and around his penis when he devel- surance seeking would be diminished and that oped a rash. She also was able to allow her her anxiety preoccupation with the unwanted unwanted intrusive thoughts to enter her mind thoughts would similarly decline. without needing to resist or suppress them. In the fourth session, an exposure hierarchy Although urges to say prayers about these was developed collaboratively. After a thorough thoughts sometimes occurred, Elaine understood discussion of the rationale for therapeutic expo- the importance of resisting these urges and prac- sure and response prevention, Elaine agreed to ticing exposure to her fear cues. She reported confront a number of situations that she had been being able to spend more and more time with avoiding over the remaining 11 sessions while Ryan and being alone with him. She also began also attempting to gradually drop her compulsive to feel more worthwhile as a parent, and her feel- behaviors. Elaine also continued to practice cog- ings of being a bad mother had disappeared. An 16 Comorbid Depression 251 important aspect of Elaine’s reduction in depres- have advocated that CT strategies be used sion was the genuine recognition and reinforce- routinely to help patients confront feared situa- ment she received from her family, who had tions during exposure. observed her hard work and improvement over Elaine’s depression was clearly secondary to the course of therapy. her OCD. That is, she was primarily depressed At the end of treatment, Elaine’s Y-BOCS about having intrusive obsessional thoughts. score was 11, indicating a near 60% reduction in Indeed, she believed these thoughts indicated OCD symptoms. Her BDI score was 7 and her that she was a terrible person—perhaps unfi t to Hamilton score was 4, both within normal range. raise a child. Such a belief system is the sort that She felt much more in control of her obsessional routinely leads to depressive symptoms. Very and depressive symptoms. Elaine also felt able to likely, reduction in her OCD symptoms toward continue her trajectory of improvement after the the middle stages of treatment resulted in further end of therapy. Three months following the end improvements in her depression. In some of treatment, Elaine’s Y-BOCS score was 12. She instances, as mentioned earlier in this chapter, arranged to see her therapist for four additional patients’ depressive symptoms represent primary sessions to practice exposure to a few situations complaints in their own right, over and above the that continued to give her trouble, including bath- distress associated with having OCD. For exam- ing and changing Ryan. She was only infre- ple, one patient we evaluated had experienced quently asking for assurances and was no longer depression for several years before the onset of praying about her intrusive thoughts. her OCD. An important question concerns whether patients whose depressive symptoms are related to the distress or functional impair- Clinical Issues and Summary ment associated with OCD would fare better in CBT for OCD as compared to patients for whom Elaine’s case indicates that CBT using CT meth- OCD and depression represent truly unrelated ods to augment exposure-based CBT procedures diagnoses. holds potential for treating OCD patients with comorbid major depression. At least for this particular individual, the 16-session, twice- Conclusions and Future Directions weekly treatment regimen appeared to improve the tolerability of anxiety-evoking exposure To date, the following can be said about the assignments so that she was able to engage in in fl uence of comorbid depression among (and bene fi t from) them. Given Elaine’s nega- psychological treatment for anxiety disorders: tive disposition toward exposure during her ini- (a) depression and anxiety go hand in hand, tial assessment, it is likely that she would have and many patients with anxiety disorders also had diffi culty with compliance (if not discontin- suffer from depression; (b) it appears that in ued therapy altogether) if exposure had been most instances, depressive symptoms emerge begun immediately. Instead, by introducing CT following the onset of anxiety disorder symp- fi rst, Elaine had the opportunity to (a) establish toms, and perhaps in response to the distress rapport with her therapist, (b) see that the thera- and functional impairment associated with pist understood her OCD symptoms, (c) come to severe anxiety; and (c) the presence of comor- better understand her own obsessional thoughts bid depression hinders outcome of CBT, which in a less threatening way, and (d) develop cogni- is the most effective treatment for anxiety dis- tive coping strategies to reduce her depressive orders, although the precise mechanisms for symptoms and prepare her for exposure sessions. this are not fully understood. It is interesting to speculate whether these factors Although the anecdotal case notes we present contributed to Elaine’s engagement in the more above provide reason for cautious optimism, much diffi cult aspects of the therapy. 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compulsive disorder. Journal of Anxiety Disorders, 9, and agoraphobia. Comprehensive Psychiatry, 42 , 249Ð256. 76Ð86. Salcioglu, E., Basoglu, M., & Livanou, M. (2003). Long- Sundquist, K., Johansson, L., DeMarinis, V., & Johansson, term psychological outcome for non-treatment-seek- J. (2005). Posttraumatic stress disorder and psychiatric ing earthquake survivors in Turkey. The Journal of co-morbidity: Symptoms in a random sample of Nervous and Mental Disease, 191 , 154Ð160. female Bosnian refugees. European Psychiatry, 20 , Schneier, F. R., Johnson, J., Hornig, C. D., & Liebowitz, 158Ð164. M. R. (1992). Social phobia: Comorbidity and morbidity Weissman, M. M., Bland, R. C., & Canino, G. J. (1997). in an epidemiologic sample. Archives of General The cross-national epidemiology of panic disorder. Psychiatry, 49 (4), 282Ð288. Archives of General Psychiatry, 54 , 305Ð309. Seligman, M. E. P. (1975). Helplessness . San Francisco: Wells, A. (1997). Cognitive therapy of anxiety disorders: Freeman. A practice manual and conceptual guide. West Sussex: Stavrakaki, C., & Vargo, B. (1986). The relationship of Wiley. anxiety and depression: A review of the literature. The Yaryuba-Tobias, J., Todaro, J., Gunes, M., McKay, D., British Journal of Psychiatry, 149 , 7Ð16. Stockman, R., & Neziroglu, F. (1996). Comorbidity Steketee, G., Chambless, D. L., & Tran, G. Q. (2001). versus continuum of Axis I disorders in OCD . Paper Effects of Axis I and II comorbidity on behavior presented at meeting of Association for Advancement therapy outcome for obsessive-compulsive disorder of Behavior Therapy, New York, NY. Limited Motivation, Patient-Therapist Mismatch, 1 7 and the Therapeutic Alliance

Alessandro S. De Nadai and Marc S. Karver

As described in Chap. 1 of this volume, anxiety However, while CBT presents many outstanding disorders present a series of disabling conditions, bene fi ts in the treatment of anxiety disorders, a which affect millions worldwide and create a substantial proportion of children and adults do staggering cost to society, which is estimated to not experience full remission of symptoms at the be $42.3 billion annually in the United States end of treatment. This could be for several rea- (Greenberg et al., 1999 ) . Furthermore, they have sons. One explanation is that CBT requires active a profound impact for those who suffer from patient participation, which involves coming to them at work, school, and in the home (Langley, treatment sessions on a regular basis, actively Bergman, McCracken, & Piacentini, 2004 ; Rubin participating during treatment, and participating et al., 2000 ) . Fortunately, through progress in outside of treatment sessions in the form of home- behavioral science research in the past century, a work. Given dropout rates of approximately 23% variety of empirically supported treatments observed in randomized controlled trials (RCTs) (ESTs; American Psychological Association for anxiety disorders for both adults and youth Presidential Task Force on Evidence Based (Hofmann & Smits, 2008 ; Kendall & Sugarman, Practice, 2006 ) have been developed and estab- 1997; Pina, Silverman, Weems, Kurtines, & lished as effi cacious interventions for anxiety Goldman, 2003) , along with the observation that disorders, with the vast majority that are appli- such rates may be even higher in the real world cable to anxiety disorders consisting of forms of (Westen & Morrison, 2001 ) , it is clear that many cognitive behavioral therapy (CBT) that include patients do not even complete treatment. the principles of exposure and response preven- For those who remain in treatment, within- tion (ERP; Barlow, 2008 ; Ollendick & King, session participation may be suboptimal, thus 2010 ) . In comparison to other effi cacious treat- negating the benefi ts provided by CBT. While ments such as pharmacotherapy, CBT has the coming to treatment out of one’s own volition bene fi ts of no medicinal side effects, provides the indicates a desire for symptom relief, patients requisite skills for retaining treatment bene fi ts display differing levels of willingness to change and preventing relapse, and is often more cost- behavior, which can affect willingness to partici- effective than pharmacotherapy for anxiety disor- pate in the procedures that achieve such change. ders in the long term (McHugh et al., 2007 ) . In CBT, such procedures can sometimes be diffi cult. Given that patients have often gone years with the same behavior patterns of anxiety, A. S. De Nadai , M.A. (*) ¥ M. S. Karver , Ph.D. which often are seen as a protective mechanisms Department of Psychology , University of South Florida , against harm (Barlow, 2002 ) , it is not surprising 4202 East Fowler Avenue, PCD 4118E , Tampa , FL 33626 , USA that in-session participation would at times be e-mail: [email protected] suboptimal.

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 255 DOI 10.1007/978-1-4614-6458-7_17, © Springer Science+Business Media New York 2013 256 A.S. De Nadai and M.S. Karver

Moreover, factors outside of the treatment session itself can further attenuate the effects of Factors That Contribute to Complexity CBT. Given that patients often spend only 1 h per week in treatment, they have 167 other hours A number of factors contribute to treatment in the week that can serve to either improve or complexity for treatment of anxiety disorders for reinforce their symptoms. Patients can spend a variety of populations. At present, practitioners this time working to generalize the components have access to treatments that work well but of therapy, or they may revert back to the same require patients to be engaged, and traditional behaviors that maintain their anxiety. CBT often CBT manuals provide little guidance regarding addresses this situation through the assigning of how to achieve such engagement. Given the homework (Huppert, Ledley, & Foa, 2006 ) . aforementioned diffi culties of engaging patients Indeed, patients who spent more time doing in session and outside of sessions (via complet- homework between sessions have been observed ing homework), many patients receive an inade- to have better outcomes for agoraphobia quate dose of this effi cacious treatment. Several (Edelman & Chambless, 1993 ) , and early com- hypothesized barriers that contribute to the compliance with homework has also been associated plexity in treating anxiety disorders are ambiva- with more positive outcomes for social phobia lence in motivation for behavior change, mismatch (Leung & Heimberg, 1996 ) and obsessive-com- of clinician and patient, and limited therapeutic pulsive disorder (OCD; Araujo, Ito, & Marks, alliance. Indeed, clinicians have reported that 1996 ) . However, homework completion has two substantial barriers to treatment for panic been observed to be suboptimal (Kazantzis, disorder are forming an alliance with patients and Deane, & Ronan, 2004 ) . Helbig and Fehm having patients present for treatment with limited (2004 ) surveyed 77 CBT therapists, who motivation (Goldfried, 2011 ) . If a patient has less identifi ed that 74.5% of their patients displayed than full conviction to leave his or her avoidant diffi culties in completing homework and indi- habits behind, feels mismatched with the clini- cated that only 38.9% were fully compliant. cian, or does not feel connected with the therapist This is particularly unfortunate given the sub- (i.e., a poor therapeutic alliance), this likely will stantial in fl uence homework has on CBT treat- lead to diffi culties in engaging in the treatment. ment; in a recent meta-analysis (where 57% of In the sections that follow, we review the evidence the studies focused on anxiety; Kazantzis, supporting how these factors contribute to the Whittington, & Dattilio, 2010 ) , homework was complexity of treating patients struggling with observed to have a large effect size in treated anxiety disorders. groups ( d = 1.08) and presented an incremental improvement over no-homework conditions ( d = 0.48). Motivation In considering these external factors, it becomes readily apparent that treatment for Motivation for behavior change is a pivotal factor anxiety disorders goes far beyond applying in a variety of psychological treatments, and anx- CBT to patients. While the principles of CBT iety disorders are no exception. Given that human have been established with rigorous scienti fi c beings typically seek homeostasis and stability control in the laboratory, other factors are (Monroe, 2008) , it should not be surprising that involved in transitioning them to the fi eld. patients have some reluctance to make changes in Thus, the core elements of CBT are empiri- any behavior, including their ingrained habits cally justifi ed and necessary but also are not which have provided comfort but also have main- suffi cient in order to achieve symptom relief. tained anxiety symptoms. Motivation is often A further examination of issues that can mod- construed in the context of patient readiness for erate and mediate the effects of CBT on symp- behavior change where such readiness is pre- tomology is warranted. sented in a framework of multiple stages, where 17 Motivation Mismatch Alliance 257 patients may have not considered change outcomes in generalized anxiety disorder (GAD; (precontemplation), may be considering change Dugas et al., 2003 ) . Ambiguity in commitment to (contemplation), may be actively planning change change has been indicated to be as a particularly (preparation), or are taking action and/or working troublesome barrier in the treatment for compul- to maintain such change (action and maintenance, sive hoarding, and suboptimal outcomes in a respectively; Prochaska & DiClemente, 2005 ) . recent open trial for compulsive hoarding were This conceptualization of motivation eschews the attributed to problems with completing home- notion of the construct being an inherent trait and work in the context of such motivation (Tolin, rather construes it as one that is modifi able over Frost, & Steketee, 2007 ) . While many patients time. Motivation for behavior change fi rst may have suffi cient initial motivation to achieve received major attention in psychological treat- benefi t from CBT for anxiety disorders, a large ments when addressing problematic alcohol use number of patients appear to experience ambiva- (Miller, 1983 ) and has been identifi ed as present- lence and outright resistance to treatment, which ing barriers to treatment for conditions such as are complications that are typically not addressed diabetes, asthma, and AIDS (Rubak, Sandbæk, by traditional CBT. Lauritzen, & Christensen, 2005 ) . Oftentimes, In considering the issue of patient motivation patients seek relief for conditions and have initial for patients with anxiety disorders, it is important motivation to work toward symptom manage- to understand that it is not necessarily that patients ment, but diffi culties in engaging in the tasks nec- low in motivation have no motivation to change essary for such relief can present impediments to at all but rather that they often experience ambiv- symptom reduction. Thus, the degree of commit- alence related to confl icting feelings about enact- ment to change can attenuate the effect of the pre- ing change. Anxiety disorders differ from alcohol scribed intervention on the target outcome. and substance use regarding the sources of Similar parallels can be drawn in the role of ambivalence, as many patients with anxiety dis- motivation for behavior change in CBT for anxi- orders do not want to participate in behaviors that ety disorders. Many patients come in for treat- are characteristic of their psychopathology ment where they commit a substantial amount of (unlike substance use) but may have ambivalence money and time for services, but even then, sub- about the speci fi c tasks required to achieve relief stantial patient effort both within and outside the (e.g., exposure; Slagle & Gray, 2007 ) . While the session is required in the context of competing major part of the motivational balance in alcohol life priorities. In psychological treatments as a use hinges on the adverse consequences of alco- whole, those identi fi ed to be at the precontempla- hol use in comparison to the enjoyment of drink- tion stage of readiness for change have been indi- ing, in anxiety disorders the primary decisional cated to not fare as well in treatment as those in balance is that changing via CBT offers a more the contemplation or action stages (Krebs, distal goal of eventual anxiety reduction in com- Prochaska, & Norcross, 2011 ) , and there is no parison to the immediate salience of fear, which reason to indicate that these fi ndings should dif- is immediately reduced by safety behaviors (that fer in anxiety disorders. In a recent survey of are the opposite of CBT-prescribed behaviors). therapists who treat panic disorder, 67.1% of par- Paradoxically, exposure increases distress in the ticipating therapists reported initial motivation short term compared to safety behaviors which from patients as a common barrier to treatment escape stressors and give an initial sense of com- (Goldfried, 2011 ) . Patients low in motivation fort but then lead to adverse distal consequences have been observed to have poor treatment out- via negative reinforcement of safety behaviors comes for manualized CBT for panic disorder, no (which maintain stimuli as anxiety provoking). matter how well the therapist follows the outlined Indeed, it is logical that patients with anxiety dis- procedures (Huppert, Barlow, Gorman, Shear, & orders would have ambivalence with regard to Woods, 2006 ) . Similarly, low motivation for treat- enacting procedures for changes in thinking and ment participation has predicted poorer treatment behavior. Problems that bring people to seek 258 A.S. De Nadai and M.S. Karver treatment do not solely cause discomfort but also “what treatment for which speci fi c problem”), involve these protective but ineffective safety but less research has focused on them being behaviors (both cognitive and behavioral) that delivered “by whom” and “for this individual,” temporarily alleviate anxiety-related distress with along with the interaction between these two an associated long-term cost. For example, indi- variables. Patients and therapists can mismatch viduals with GAD report worry to be problematic on a variety of issues, which may lead to attenu- but also simultaneously to serve as a protective ation in motivation for change, therapeutic mechanism (Borkovec & Roemer, 1995 ) . For alliance, and overall treatment outcome. For such patients, worry helps to prevent from forget- example, if a therapist focuses on psychoeduca- ting and acts as a mechanism to exert perceived tion before a patient is ready while the patient control over circumstances. Similarly, patients is still internally wary of the consequences of with agoraphobia who have concern over having giving up safety behaviors (a mismatch on read- public panic attacks and patients with OCD who iness to change), this can increase negative have concern with becoming ill engage in unpro- perceptions about treatment and thus tip the deci- ductive avoidance behaviors in an attempt to pro- sional balance away from change (reducing moti- tect from such undesired outcomes. Thus, patients vation) and result in a disagreement/mismatch on with anxiety disorders may have ambivalence in treatment goals (reducing the therapist-patient simply abandoning such behaviors that have pro- alliance). Reduced motivation to change and a vided a great deal of comfort for them despite poor alliance could then work to attenuate over- their adverse consequences in the long run. Such all treatment outcome. It is important to note ambivalence in behavior change is one of the rea- that therapist-patient mismatches do not occur sons that patients with panic disorder, social pho- in isolation but rather in the context of a variety bia, and OCD have been found to enter CBT with of issues when applying CBT with a particular some hesitancy (Buckner & Schmidt, 2009 ; patient. Dozois, Westra, Collins, Fung, & Garry, 2004 ; Research in psychotherapy has traditionally Maltby & Tolin, 2005 ) . A further threat to moti- divided variables for matching in terms of thera- vation is the high comorbidity rate of anxiety dis- pist characteristics (Beutler et al., 2004 ) , patient orders with depression (Kessler, Chiu, Demler, characteristics (Clarkin & Levy, 2004 ) , content Merikangas, & Walters, 2005 ) and the associated and tailoring of speci fi c interventions (Griner & anhedonia and reduced motivation to participate Smith, 2006 ) , and therapist behaviors in the con- in a variety of activities that come with depressed text of therapist-patient interaction (Beutler et al., mood. Motivation for these comorbid patients 2004) . Patient and therapist factors can be further may be further impaired with regard to engaging classifi ed in terms of basic demographics (e.g., in treatment for anxiety. SES, gender, age, ethnicity), psychological variables (e.g., patient presenting problem, patient personality traits, level of impairment, patient Therapist-Patient Mismatch insight into symptoms), and the values, beliefs, attitudes, and cultural history of all parties in What treatment, by whom, is most effective for treatment. Given these characteristics, therapist this individual with that specifi c problem, and behaviors and the use and adaptation of interven- under which set of circumstances? (Paul, 1967 , tions may differ depending on patient and thera- p. 111) pist characteristics in order to achieve an optimal Gordon Paul’s seminal quotation still reso- match. nates today in a variety of fi elds, with treatment Therapist-patient mismatches can be divided for anxiety disorders being particularly relevant. into two major categories: structural mismatches, A mismatch between therapist and patient is of which refer to mismatch on preexisting char- speci fi c interest, as currently there are a variety of acteristics over which the therapist has little con- effi cacious treatments for anxiety disorders (i.e., trol (e.g., ethnicity, gender), and behavioral 17 Motivation Mismatch Alliance 259 mismatches, which refer to mismatch of speci fi c patients who matched their clinician on ethnicity. behaviors over which the therapist exerts direct However, these effects were not seen when pairing control (e.g., interpersonal style, therapeutic Caucasian patients with African-American thera- expectations). Hypotheses regarding the effects pists. Precisely disentangling these effects would of structural mismatch often trace their empirical require further prospective work given the con- origins to Festinger ( 1954 ) , who found that peo- founding concept of pretreatment commitment to ple often prefer and identify with others who are participate, as once this variable was included in similar to themselves, relative to those who are the model along with treatment type, the ethnic more dissimilar (and thus are more mismatched matching effects were no longer observed. structurally). The notion of behavioral mismatch Nonetheless, these results do coincide with other has been highlighted by Beutler et al. ( 2004) , who fi ndings that African-Americans are more likely have emphasized specifi c therapeutic approaches than other racial groups to prematurely terminate for speci fi c patient characteristics under the treatment (Diala et al., 2000 ; Sue, Ivey, & umbrella of “prescriptive psychotherapy.” Pedersen, 1996 ) and, in multiple other instances, Tailoring treatments for idiographic patient care ethnicity has been identi fi ed as a predictor of has also become of increasing importance in the treatment retention in both adult and child therapy strategic aims of the National Institute of Mental (Miller, Southam-Gerow, & Allin, 2008 ; Sue & Health (Insel, 2009 ) in recent years, as psycho- Lam, 2002) . A variety of ethnic and racial groups therapy moves beyond a “one-size-fi ts-all” have cited treatment stigma and apprehension in approach. As patients with anxiety disorders are a working with a treatment provider as the main heterogeneous group (Kessler et al., 2005 ) , such reason for not seeking psychological treatments efforts to identify and ameliorate mismatches are and have also reported these attributes at elevated also of increasing relevance for these patients as levels relative to Caucasians (U.S. Public Health well. In this section, we aim to identify a variety Service, 1999 ) . of potential structural and behavioral mismatches Despite the dearth of evidence for ethnic mis- for patients with anxiety disorders. match and its effect on treatment, its conse- The two most readily identi fi ed structural mis- quences on the treatment process can be matches involve race/ethnicity and gender. signifi cant. For example, consider the situation Current indications are that racial and ethnic mis- where a therapist treats a native Irish patient with match may not predict distal outcomes in psy- compulsive hoarding, who comes from a cultural chotherapy (e.g., symptom reduction) but may subgroup that values minimal waste and reuse of predict proximal outcomes such as treatment all items (possibly in response to limited retention and comfort in participating in therapy resources) and has some disdain toward regular (e.g., Zane, Hall, Sue, Young, & Nunez, 2004 ) . discarding of items. In this case, simply proceed- Research into racial/ethnic matching effects in ing with treatment to reduce such behavior would CBT for anxiety is extremely sparse, with one be inadvertently invalidating to cultural values. study directly evaluating its impact. Rosenheck, Additionally, some ethnic minority groups may Fontana, and Cottrol (1995 ) identi fi ed that when emphasize a more somatic presentation of anxi- African-American patients with posttraumatic ety disorders (U.S. Public Health Service, 1999 ) , stress disorder were matched with Caucasian and failure to recognize these symptoms as con- therapists, increased termination rates were sistent with a traditional anxiety disorder presen- observed both after the fi rst session as well as tation could lead to clinician-patient disagreement/ before the completion of the 12-week treatment mismatch on what to treat and the best way to protocol relative to those patients who were approach treatment. paired with African-American therapists. With regard to gender match, early studies Additionally, these Caucasian therapists rated the evaluating this construct suggested that patients same patients as having reduced clinician-rated stayed in therapy longer or had better outcomes commitment to treatment relative to Caucasian when patients and therapists matched on gender. 260 A.S. De Nadai and M.S. Karver

However, closer examination of these studies wonder when the therapist will adequately showed numerous methodological fl aws. In more address their primary presenting issues. Consistent recent, methodologically stronger studies, gender with the principal that match is based on a fl exible match has not been indicated to be an overall pre- balance between patient and therapist agendas, dictor of treatment dropout or outcome over a Hogue et al. ( 2008 ) found that moderate levels of variety of conditions (Beutler et al., 2004 ) , and adherence to a treatment protocol predicted the the one study of this concept in anxiety disorders best treatment outcomes for adolescents with also did not fi nd gender match as a predictor of externalizing problems, especially in comparison outcome in CBT for panic disorder (Huppert to those therapists who displayed very high or et al., 2001 ) . Nevertheless, given the limited low adherence levels. Moreover, in treatment for research base with anxiety disorders, potential panic disorder, Huppert et al. ( 2006 ) found that for mismatch on gender issues does exist. For high protocol adherence was associated with example, a clinician treating a postpartum female poorer outcomes among those who had low moti- with OCD could easily forget that mothers of vation for behavior change. Kendall and Chu children who have not yet received vaccinations ( 2000) have found that therapists vary in how are often instructed to keep a relatively clean fl exibly they deliver a manualized treatment, environment for their children. Thus, a new which is not necessarily a nuisance confound if mother with OCD could view a male therapist some patients require differing levels of protocol who challenges notions of appropriate cleanli- deviation. A therapist must have grounding for ness as insensitive and lacking proper under- the specifi c treatment that he/she implements but standing of the issues being dealt with. Such a also must be careful regarding how and when to process could lead to a rupture of the therapeutic implement it with a speci fi c patient. Clinicians alliance which the mother attributes to the thera- are thus presented with a balancing act, where pist’s gender mismatch. they are tasked with implementing CBT to reduce While structural mismatches exist regardless symptoms of anxiety while simultaneously of any behavior of the individual clinician, behav- addressing other patient goals. ioral mismatches depend on the behavior of the A related issue where a therapist can mismatch clinician once he/she is in the presence of a with a patient is on the method of presentation of patient. One common mismatch that can occur in treatment roles to a patient. On one end of the CBT treatment for anxiety disorders is rooted in spectrum, therapists can work as collaborative the decision of when to implement speci fi c CBT partners, whereas on the other end it is more an procedures during treatment (Kendall & Chu, authoritative style. Here, matching is in context 2000 ) . Adhering too closely to a treatment man- of the notion of patient reactance, which refers to ual with a patient who wishes to discuss emerg- a style of responding to an authority fi gure (where ing personal issues can result in mismatch on high reactance corresponds to defi ance in the face session and overall treatment goals. The therapist of authority and low reactance corresponds to following a manualized treatment too closely submissive behavior; Brehm, 1966 ) . Thus, a could force an agenda of exposure to anxiety- patient who is high on reactance would match provoking stimuli while neglecting a patient goal poorly with a therapist who takes an authoritative to address recent matters aside from anxiety that stance, while a patient low in reactance may have occurred in the patient’s life. Adhering too match poorly with a therapist who is well mean- little to the manual, however, can also lead to ing in a collaborative style but does not provide mismatch on session and treatment goals. A ther- suf fi cient direction. Over a variety of treatments, apist feeling the need to be responsive to every it has been observed that patients high in reac- issue raised by a patient can end up neglecting tance benefi t from less structured treatment, standardized procedures that address the main while those in low reactance bene fi t from more goal of symptom remission, thus delaying the therapist guidance and structured therapy associated benefi ts and leaving the patient to (Beutler, Harwood, Michelson, Song, & Holman, 17 Motivation Mismatch Alliance 261

2011) . The implications of these fi ndings quickly mismatch of treatment expectations. Patients may become pertinent in CBT for anxiety, given that be unaware of how much of the focus of CBT is patients sometimes require urging by clinicians on their participation, expecting the therapist to to engage in exposures. Patients high in reactance do a preponderance of the work. Thus, such mis- may bristle at being strongly encouraged into matches between what a therapist and patient conducting exposures and may refuse to partici- may expect in therapy could be troublesome. pate, or they may acquiesce to participating half- Patients and therapists can also mismatch on heartedly in session and not practice at home. patient-specifi c preferences for treatment proce- Conversely, patients low on reactance may work dures, and conversely achieving such a match can better with clinicians who use authoritative serve to assist in treatment implementation. With expectations of success to progress the patient regard to overall treatment choices for a broad through an exposure hierarchy. array of psychological conditions, a small but Another issue to consider in behavioral mis- consistent effect has been observed for matching matches is the patient’s perception of what treat- treatment techniques to patient preferences (in ment ought to be and how quickly it will work contrast to not matching at all). Some ethnic and and whether therapist behaviors match these racial minority patients have displayed a propen- expectations. Patient expectations of treatment sity for alternative treatments as opposed to tradi- may play a powerful role, as they have been indi- tional psychological treatments, such as self-help cated to predict better CBT outcome for several methods or consultations with religious or other anxiety disorders (through a pathway of increased group leaders (Thomason, 2000 ; Thompson, homework compliance and early symptom Bazile, & Akbar, 2004 ) , and this may well be true improvement; Westra, Dozois, & Marcus, 2007 ) for some patients from majority groups as well. and have been indicated to mediate SES-dropout These fi ndings create a challenge for clinicians relationships (Pekarik, 1991 ) . Indeed, establish- when treating patients with anxiety disorders, ing positive expectancies for treatment outcome where CBT prevails and other effective behav- has been related to stronger rates of symptom ioral treatment options are not readily available. reduction in fear of fl ying (Price, Anderson, This presents a continued challenge to the clini- Henrich, & Rothbaum, 2008 ) . With regard to cian who may feel compelled to implement a such outcome expectancies, patients who expect CBT framework while negotiating a variety of no relief may feel a mismatch if their therapist potential patient preferences. does not validate their view (e.g., portraying In a similar vein to the consideration of out- relief by exposing oneself to feared situations as come, role, and procedural expectancies is the straightforward and easy to those who have strug- potential mismatch with the patient in the content gled for years with various fears). On the other and pace of exposures, with particular regard to hand, those who expect immediate relief would pairing exposures carefully to a patient’s hierar- experience mismatch if symptom reduction was chy of fears. It is possible that the clinician may not immediate but experienced over a period of want to move up the hierarchy too rapidly, thus weeks. With regard to matching on expectations risking mismatch with the pace and content on treatment procedures, patients may have dif- that the patient is ready or willing to address. fering views from their therapists for their expec- With this mismatch, the patient may resist par- tancies of what treatment consists. While ticipation in the exposure or may attempt an increasing in popularity, many patients may still exposure that is perceived as too diffi cult, which not be well aware of the principles of exposure can lead to patient withdrawal during the exposure. treatments and CBT in general (Westra, Aviram, This can lead to additional consequences such Barnes, & Angus, 2010 ) and may instead expect as reduction of patient self-ef fi cacy, adversely long hours on a couch for a period of years. When affecting any future willingness to participate in the therapist starts explaining about CBT skills exposures. On the other hand, if the clinician and procedures, the patient may experience a chooses an exposure pace that is slower than what 262 A.S. De Nadai and M.S. Karver the patient desires, this mismatch can lead to week without the therapist. Parents can either patient frustration with rate of progress, which accommodate the avoidant behavior often seen in can also lead to treatment dropout. Also, expo- anxiety disorders (and thus maintain symptoms; sures that are not matched to speci fi c patient con- Storch et al., 2007 ) , or conversely they can aug- cerns/fears may not be perceived as particularly ment treatment by becoming “co-therapists” and relevant and thus not of optimal benefi t to a being strong advocates to reduce avoidance and patient. For example, a patient with a fear of achieve full symptom remission (Kendall, snakes may have little diffi culty encountering a Hudson, Gosch, Flannery-Schroeder, & Suveg, harmless snake in the clinic, but only in his back- 2008) . For example, if parents are not on the yard does he experience the necessary arousal to same page with therapists as far as treatment begin emotional processing, which is believed to rationale and agreement with the tasks to be be necessary to achieve extinction of anxious performed during treatment, this can undermine symptomology (Foa & Kozak, 1986 ) . However, a the in-treatment procedures. It can be dif fi cult patient may not verbalize this unless a clinician is for parents to see their children endure marked attentive and ensures that the content of expo- distress from anxiety, and a natural instinct can sures is pertinent to the patient. be to provide short-term comfort and accommo- Also related to appropriate matching on expec- dation. Without proper understanding of the tancy for treatment procedures is agreement on rationale of treatment, this tendency to accom- the rationale behind treatment, as some patients modate can be diffi cult to resist, leading to poorer may not be fully understanding of or agree with longer-term outcome. Furthermore, parents the cognitive behavioral model of anxiety. The matching with clinicians regarding their role in importance of conveying a rationale to patients treatment is also essential, as some parents may has been emphasized for a variety of treatments wish to drop off their child at therapy and remain (Addis & Carpenter, 2000; Wampold, 2001 ) . relatively uninvolved, while on the other end of With respect to anxiety disorders, patient agree- the spectrum, some may wish to be active partici- ment with treatment rationale has been indicated pants in every aspect of treatment. Mismatch on to predict adherence to within-session exposure such parental role expectations can preclude procedures and better treatment outcomes for implementation and generalization of treatment OCD (Abramowitz, Franklin, Zoellner, & and perhaps even lead to parental withdrawal of DiBernardo, 2002 ) and improved outcome in their child from therapy. Incorporating parents treatment for GAD (Borkovec, Newman, Pincus, and adapting treatment to child needs in CBT for & Lytle, 2002) . In fi nding agreement on the treat- pediatric anxiety disorders raise additional factors ment rationale for CBT, careful consideration to consider in comparison to conventional treat- may be necessary in the context of the CBT meth- ment for adult anxiety disorders. ods of cognitive restructuring and challenging Several other issues with regard to patient- maladaptive thoughts, which involve challenging therapist match include mismatch on perception thinking that has often served a function for the of the problem (as therapists, parents, and patients patient in the past. Telling patients who do not often have different perceptions of the priority match therapists in their belief in the treatment problem; Grills & Ollendick, 2003 ), coping orien- rationale that their thinking is maladaptive can be tation (e.g., active in solving problems or avoidant a potential source of invalidation (Addis & in addressing challenges), and interpersonal style Carpenter, 2000 ) , which can interfere with the (e.g., a high-energy therapist being a poor match therapeutic alliance. for a low-energy patient). As can be seen, a series In psychological treatments for pediatric anxiety of pitfalls await therapists implementing treatment disorders, mismatch with parents also needs to be for anxiety disorders for a heterogeneous patient addressed, as they are essential participants in population. Navigation of these potential mis- therapy. If a child is in the therapy offi ce for 1 h matches has direct implications for engaging per week, he/she has 167 other hours during the 17 Motivation Mismatch Alliance 263 patients in CBT and in developing a working tic alliance is a robust predictor of treatment out- treatment relationship. come (Martin, Garske, & Davis, 2000 ; Shirk & Karver, 2011 ) . Consistent with the general treatment literature, the alliance has been found, pre- Therapeutic Alliance dominantly in CBT studies, to predict proximal (e.g., change in cognitions) and distal (e.g., change The sections on patient motivation and therapist- in anxiety symptoms) outcomes in the treatment patient mismatch reveal that treating youth and of multiple anxiety disorders (e.g., Casey, Oei, adult anxiety disorders is more complex than just & Newcombe, 2005 ; Hayes, Hope, VanDyke, & having a clinician select and implement an EST. Heimberg, 2007 ; Langhoff, Baer, Zubraegel, An unmotivated patient will not be suddenly & Linden, 2008 ; Newman & Stiles, 2006 ; motivated by the clinician starting to implement VanDyke, 2002; Vogel, Hansen, Stiles, & an EST. Similarly, a patient who is mismatched Gotestam, 2006) and youth anxiety disorders with the therapist on matters such as role and out- (e.g., Chiu, McLeod, Har, & Wood, 2009 ; Creed come expectations also will not just disregard the & Kendall, 2005 ; Hughes & Kendall, 2007 ; mismatch because the clinician has evidence- McLeod & Weisz, 2005 ) . based treatments at his/her disposal. These points Although most studies have found a positive demonstrate that an important additional element therapeutic alliance related to therapeutic gain in of treatment, the therapeutic alliance, must be treatment of anxiety disorders, a handful of stud- taken into account when treating patients with ies have not found this relationship (Kendall, anxiety disorders. 1994; Kendall et al., 1997 ; Southam-Gerow, The therapeutic alliance has been de fi ned as a Kendall, & Weersing, 2001 ; Woody & Adessky, working relationship between a therapist and a 2002) . It has been suggested that this may be patient in which the patient feels an affective because the anxious patients in these studies bond with the therapist and agrees with the thera- reported very high and/or increasingly high ther- pist on the goals and therapeutic tasks of treat- apeutic alliance ratings, thus resulting in limited ment (Bordin, 1979 ) . It should be noted that variability (Kendall, 1994; Ramnero & Öst, present research supports these three factors with 2007) . It may be that anxious patients are quite adult patients but has not supported these compo- vulnerable to a social desirability bias, where nents as making up elements of the alliance with they worry about the consequences of not report- youth patients (Zack, Castonguay, & Boswell, ing a positive alliance. Another possibility for 2007 ) . Karver, Handelsman, Fields, and Bickman why alliances may be highly rated could be that (2005 ) suggested that the therapeutic alliance in the anxious patients may be very eager to be youth therapy consists of an emotional/affective approved by their therapist and thus readily form connection (e.g., bond, trust), a cognitive connec- a relationship with the therapist. tion (e.g., agreement on goals, hopefulness), and A patient-therapist alliance is likely an inte- a behavioral connection (e.g., collaboration on gral element that needs to be addressed in suc- tasks and other forms of patient participation). cessful CBT for anxiety disorders. While the More recently it has been suggested that youth primary component of CBT for anxiety disorders treatment participation may be a separate con- involves exposure, this process requires getting struct that follows from or is facilitated by the patients who are often shy, avoidant, and inhib- affective and cognitive elements of the alliance ited to approach rather than escape from that (Shirk & Karver, 2011 ) . An additional element which is directly related to their disorder. Without that needs to be attended to uniquely in youth a healthy alliance, the therapist may be unable to therapy is the therapist-parent alliance (Karver convince the anxious patient (or the patient’s par- et al., 2005 ) . ents in a youth treatment case) to trust enough to Studies of the therapeutic alliance in adult and cooperate and expose him/herself to a feared youth treatment have revealed that the therapeu- stimulus, especially the fi rst time when the patient 264 A.S. De Nadai and M.S. Karver has not yet experienced proof that doing some- et al., 2007 ) . Further, the alliance likely also thing that seems illogical to them due to their facilitates patient willingness to learn and prac- cognitive biases (and may seem cruel to parents) tice additional CBT therapeutic skills both in ses- is actually helpful (Hayes et al., 2007 ; Langhoff sion and at home (Chu & Kendall, 2004 ) . This is et al., 2008 ) . It may be that an initial emotional additionally important given that patient willing- connection with the therapist, one that establishes ness to learn new coping skills and participation the therapist as safe and trustworthy, needs to be in treatment (including homework) have been made in order to facilitate a patient’s willingness found to be related to treatment outcome (Chu & to listen to the therapist explain the treatment Kendall; Edelman & Chambless, 1995 ; Huppert rationale. This is not to be taken for granted given et al., 2006 ; Karver, Handelsman, Fields, & that anxious patients likely question whether or Bickman, 2006 ; Kazantzis et al., 2010 ) . not the therapist likes or respects them (VanDyke, In addition, it should be noted that the parent- 2002) . A well-explained treatment rationale with therapist alliance has also been found related to proper orientation and clari fi cations as to what to treatment dropout (Hawley & Weisz, 2005 ) and expect can establish therapist trust, credibility, improvement in youth anxiety symptoms and hopefulness that will be vital when a patient (McLeod & Weisz, 2005 ) . This is not surprising starts an emotionally demanding exposure where given that anxious youths have frequently been the therapist supports and encourages the patient found to have anxious parents (Bienvenu, to endure discomfort while preventing escape Hettema, Neale, Prescott, & Kendler, 2007 ) . By from the threatening stimulus (Caron & Robin, forming an alliance with the parents, the therapist 2010) . In fact, the therapeutic alliance has been may be able to overcome parental anxieties (such found related to patient participation in treatment as embarrassment that their child has a problem for anxiety disorders (Liber et al., 2010 ) and, or anxiety about being evaluated negatively by more specifi cally, patients’ willingness to expose the therapist) about bringing their youth to treat- themselves to higher anxiety-provoking situa- ment and about seeing their child be required to tions and to stay in the situations long enough to face anxiety-provoking situations. The clinician habituate (Hayes et al., 2007 ) . It logically follows may even be able to involve the parents in the that the emotional bond elements of the alliance treatment, which has been found to result in bet- would decrease during an exposure due to the ter youth treatment outcomes (e.g., Mendlowitz unpleasant feelings experienced, leading to the et al., 1999 ) . patient feeling upset at the therapist for making them experience the uncomfortable feelings. However, the more cognitive aspects of the alli- Approaches to Address Issues with ance, focusing on negotiating agreement with the Alliance, Motivation, and Therapist- patient on goals and tasks to achieve those goals Patient Mismatch Building Alliance and encouraging the patient to remain in an exposure, even if they are voicing concerns that they Although it is bene fi cial that much of the treat- cannot do it or are failing, may contribute to why ment literature and many treatment manuals now a reluctant patient would continue to participate mention the importance of forming a therapeutic in the exposure and not drop out of the exposure alliance with an anxious patient, they neglect to and/or the treatment (Kendall et al., 2009 ) . This address how this should actually be done. In fact, probably explains why both youth and adult the therapeutic alliance is often confusingly patients receiving an exposure treatment for anxi- addressed as if it were a treatment approach rather ety disorders would attribute treatment success to than the product or result of treatment techniques. features of the therapeutic relationship (Kendall Indeed, the common terse recommendation for a & Southam-Gerow, 1996 ) and why the therapeutic clinician to “form an alliance” with a patient is alliance has been found related to anxious not particularly informative. Fortunately, research patients’ ratings of session helpfulness (Hayes has attempted to identify therapist behaviors that 17 Motivation Mismatch Alliance 265 predict the formation of a positive therapist- it makes sense how the patient feels and acts patient alliance. given past or current circumstances, automatic In particular, therapist interpersonal skills thoughts that are generated, and situations that such as empathy, warmth, and genuineness have have been experienced. Instead of challenging repeatedly been found to predict the therapist- patient reluctance, the clinician would validate patient alliance and patient engagement in both reluctance and avoidance and acknowledge that youth and adult treatment (Horvath & Bedi, 2002 ; the patient’s reluctance makes sense given how Karver et al., 2006 ) . Therefore, not surprisingly, certain situations make the patient feel. these same interpersonal skills have been recom- However, the therapist will need to switch to mended as playing an important role in a thera- other alliance-building behaviors as therapy pist getting an anxious patient to participate in progresses. Keijsers et al. ( 1995 ) found that cognitive behavioral treatments (Langhoff et al., empathic listening in the third vs. the fi rst ses- 2008 ) . Surprisingly little research has examined sion was related to worse therapeutic outcomes, and demonstrated the relationship between thera- while directiveness/guidance later in treatment pist empathy and the therapeutic alliance in the predicted better outcomes. This makes sense in treatment of anxiety disorders (e.g., DeGeorge, that while initially a patient needs to feel under- 2008) . However, indirect evidence in the form of stood and accepted, eventually the patient the relationship between interpersonal skills needs the focus of therapy to shift toward relating to symptom improvement in anxiety dis- change. Without more direction from the clini- orders suggests that these skills help build the cian, therapy will seem purposeless and alliance with these patients (e.g., Keijsers, avoidant of change (i.e., it will appear that Schaap, Hoogduin, & Lammers, 1995 ; Newman nothing will be done to actually deal with the & Stiles, 2006 ) . When using these skills, it is patient’s anxious symptoms). The therapist of important that therapist provides an interest in the course should still be supportive and caring, as patient that is genuine, as clinician overemphasis this has been found to be related to patient will- on commonality with the patient can come across ingness to enter anxiety-provoking situations as inauthentic and has been found to negatively (Williams & Chambless, 1990 ) . predict the therapeutic alliance (Creed & Kendall, An additional related therapeutic approach 2005 ) . On the other end of the spectrum, clini- to engaging anxious patients that has been sug- cians who are overly formal, didactic, directive, gested as very important is for the therapist to and who grill their patients with questions about take a teamwork-oriented collaborative stance anxiety and anxiety-provoking situations, espe- with the patient (Caron & Robin, 2010 ; Chu, cially early in treatment, have been found to form Suveg, Creed, & Kendall, 2010) . With this poor alliances and/or have worse outcomes with approach, the therapist collaboratively sets anxious patients (Creed & Kendall; Keijsers goals with the patient and works together with et al., 1995 ) . Thus, it is likely that at treatment the patient to determine the treatment tasks and onset, therapist rapport-building behaviors that the pace of treatment. In order to do this, the focus on building an affective bond/emotional therapist must listen to and validate the connection, such as empathy, respect, validation, patient’s perspective about treatment and then acceptance, and genuineness, will be needed for be fl exible in how treatment is conducted with an anxious/avoidant patient to initially engage the patient (Shirk & Karver, 2011 ) . Consistent and open up with a therapist. This would be the with this, Creed and Kendall ( 2005 ) found ther- clinician listening to the anxious patient and apist collaborativeness to predict later ratings showing understanding by validating the of the patient-therapist alliance while Chu and patient’s experience such as acknowledging how Kendall ( 2009) found therapist fl exibility to diffi cult the patient’s feelings are and how chal- predict patient involvement for anxious patients. lenging and painful anxiety-provoking situations A fl exible therapist could implement a treat- seem. The clinician would make statements that ment for an anxiety disorder but fl exibly adapt 266 A.S. De Nadai and M.S. Karver the treatment in a way to make it more interest- with anxiety disorders (e.g., Borkovec et al., ing (e.g., changing typical manual examples or 2002 ; Newman & Fisher, 2010 ) . handouts), more responsive to newly present- More broadly, part of therapists’ being con- ing patient issues (e.g., use presenting issues as vincing that it is worthwhile to work with them is examples for use of skills being taught), and not just their explanation of the treatment ratio- more applicable to patient needs and goals for nale but how credible the therapists appear over- the patient. These techniques can serve to more all. Part of appearing credible to an anxious easily retain the patient’s attention when imple- patient is that the therapist demonstrates a combi- menting the treatment (Connor-Smith & Weisz, nation of expertise, confi dence, trustworthiness, 2003 ) . In addition, the fl exible therapist would organization, and preparedness (Karver et al., pace the treatment such that the patient is not 2005) . Consistent with this, Williams and forced to engage in a treatment component Chambless (1990 ) found that therapists perceived (such as exposure) before being ready. as more con fi dent were more likely to have Of course, in order for an anxious patient to patients approach anxiety-provoking stimuli. feel like an equal member of the therapeutic Perceptions of therapist expertise, self-con fi dence, team, the patient needs to fully understand the and directiveness have also been found related to treatment approach that the therapist is suggest- treatment outcome (Keijsers et al., 1995 ) . ing. Thus, the therapist needs to carefully explain Once the patient starts to participate in treat- to the patient the rationale behind the treatment ment and take part in exposures, the therapist’s procedures, orient the patient to each of their engagement work is not done. In addition to roles, and explain to the patient how the treat- forming an initial alliance, the therapist will need ment procedures will help to alleviate the to maintain the alliance during exposures. This patient’s distressing symptoms. This is particu- would include not only reinforcing the patient for larly important for treating anxiety disorders treatment participation but also looking to repair because exposure often sounds logically aversive alliance ruptures when/if they occur. Reinforcing to patients and not escaping also seems highly treatment participation to maintain the alliance undesirable and initially can appear illogical to does not have to mean giving patients tangible an anxious patient. The therapist needs to con- rewards but can be simply praising patient effort, vincingly explain that these procedures, although as this principle has been associated with partici- causing short-term discomfort, will result in the pation in exposure procedures (Gosch, Flannery- patient feeling less anxious eventually. Only then Schroeder, Mauro, & Compton, 2006 ; Shirk, will the therapist have successfully built the cog- Jungbluth, & Karver, 2012 ) . nitive connection component of the alliance (e.g., As for dealing with alliance ruptures in the willingness to engage) with the patient and an treatment of anxious patients, this has been a expectancy/hopefulness for change. Ahmed and relatively unexplored area. Newman, Castonguay, Westra ( 2009 ) detail this process, where an ade- Borkovec, Fisher, and Nordberg ( 2008 ) found in quately presented treatment rationale is used to a study of treatment for anxious patients that increase the likelihood of anxious individuals enhancing standard CBT with a component that participating in exposure to anxiety-provoking to some extent targeted repairing alliance rup- situations. Accordingly, patient acceptance of tures resulted in better outcomes for anxious the clinician’s treatment rationale has been patients than has been found for standard treat- shown to be related to treatment outcome (Addis ment on its own. It may be that during critical & Carpenter, 2000 ) . Along similar lines, patient treatment junctures with anxious patients, when ratings of treatment credibility (i.e., the degree to the patients are feeling misunderstood, pushed which a treatment makes logical sense in that it too much and too fast, and/or overwhelmed by what can be helpful) has been repeatedly shown to be they are being asked to do and/or are considering related to ratings of the therapeutic alliance and/ abandoning an exposure or the treatment as a or treatment outcome in treatment of patients whole, it may be helpful for the therapist to 17 Motivation Mismatch Alliance 267 explore the interpersonal relationship between tive change. This focus is based on the assump- the patient and therapist (bringing attention to tion that many patients are well intentioned and alliance ruptures, taking responsibility for contri- want to change for the better but often have butions to the interaction, processing patient’s diffi culty identifying and overcoming barriers affective experiences relative to the therapeutic and ambivalence in enacting such change (Miller interaction, etc.; Newman et al.; Safran, Muran, & Rollnick, 2002 ) . & Eubanks-Carter, 2011 ) . Unfortunately the Evidence has accumulated over the past 30 study did not measure treatment processes, so we years to support the effi cacy of MI in a variety of are unable to know if the treatment attained its conditions, and preliminary evidence for its con- results through a hypothesized mechanism of junctive role with CBT for anxiety disorders has improved alliances due to repaired alliance rup- been accumulating over the past decade. Multiple tures leading to better treatment participation, meta-analyses have indicated support for the which would lead to better outcomes. Kendall overall ef fi cacy of MI (for a review, see Lundahl et al. ( 2009 ) suggest that future research is needed & Burke, 2009 ) , and it has been observed that MI to get a better understanding of rupture and repair often exerts additive effects on other psychologi- sequences that occur in the treatment of anxious cal treatments, providing a swift improvement in patients. treatment adherence and session attendance Finally, many researchers have suggested that (Hettema, Steele, & Miller, 2005 ) . Additionally, similar engagement strategies (e.g., attentive lis- MI has been successfully used to improve adher- tening, empathy, collaborating on goal and task ence to medical management for a variety of con- agreement, clarifying treatment rationale and ditions (e.g., AIDS, diabetes; Rubak et al., 2005 ) . expectations especially during exposures) are Motivational interviewing focuses fi rst on likely necessary to engage and maintain the par- increasing motivation for change (through exam- ents of anxious youths in treatment (Chu et al., ining ambivalence for change, evaluating the rel- 2004 ; Nevas & Farber, 2001 ) . However, this is a ative importance of change in contrast to other severely neglected area of research in which sug- goals, and evaluating and fostering self-ef fi cacy) gestions for engaging parents are more based on and then consolidating commitment to such clinical lore rather than actual research. change (through considering change options, goal setting, and planning to meet these goals). It is often very brief and can be provided in as few Treatment Approaches to Address as 1Ð2 sessions. While full delineation of MI is Issues with Motivation for Behavior beyond the scope of this chapter (see Miller & Change Rollnick, 2002 for more detail), we evaluate its components in the context of complications in The evidence base is more robust for addressing treatments for anxiety disorders. patient motivation for behavior change than for Basic MI tenets include expressing empathy alliance formation. In addressing patient motiva- and validation, developing discrepancy between tion, the most prominent intervention is known as life goals and behavior, rolling with resistance motivational interviewing (MI). Motivational (i.e., identifying reasons for patient resistance interviewing is not a set of circumscribed tech- and evaluating such reasoning, instead of directly niques but rather consists of a presentational style combating it), and fostering self-effi cacy. These consisting of an empathetic, accepting, and non- concerns are particularly salient in treatment for judgmental style based in patient-centered ther- anxiety disorders, as Issakidis and Andrews apy but then incorporates a directive but ( 2002 ) found that in evaluating reasons for collaborative approach toward enacting patient abstaining from treatment among patients with change (Lundahl & Burke, 2009 ) . It does not anxiety disorders who had not sought therapy, serve to coerce an unwilling patient to participate 58% indicated that such refusal was re fl ected in a but rather capitalizes on patient desire for posi- desire to manage their disorder without help, 268 A.S. De Nadai and M.S. Karver

20% indicated a reason in avoiding treatment was Buckner & Schmidt, 2009 ) have indicated that the fear of seeking help, and 14% indicated a MI interventions improve the likelihood of those rationale that clinical improvement was unlikely. with social phobia to seek treatment, which is In the context of treating anxiety disorders, MI particularly notable given that treatment process principles such as developing discrepancy itself involves the feared condition of these between life goals and behavior directly address patients (i.e., social engagement) and thus is of those who express a desire to manage their particular interest for this population. Motivational pathology without intervention, empathy and interviewing has also shown results in increasing validation are particularly pertinent to those who enrollment in ERP treatment for OCD (Maltby & indicate a fear of seeking help, and fostering self- Tolin, 2005 ) and has helped with treatment adher- ef fi cacy is relevant for those who believe that ence and treatment response with this condition clinical improvement is unlikely. Patients may (Merlo et al., 2009 ; Meyer et al., 2010 ) . never have considered how feasible exposure is, To some degree, motivational interviewing as the habit of avoidance has been in practice for stands in contrast to CBT for anxiety disorders, so long that they may consider exposure as which often uses psychoeducation as a factual- impossible, despite the fact that that numerous based argument in convincing the patient to patients with similar problems have successfully change, and certainly many patients are eager for faced such feared situations with great bene fi t. It information bene fi t from this approach. However, is important to foster such self-effi cacy, as a some patients may be reactant, where they feel as mediational model has been supported where if a didactic approach can be an authoritative positive expectations for anxiety change at base- stance, which can lead to resistance (Brehm, line predict homework completion, which subse- 1976 ) , and some research has indicated that peo- quently predicts initial CBT improvement for ple with a propensity for such reactance do not anxiety disorders (Westra et al., 2007 ) . fare as well with CBT (Beutler, Rocco, Moleiro, With regard to its application in anxiety, MI & Talebi, 2001 ) . Therapist behavior has been fi rst appeared in the research literature in the indicated to increase or decrease resistance form of case series (Westra, 2004 ; Westra & (Patterson & Forgatch, 1985 ) , and a therapist’s Phoenix, 2003 ) . Subsequently, MI was applied as relational style can indeed impact patient motiva- a part of a pilot trial by Westra and Dozois ( 2006 ) tion (Norcross, 2002) . The focus on psychoedu- involving 55 patients whose principal diagnoses cation in CBT for anxiety disorders can be greatly consisted of panic disorder (45%), social phobia helpful but may not be a “one-size- fi ts-all” (31%), and GAD (24%), where patients were approach. In contrast, motivational interviewing randomized to CBT with or without a pretreat- approaches this issue by advising the patient to ment MI intervention. Those in the MI condition consider the pros and cons of changing. For displayed better homework adherence, higher example, many patients with anxiety want to expectancy for anxiety control, and a higher rate improve but are unwilling to leave behind strate- of treatment response than CBT alone, as the gies which previously have been very protective effect size for treatment response in the MI con- for them (i.e., avoidance). Instead of providing dition had an effect size of d = 0.38 compared to more evidence for the success rate of treatment, the control group (i.e., those who received CBT an approach more consistent with MI principles without pretreatment MI). Subsequently, Westra, would be to consider the pros and cons of retain- Arkowitz, and Dozois (2009 ) found that MI ing the current behavior pattern vs. changing. increased homework compliance and outcome Many patients in this case can then recognize that for GAD in a similar RCT for GAD where groups while avoidance provides short-term relief (a reason were randomized to conditions where they for maintaining the status quo), it actually leads received with MI or no MI at pretreatment, while to longer-term discomfort (a reason for abandoning both received CBT. Buckner and colleagues the status quo), whereas engaging in exposure (Buckner, Ledley, Heimberg, & Schmidt, 2008 ; provides short-term discomfort (a reason for 17 Motivation Mismatch Alliance 269 resisting change) but allows one to live a life than when used with adults. These children may unencumbered by excessive anxiety (a reason for be initially motivated to change and participate enacting change). On the other hand, simply pro- during of fi ce sessions but fi nd dif fi culty complet- viding further evidence in support of CBT to a ing exposures at home. In response, one method moderately reactant patient may simply elicit that has been proposed to address this barrier verbalization in defense of the status quo, which involves employing technology in exposure pro- only solidifi es commitment to avoidance and tocols (e.g., video games, interactive media; Chu ambivalence toward full treatment participation. et al., 2004 ) . A further consideration is that responsibility As can be seen, motivational interviewing to address motivation is not restricted to pretreat- principles can be used in a variety of situations to ment interventions. Given the observation from augment CBT for patients with anxiety disorders therapists that a substantial proportion of patients across developmental levels. For instance, rolling often experience reduced motivation after initial with patient resistance can help move patients relief (Goldfried, 2011 ) , a therapist must continu- away from the use of previously comforting and ally monitor a patient’s motivation to fully engage habitual patterns of avoidance. Similarly, foster- throughout treatment, as it may fl uctuate. For ing self-ef fi cacy and continually looking for example, a patient may be more motivated to par- opportunities to validate patients’ experiences ticipate at easier stages of an exposure hierarchy can help them to feel empowered in making but may have more ambivalence about approach- dif fi cult behavior changes, and evaluating moti- ing the more dif fi cult stages of the hierarchy. vation throughout the course of treatment can A midtreatment addressing of motivation as prevent regression from treatment progress. The higher points of the hierarchy are addressed may current state of research in increasing motivation be appropriate for such patients. In this way, sim- for patients with anxiety disorders is nascent but ply following an EST manual step by step can growing rapidly, and traditional CBT for patients lead to the neglect of certain times where it is with anxiety disorders stands to benefi t from its necessary to address patient motivation to con- increased application in the coming years. tinue treatment. Otherwise, partial response may be achieved (e.g., a patient achieves 50Ð75% of his/her hierarchy and then stops), or a patient Treatment Approaches to Address completes his/her hierarchy in an obligatory fash- Therapist-Patient Mismatch ion but then does not challenge him/herself outside of the therapy of fi ce both during and after While alliance and motivation are common fac- the completion of treatment. Patients also may tors that apply to treatment for all patients with have differential motivation for varying compo- anxiety disorders, idiographic variability remains nents of treatment. For example, some may be for the relationships established between indi- afraid to initiate treatment, but once treatment vidual therapists and patients, which can lead to a begins, they complete homework fastidiously, variety of structural and behavioral mismatches. while others may have perfect attendance but are In looking to address such mismatches, the cur- not immediately willing to perform exposures at rent evidence base for speci fi c strategies in anx- home. Still others may complete treatment but iety disorders is fairly sparse, despite sources may not continue to perform exposures and revert suggesting that addressing therapist-patient to avoidance posttreatment, leading to relapse. mismatches are of substantial value in clinical Identifying speci fi c barriers for each instance and practice (Castonguay & Beutler, 2006 ) . what competing priorities may be interfering Nevertheless, a variety of techniques can be with full treatment adherence through techniques employed to maximize match and foster person- based in MI is thus appropriate. For example, one alized treatment within a manualized therapy barrier when working with children can be that framework. In addressing ways to address typical exposure exercises may be less engaging therapist-patient match and mismatch, we employ 270 A.S. De Nadai and M.S. Karver the extant literature while acknowledging that a dence is lacking for direct intervention strategies considerable amount of research remains to be for structural mismatches in the context of clini- done and that much knowledge on the topic has cal trials for anxiety disorders, these converging some basis in clinical judgment. sources provide a foundation for clinical With regard to ethnic mismatch between practice. patient and therapist, while it may have not been With regard to behavioral mismatches, one observed to directly attenuate outcome in CBT common issue that arises involves matching the for anxiety (Newman, Crits-Christoph, Gibbons, procedures delineated in a treatment protocol to & Erickson, 2006 ) , a clinician must be aware of the particular symptom presentation of an anx- such mismatch insofar as it could affect patient ious patient. Indeed, a common complaint from receptivity to CBT procedures. For example, clinicians (and perhaps patients also) is that treat- small cultural differences may exist which could ment manuals can sti fl e creativity insofar as lead to inadvertent damage to the therapeutic matching standardized procedures to the speci fi c relationship or reduce the patient’s motivation for patient at hand (Addis & Krasnow, 2000 ) . Two change, possibly stemming from the clinician major approaches to address this issue are known expressing or emphasizing views that are subtly as “fl exibility within fi delity” (Kendall & Beidas, culturally discrepant from that of the patient (e.g., 2007 ) and modular treatment approaches (e.g., minimizing a patient’s focus on “stomach aches” Weisz & Chorpita, 2012 ) . The former approach and instead emphasizing cognitions as “classic espouses a philosophy of holding true to tenets of anxiety,” when the former topic is the patient’s CBT (i.e., fi delity) while working within these culturally acceptable way of expressing anxiety; basic parameters to adapt them to the speci fi c Spendlove, Jackson, & Borrego, 2010 ) . To patient at hand (i.e., fl exibility). Modular treat- address this, one recommendation is that thera- ment approaches address this issue by breaking pists assess their own cultural value systems with down CBT treatments into varying components regard to both overarching beliefs and their views that can be delivered fl exibly as opposed to toward various presentations of abnormal behav- sequentially with each patient who presents for ior, with a particular focus on how their views treatment. Both frameworks aim to match core might affect treatment (American Psychological CBT tenets to patient-speci fi c problems. For Association, 2003 ) . This can facilitate rapid and example, some patients may need speci fi c exam- effective in-session validation of the patient’s ples or idiographic techniques in order to engage experience of anxiety, which can be of great value them in exposure. For instance, presenting the in treatment for anxiety disorders (Welch, case of a favored celebrity who engaged in expo- Osborne, & Pryzgoda, 2010 ) . A complementary sure to overcome stage fright can serve as a role recommendation is to develop a cursory knowl- model for effi cacy, or playing a board game with edge of the customs and beliefs associated with a shy youth before beginning exposures can serve the patient’s culture through reading relevant to build a therapeutic relationship. Such strate- research articles (e.g., cross-cultural treatment gies may not be delineated within a treatment studies of anxiety assessment and intervention), manual but are small appropriate deviations in talking to local cultural experts, and evaluating protocol that can be fl exibly integrated with the other written and electronic sources while taking core treatment protocol while maintaining fi delity into account the evidence that within-culture to its tenets. A modular framework also provides variability is often greater than between-culture the opportunity to match the pace and intensity of variability (Triandis, 1997 ) and evaluating the varying components of treatment to a specifi c role, if any, such cultural values play with a patient’s state of functioning or motivation. To speci fi c patient. This approach can be also applied illustrate, consider the example of Simpson et al. to a variety of structural mismatches, such as ( 2010) , who found no improvement in outcomes when working with a patient of the opposite sex despite adding MI to treatment for OCD. After or of an alternate sexual orientation. While evi- close inspection, they identifi ed their sample as 17 Motivation Mismatch Alliance 271 having relatively high scores on readiness for comorbidity rates among these disorders (Kessler change at pretreatment, indicating that they were et al., 2005 ) , some con fl ict among multiple goals already motivated and had a lesser need for a MI for treatment and the order of addressing them intervention. In this case of such patients with can be quite common. Methods to address this stronger motivation for change, a MI module may scenario include establishing if one disorder is be less appropriate (as it would be ignoring the primary relative to any others (e.g., the anxiety issue of match), while the cognitive restructuring directly preceded the depression), identifying if and exposure modules would likely still remain treating one disorder might reduce symptomol- pertinent. This matching of modules to a specifi c ogy in other comorbid conditions (Craske et al., patient’s level of functioning can extend further. 2007 ) , and incorporating patient preferences in For example, a patient who is apprehensive with which problem to fi rst address. In these ways, cli- regard to engaging in exposures could have the nicians can match the order of treatment delivery therapist spend more time with him regarding the to the speci fi c patient in order to maximize out- sources of such ambivalence in MI and psychoe- comes. This situation extends to concurrent life ducation modules, while another who under- problems, where some patients may be more stands why she is having panic attacks and wants ready to simply proceed on addressing presenting to change immediately could spend little time on symptomology, while others might fi rst want to these modules and more quickly get to an expo- consider other factors. A resolution to such a situ- sure module. Many patients may benefi t from an ation can include identifying if the anxiety is the even greater acceleration of treatment, as single- cause or the effect of the personal interference session exposure protocols have demonstrated and subsequently addressing the originating effi cacy (e.g., Ollendick et al., 2009 ) . source of distress. For example, some patients Another point of emphasis in matching treat- may wish to discuss only vocational interference ments to speci fi c patients involves the consider- during sessions, despite such interference being ation of where patients’ anxiety fi ts in the context largely the product of an anxiety disorder. With of their overarching priorities. For example, sub- these patients, developing insight that the anxiety optimal homework completion has been partially is a cause of the interference at work and estab- attributed to clinicians not matching the assign- lishing consensus that the anxiety has to be ment of topics to life domains that are pertinent resolved can be useful while remaining attentive to the patient; thus, one recommendation to to the emotional implications of a diffi cult work improve the effectiveness of homework imple- environment (e.g., negative affect due to dealing mentation involves matching homework assign- with a supervisor who is unhappy with subopti- ments to short- and long-term patient goals and to mal production resulting from the patient’s anxi- issues of current relevance to the patient (Bryant, ety). This could also be addressed by directly Simons, & Thase, 1999) . Some patients may be incorporating the life issue at hand into session better than others in expressing which domains plans, which may require adjusting the pace of are higher priority for them, so spending extra treatment to accommodate discussion and valida- time to identify such priorities can yield extended tion of the patient’s extramural problems while benefi ts. Another consideration in matching treat- still making continued progress with the anxiety ments to patients’ overall functioning is comor- treatment. bidity, as there often is some ambiguity as to With regard to matching on preferences for which EST to apply at which time in such situa- treatment, a therapist is not often in a position to tions. Further complicating matters is the fact have a treatment aside from CBT to choose from that patients with anxiety have been observed to when behaviorally treating anxiety disorders. primarily focus on symptom relief, while Although psychodynamic approaches for panic depressed patients may have more heterogeneous disorder have recently displayed preliminary treatment goals (Grosse Holtforth, Wyss, Schulte, indications of effi cacy (Milrod et al., 2007 ) , CBT Trachsel, & Michalak, 2009 ) . Given the high remains the contemporary gold standard. 272 A.S. De Nadai and M.S. Karver

However, within a CBT framework, therapists ness. At fi rst glance, a directive CBT therapist can still accommodate patient preferences. For may not match well with reactant patients. example, some patients may prefer massed expo- However, a fl exible therapist, aware of the impor- sures over a few weeks, while others may prefer tance of matching, can identify when to push and traditional weekly treatment. Given evidence when to back off on exposures based on patient where it is available for such massed procedures reactance. For example, a more directive approach (e.g., Storch et al., 2007 ) , matching the pace of may be appropriate for patients who are looking implementation fosters patient participation with for change and eager for guidance (i.e., low in the treatment by validating the patient’s prefer- reactance), while a supportive and collaborative ences. In this way, a clinician can match patient style is appropriate for those who may show preferences for treatment processes while retain- resistance to engaging in exposure (Neziroglu, ing the core CBT elements. Forhman, & Khemlani-Patel, 2011 ) . Such reac- While the concept of matching the pace of tance may even change throughout treatment; for treatment involves the therapist modifying treat- example, some patients may be initially reactant ment to match patient preferences, another impor- at fi rst but, after seeing initial gains, become more tant consideration is how to match therapist and amenable to a higher level of therapist directive- patient expectations for the procedures within ness. These principles also apply throughout treatment sessions. Sometimes match can be other components of treatment (e.g., psychoedu- accomplished when the therapist orients the cation, cognitive restructuring; Beutler et al., patient to treatment expectations. A well-done 2011 ) . In this way, it is not just what a clinician orientation can bring the patient to match the delivers (i.e., CBT for anxiety) but also how he/ therapist’s views of treatment processes. Current she delivers it that leads to effective therapist- recommendations for CBT for anxiety disorders patient match. are to explicitly delineate what the patient will be When working with children and adolescents expected to do in treatment. For example, with anxiety disorders, several further consider- Abramowitz (1996 ) found that patients receiving ations arise with regard to behavioral matching. strict instructions in response prevention for OCD An important consideration is that the style of had better outcomes than ones receiving no or treatment delivery may need to be modifi ed to partial instructions to engage in response preven- match the developmental level of youth patients. tion—that is, being very direct on the expecta- For example, it has been found that being “overly tions of treatment led to better outcomes. Patients formal” with youths receiving child anxiety may come in with a variety of expectations for treatment predicts poorer therapeutic alliance therapy, and unambiguous explanations can help (Creed & Kendall, 2005 ) . To address this con- to facilitate participation in the procedures cern, several techniques can be used, including employed in CBT protocols. Moreover, the tech- reduced formality in presenting the treatment; niques mentioned in the section on fostering a utilization of youth-oriented props, toys, or therapeutic alliance can also serve to improve the dolls; and avoiding delivering the treatment in a match on expectations between patients and ther- formal “sitting in chairs” fashion. This less for- apists during anxiety treatment, as these con- mal approach is more likely to get the youth structs are intertwined (Greenberg, Constantino, patient interested in participation. One method & Bruce, 2006 ) . In many ways, establishing to accomplish this can be done by using the agreement on the tasks to be performed and the environment proximal to the clinic; for instance, goals to be achieved in therapy (essential compo- for youth who are afraid of speaking with adults, nents of alliance) is a procedure to improve match walking to a nearby cafeteria or convenience on patient expectancies for treatment process. store and striking up a brief conversation with the Another match issue that arises with CBT for cashier can be an exposure that is more engag- anxiety disorders that can potentially threaten the ing and also more generalizable to the real world. therapeutic alliance involves therapist directive- Similarly, matching on social developmental level 17 Motivation Mismatch Alliance 273 can further facilitate treatment engagement, their child to treatment but rather should expect where younger children may frequently work to be actively involved in enacting the protocol. better with a nurturing parental-type fi gure, while with adolescents, clinicians can be cogni- zant of avoiding an authoritarian stance. Case Example Furthermore, matching on the cognitive level of the youth (e.g., using age appropriate language, To illustrate the principles addressed in this chap- using developmentally relevant examples) can ter, we present a deidenti fi ed case example. In further facilitate treatment engagement. The this instance, the application of the aforemen- importance of such matching with youth on a tioned engagement techniques successfully variety of developmental aspects has been resolved barriers to completing CBT for symp- refl ected by an increasing focus on these aspects toms of anxiety. in newer treatment protocols such as the Johanna was a 32-year-old married female FRIENDS for Life program (Barrett, Webster, & with a 5-year-old son who presented to our clinic Turner, 2004 ) . These points are vital consider- with a fear of recurrent panic attacks. These ations given that midtreatment child involve- attacks had been occurring off and on for 5 years, ment in treatment (which is often related to with an exacerbation in symptoms over the past 9 alliance) has predicted symptom reduction in months. She had been prescribed benzodiaz- CBT for pediatric anxiety disorders (Chu & epines by her primary care physician to manage Kendall, 2004 ) . the attacks 5 months before presenting for CBT, Another novel consideration in pediatric psy- which she took at a low dose approximately twice chological treatments for anxiety involves match- per week to manage panic-related sensations. ing treatments and their presentation to parents. While the medication provided some immediate While interventions for pediatric anxiety disor- relief for her attacks, they did not prevent their ders have successfully incorporated family frequent recurrence. A thorough intake assess- involvement (e.g., Kendall & Hedtke, 2006 ) , few ment revealed that she had panic attacks that were empirically based guidelines for matching to characterized by heart palpitations, heavy breath- parental characteristics currently exist. This is ing, dizziness, a perceived loss of control over unfortunate, as parents maintain and improve herself, and a sense of impending doom. She had therapeutic gains at home, and the child patient is worked as a cashier at a local grocery store but wholly dependent on them for treatment atten- discontinued her employment due to fear of unex- dance. Indeed, indications are that parental pected panic attacks. Johanna also displayed sub- engagement in treatment improves youth treat- stantial agoraphobia, as when she presented for ment outcome for anxiety disorders (Podell & treatment, she reported that to avoid having panic Kendall, 2011 ) . To improve communication of attacks she had only left the house fi ve times in the treatment rationale (with the intent of facili- the prior 2 months. She reported that this was tating engagement and active parental involve- highly frustrating both for her as well as for her ment in the treatment), it has been recommended husband and child. to give parents a companion document that Initially, Johanna had a great deal of ambiva- describes the treatment in depth (Kendall, Podell, lence about therapy. She was hesitant to even & Gosch, 2010 ) . This can help to further convey leave her house and come to therapy, but she the message that parents are co-therapists at wanted relief from her symptoms and from the home, as well as working to ensure that parents strain she was putting on her family. In fact, at understand the treatment rationale and the cogni- fi rst, she was only able to leave the house and tive behavioral model of anxiety. In these ways, travel to therapy accompanied by her family. clinicians can work to fi nd a match with the Thus, even starting during the intake assessment parent on expectations for treatment, where they with Johanna, the fi rst task of the clinician was to are not passive participants who simply bring form an alliance, as the absence of a strong working 274 A.S. De Nadai and M.S. Karver relationship could have precluded her from fully to each component of treatment and each task engaging in treatment. Given Johanna’s initial that would be performed with the patient. The ambivalence about treatment, the therapist’s fi rst therapist also presented the treatment with efforts were to listen carefully with interest and expected roles for the therapist and the patient. In concern and then validate Johanna’s fears and addition, the therapist carefully explained the show warmth and empathy regarding her suffer- rationale for the choice of treatment and for ing. One way to demonstrate empathy was to use the speci fi c roles involved with the treatment. her speci fi c language when discussing her panic, The therapist carefully made sure that Johanna as Johanna had several idiographic labels for her understood and agreed with the treatment ratio- symptoms. For example, she referred to a wave nale and the involved roles. This would be neces- of panic sweeping over her as “the feeling.” Thus, sary for patient and therapist to have agreement the clinician often referred to oncoming sensa- on the tasks of therapy and for her to view the tions of panic as “the feeling” taking hold, in therapist as credible. In order to ensure a match order to match her terminology and work within and commitment to treatment tasks, the therapist her conceptualization of the problem. aimed to explore the patient’s view of the pros The clinician realized that he could not even and cons of engaging in the proposed treatment. move to explaining the treatment rationale until In particular, the therapist helped to identify the patient was ready. The patient would be ready Johanna’s specifi c barriers relative to engaging in to listen to the clinician only when she felt under- facing her fears. While Johanna was eager for stood. The clinician’s listening and validating relief, she presented some ambivalence with skills (making statements about how her fear of regard to exposure treatment. On one hand, she leaving the house made sense given her fear of was excited to begin treatment, but on the other, reexperiencing “the feeling”) would provide the she was quite afraid of doing the tasks she had initial reasons why Johanna would view the ther- avoided for so long. She frequently verbalized apist as someone who had credibility and was this fear with statements such as, “you’re not “safe” and trustworthy. going to make me leave the house alone, are The second focus in alliance formation you?” The clinician responded by validating her involved empathetically working collaboratively view that it is normal to feel fear and reluctance to fi nd a match on the goals of therapy. For fi nding to expose herself to feared situations but also pre- a match on goals, the therapist asked the patient senting expectations that Johanna could and about her short- and long-term goals for treat- would succeed in facing her fears. During this ment. She mentioned that her short-term goal discussion, the clinician assured her that she was was to feel some sense of immediate relief and not the fi rst to experience these symptoms and her longer-term goals included returning to work that many other patients had similar fears which and spending more time at outside activities with were successfully resolved by the proposed treat- her husband and son. The therapist knew that ment. The therapist also directly addressed emphasizing these patient goals throughout treat- Johanna’s fears that the exposures might be ment and tying these goals to any planned treat- unsafe. After the clinician explained in detail ment would be critical in keeping the patient how the exposures would not put her in actual focused and willing to work on the challenging dangerous situations, Johanna recognized that tasks of therapy. she avoided feared situations almost as a refl ex The planned treatment consisted of psychoed- and she estimated the likelihood of any actual ucation, cognitive restructuring, and exposure. harm as very remote, which helped tip her deci- During the initial therapy session, the clinician sional balance in favor of exposure. In addition, explained how the proposed treatment could get the therapist explained how the treatment was Johanna to her goals, thus creating positive fl exible in that an exposure hierarchy could expectancies for change. Throughout psychoedu- be constructed to match Johanna’s short- and cation, the therapist carefully oriented the patient long-term goals in sequence, with easier tasks 17 Motivation Mismatch Alliance 275 occurring fi rst. Johanna noted that she liked the epines available would produce very strong feel- structured but fl exible guidance relative to the ings of anxiety. proposed treatment and that this gave her In session four, Johanna was asked to practice confi dence in the sense of direction for the treat- her fi rst exposures in the offi ce. Despite some ment. She also appreciated that there were trepidation, with therapist encouragement, she behavioral explanations for what she was feel- engaged in exposures including interoceptive ing, as she previously had dif fi culty identifying exposures of spinning in a chair until dizzy and the nature of her sensations. This validating, breathing through a coffee straw for 1Ð2 min. normalizing, orienting, fl exibility, collaborative During these exposures, she reported initial ele- matching, discussing the pros and cons of vations in anxiety followed by anxiety reduction engaging in the proposed treatment, and pre- and perceived mastery of her fear in these limited senting an expectancy of success seemed to help situations. The therapist was careful to reinforce/ alleviate her reluctance to participate, and thus praise Johanna’s efforts in participating in these Johanna committed to participate in the pro- initial exposures. After her initial successes, it posed treatment. was decided that her fi rst exposure outside of the The next two sessions focused on cognitive of fi ce would include shopping alone at a local restructuring and further orientation to exposure grocery store without having benzodiazepines tasks. One particular technique of cognitive available. restructuring that proved useful for Johanna was At our next session, we evaluated how her fi rst estimating the actual odds of harm—while at fi rst outside of offi ce exposures went. Johanna Johanna mentioned terror about her panic symp- reported that she experienced much distress toms, when she challenged her thoughts about if because she was only able to remain at the gro- actual harm would be incurred, she identifi ed that cery store for 5 min and returned home after feel- she was at very little risk of actual harm. After ing a panic attack coming on. In discussing why practicing identifying automatic thoughts, she she left so abruptly, Johanna indicated that she also learned to develop the habit of asking herself became very scared and reverted to what had “is this true?” when she had thoughts about her helped in the past (avoidance). She expressed anxiety. Johanna found this challenging of her doubt that this treatment could actually help for automatic thoughts as providing some comfort, symptoms that were “actually physical.” as previously she had simply assumed that her Additionally, she mentioned frustration with the thinking was accurate. These techniques also therapist. Although she felt that the exposure in increased her self-ef fi cacy with regard to engag- the offi ce was easy for her, she stated that she ing in exposure, where she still expressed some should have been warned about how dif fi cult this ambivalence, but such ambivalence was much new exposure would be for her. reduced compared to our initial assessments. The Instead of being defensive or taking an overly therapist and Johanna then collaboratively con- technical perspective of engaging in further psy- structed a hierarchy of feared situations. At fi rst, choeducation regarding the physiological changes she was only able to produce a few situations, but that can be produced by exposure (which had after exploring a variety of situations, she was able been already presented earlier in treatment), the to come up with 15 possible situations for expo- therapist worked on repairing the alliance. To sure, with a range of tasks that spanned the range repair the alliance, the therapist validated the of low, medium, and high levels of anxiety. For patient and took responsibility by acknowledging example, leaving the of fi ce alone without carry- that he may have pushed too hard and too fast. ing her prescribed benzodiazepines for 5 min The therapist expressed empathy that these tasks produced mild anxiety, being alone at home and are dif fi cult to accomplish and that many others going shopping alone without benzodiazepines have dif fi culty generalizing exposure work to available would cause a moderate level of outside the offi ce. Showing fl exibility and a anxiety, and going to work without benzodiaz- collaborative attitude, the therapist told Johanna 276 A.S. De Nadai and M.S. Karver that treatment could be adjusted to a pace that seemed reasonable but she did not think she could works for her. This calm, fl exible, and validating do it, the clinician responded by indicating that approach improved patient-therapist match and many others similar to her had overcome these made the therapist come across as more genuine initial roadblocks and that she was just as capable and respectful while maintaining a sense of cred- as these others. This encouragement and support ibility and competence. By the therapist’s calm from the therapist helped Johanna to believe that response that the patient’s reaction was not she could succeed with the exposures. uncommon, the clinician increased patient In approaching the exposures that followed, con fi dence as Johanna perceived that the thera- the clinician was very clear in instructing that she pist had an understanding of the process at hand. must remain in each setting without avoiding the Johanna appreciated this response and felt vali- situation in order for exposure to be successful. dated in that she was not alone in having diffi culty This focus on clarity facilitated a clinician-patient and that she had not “failed” treatment. match on the expectations necessary for the treat- Additionally, the therapist invited her to feel free ment process to achieve symptom relief. In addi- to directly address any concerns she ever has in tion, the therapist carefully explored and their therapeutic relationship and to inform him if collaboratively problem solved ahead of time she did not feel ready for future exposures so as potential obstacles to success or questions to facilitate open conversations and trust. This Johanna had relative to each exposure. Further, would also help to accurately match the dif fi culty after checking that the patient felt ready to attempt of exposures to her level of readiness, as well as an exposure, the clinician elicited a commitment providing an opportunity to work through any from Johanna that she would indeed do the expo- barriers or further therapeutic ruptures together. sure assignment. This preparatory work helped Given Johanna’s continued hesitation relative Johanna to feel more capable and committed to to engaging in further exposure, the therapist uti- each exposure that she attempted, thus increasing lized motivational interviewing methods. This the likelihood that she would fully engage cor- included not confronting but rather rolling with rectly in her subsequent exposure assignments. Johanna’s resistance and listening carefully and After each attempted exposure assignment, the refl ecting her concerns. The therapist then dis- therapist started each session with checking in on cussed with Johanna the pros and cons of her cur- the assignment and reinforcing her efforts and rent methods of dealing with anxiety and the pros successes, in order to strengthen the clinician- and cons of engaging in exposures. The clinician patient alliance and to increase the likelihood that was careful to be accepting and nonjudgmental she would be motivated to continue to attempt relative to the patient’s discussion of the pros of exposures in the future. not changing and the cons of engaging in expo- Over the next eight sessions, Johanna reported sures. However, the clinician highlighted the dis- success in completing each step of her exposure crepancies between Johanna’s current behavior hierarchy. In addition, she reported that she had and the subsequent likelihood of achieving her the con fi dence to expose herself to previously goals. In addition, the therapist took a gentle par- feared situations that were not even listed on her adoxical position (devil’s advocate) with Johanna exposure hierarchy. As a result, she reported that by mildly amplifying some of Johanna’s reasons her functioning across numerous domains (fam- for not changing. This resulted in Johanna taking ily, work, etc.) was dramatically improving and the opposite position and arguing that she really that she no longer needed benzodiazepines to be did want to change. Then, the clinician was able available when she left her house. At her fi nal to highlight Johanna’s desire for positive change posttreatment assessment, Johanna had a score and the connection of change to her treatment of 7 on the Beck Anxiety Inventory (where it goals. The result was that Johanna had renewed was a 51 before treatment). Johanna expressed motivation and commitment to try exposure appreciation for how the therapist had helped again. When Johanna expressed that the plan with her anxiety as well as with her personal 17 Motivation Mismatch Alliance 277 goals, thus validating his efforts to foster a match ments must adapt to serve all patients. It is between her life priorities as well as her goals for incumbent on researchers and practitioners to symptom reduction. identify reasons for treatment failures in anxiety disorders and to work to resolve them, and the aim of this chapter has been to identify a set of Conclusion and Future Directions factors that are common stumbling blocks. While some researchers have sometimes portrayed CBT has demonstrated great success in treatment “common factors” as being in confl ict with CBT for anxiety disorders, but many patients often do for anxiety disorders, we see no reason to believe not achieve maximal therapeutic benefi t. In con- that they do not compliment CBT well and can sidering the reasons for suboptimal outcomes, a help enhance its effi cacy. Acknowledging a vari- body of evidence points to limited patient moti- ety of patient and therapist variables in tandem vation, mismatch of patient and therapist, and with fresh approaches to future research can con- poor therapeutic alliance as three likely contribu- tinue to help build upon the marked success of tors. While many successful treatment protocols CBT for anxiety disorders, in order to more for anxiety disorders have been established, if effi ciently and effectively serve a broad array of patients do not participate in their use, they can- patients. not bene fi t from them. In the past decade, greater Unfortunately, research in treatment processes focus has been placed in research and its dissemi- and idiographic patient care in anxiety disorders nation to clinical practice to motivate, better remains a relatively sparse body of work (Newman match, and to foster better alliances with patients et al., 2006 ) with many unanswered questions. For with anxiety disorders in order for them to better example, many contemporary treatment manuals engage in what are often highly effective treat- for anxiety disorders recommend forming a thera- ments for these conditions. peutic relationship with the patient, but such man- When considering the roles of these variables uals often give little guidance as to how to form in treatment, it is important to consider that they such a relationship. This is of particular relevance do not function in respective isolation but rather when working with patients who may show more work in tandem. Of particular note is a possible resistance and/or less motivation for treatment par- role played by therapeutic alliance, where moti- ticipation. At present, much guidance is limited to vation and mismatch affect alliance which in turn clinical conjecture, which unfortunately is subject affects engagement. A mismatch between patient to a variety of pitfalls such as con fi rmatory bias. and therapist can attenuate the alliance, while a More research is needed to identify empirically strong match and minimization of deleterious supported engagement techniques for CBT thera- elements of mismatch can serve to improve it. pists working with patients with anxiety disorders With regard to motivation, a bidirectional effect to help them to engage patients with more compli- is likely, where a motivated patient may more cated presentations. Longitudinal investigations easily form an alliance with the therapist, but also could serve to disentangle issues such as how to a therapist who can establish an alliance with a match speci fi c alliance-building procedures to patient who has lesser motivation can work to speci fi c patient characteristics at speci fi c points in improve patient motivation and subsequent treat- treatment. While ambitious, such hypotheses are ment outcome. certainly not inaccessible, as they could be evalu- While it may seem natural to attribute treat- ated through either already existing RCT data or ment failures to unmotivated patients who were by making small additions to future clinical tri- resistant or did not want to form an alliance, cli- als (e.g., using a brief measure of alliance at nicians have empirical guidance in addressing early, mid-, and late treatment and coding ther- these domains. As Hollon ( 2008) has noted, a apy session tapes originally created for protocol more self-effi cacious attitude is to consider that adherence evaluation to investigate speci fi c alliance- patients do not fail treatment, but rather treat- building behaviors). 278 A.S. De Nadai and M.S. Karver

In looking to future research in patient engage- structured methods of coding in-session behavior ment for anxiety disorders, innovative approaches (e.g., McLeod & Weisz, 2005 ) in a quantitative to research might prove fruitful. For example, fashion, as well as employing structured qualita- Kiesler (2004 ) has suggested the notion of a “pro- tive research (e.g., Bernard & Ryan, 2010 ) with cess diagnosis,” where various facilitative and session transcripts and narratives from both counterproductive treatment processes are patient and therapist, which can provide fresh identifi ed and then specifi c interventions are approaches to old problems while maintaining developed to address them. Some of these vari- methodological rigor. While much progress has ous treatment processes might be somewhat been made with traditional research methods and unique to anxiety, and we currently have limited many insights have served to improve patient knowledge of such speci fi c treatment process engagement, further progress in understanding patterns and factors that predispose them. These and improving treatment of anxiety-disordered sentiments are echoed by DeRubeis, Brotman, patients with complicated presentations may and Gibbons (2005 ) , who note that the patient- require alternative means of approaching such therapist dyad may be a better unit of analysis to problems. We have a burgeoning base of research evaluate therapeutic alliance compared to either to guide current clinical practice, as well as a party in isolation. They suggest that instead of roadmap for further progress in order to improve assessing solely patient characteristics to address therapy outcomes for anxious patients. the likelihood of bene fi t from therapy, to rather evaluate which dyads and associated processes might prove fruitful. References In evaluating these new approaches, methodological and analytic procedures may have to be Abramowitz, J. S. (1996). Variants of exposure and adjusted as well. For example, traditional response prevention in the treatment of obsessive- between-subjects pre-post designs may be some- compulsive disorder: A meta-analysis. Behavior Therapy, 27 , 583Ð600. doi: 10.1016/S0005- what insensitive to matching effects due to lim- 7894(96)80045-1 . ited power and the diffi culties involved in Abramowitz, J. S., Franklin, M. E., Zoellner, L. A., & recruiting suf fi cient numbers of patients and ther- DiBernardo, C. L. (2002). Treatment compliance and apists in order to detect matching effects. Methods outcome in obsessive compulsive disorder. Behavior Modi fi cation, 26, 447Ð463. doi: 10.1177/01454455020 such as the actor-partner interdependence model 26004001 . (Kenny, Kashy, & Cook, 2006 ) can more pre- Addis, M. E., & Carpenter, K. M. (2000). The treatment cisely partition variance and maximize the rationale in cognitive behavioral therapy: Psychological amount of information extracted from paired mechanisms and clinical guidelines. Cognitive and Behavioral Practice, 7, 147Ð156. doi: 10.1016/S1077- data. Additionally, frameworks such as random 7229(00)80025-5 . effects modeling (e.g., Singer & Willett, 2003 ) , Addis, M. E., & Krasnow, A. D. (2000). A national survey latent class analysis, and cluster analysis can of practicing psychologists’ attitudes toward psycho- serve to identify various subgroups of treatment therapy treatment manuals. Journal of Consulting and Clinical Psychology, 68, 331Ð339. doi: 10.1037/0022- responders and nonresponders, which can help 006X.68.2.331 . identify specifi c characteristics of patients, thera- Ahmed, M., & Westra, H. A. (2009). Impact of a treat- pists, and dyads who may perform better with ment rationale on expectancy and engagement in cog- one intervention or another. Finally, the actual nitive behavioral therapy for social anxiety. Cognitive Therapy and Research, 33, 314Ð322. doi: 10.1007/ nature of the data generated merits addressing. s10608-008-9182-1 . Much intervention research focuses on measures American Psychological Association. (2003). Guidelines of symptom severity and demographic factors on multicultural education, training, research, prac- and self-reports of treatment processes, but less tice, and organizational change for psychologists. American Psychologist, 58 , 377Ð402. focus has been placed on what behaviors actually doi: 10.1037/0003-066X.58.5.377 . occur during treatment. Methods of approaching American Psychological Association Presidential this issue include recording sessions and using Task Force on Evidence Based Practice. (2006). 17 Motivation Mismatch Alliance 279

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Lindsay S. Ham, Kevin M. Connolly, Lauren A. Milner, David E. Lovett, and Matthew T. Feldner

According to the National Epidemiological Survey we highlight factors that contribute to the on Alcohol and Related Conditions (NESARC), complexity of the SAD/SUD and PTSD/SUD the prevalence rate of substance use disorders comorbidity. The bulk of the chapter describes (SUDs) is at least 50% higher for those with an interventions that have been developed to address independent anxiety disorder diagnosis than indi- these complex comorbid conditions, including a viduals without an anxiety disorder (Grant et al., review of data examining treatment effi cacy and 2004 ) . Further, the odds of having an independent a case study. Finally, we present conclusions and anxiety disorder are doubled for those with an SUD future directions. compared to those without an SUD (Grant et al.). Comorbidity rates nearly quadruple when considering only the more severe form of SUDs, sub- Substance Use Disorders stance dependence. Consequently, it is critical to identify effi cacious interventions to treat these The Diagnostic and Statistical Manual — fourth common and complex conditions. This chapter edition , text revision ( DSM-IV-TR ; American aims to provide clinicians, researchers, and stu- Psychiatric Association [APA], 2000 ) includes dents with a background in anxiety disorder/SUD two broad types of SUDs: substance abuse and comorbidity and its treatment. dependence. Substance abuse is a pattern of The present chapter focuses on two anxiety substance use that interferes with the person’s disorders: social anxiety disorder (SAD) and life, manifested by one or more adverse conse- posttraumatic stress disorder (PTSD). The chapter quences related to the substance use (e.g., failing begins by providing a description of SUDs, SAD, to ful fi ll major obligations, social or legal prob- and PTSD and an overview of the models explaining lems) occurring within a 12-month period. In the comorbidity between these disorders. Next, contrast, the essential feature of DSM-IV-TR substance dependence is a cluster of physiological (e.g., tolerance, withdrawal) and psychological (e.g., loss of control over use, signifi cant effort L. S. Ham, Ph.D. (*) ¥ L. A. Milner, M.S. and time spent seeking, using, and recovering D. E. Lovett, B.S. ¥ M. T. Feldner, Ph.D. from the substance) symptoms occurring within a Department of Psychological Science, University 12-month period. The concept of “addiction” of Arkansas , Fayetteville , AR 72701 , USA aligns most closely with substance dependence. e-mail: [email protected] Lifetime prevalence rates for SUDs are esti- K. M. Connolly, Ph.D. mated to be approximately 14% (Kessler, Chiu, G.V. (Sonny) Montgomery VAMC and University of Mississippi Medical Center , Demler, Jin, & Walters, 2005 ) . In 2009, an esti- Jackson , MS , USA mated 8.9% of the United States population aged

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 285 DOI 10.1007/978-1-4614-6458-7_18, © Springer Science+Business Media New York 2013 286 L.S. Ham et al.

12 years or older was classi fi ed with a past-year and 22.3% had a drug use disorder (excluding SUD (SAMHSA, 2010 ) . Of these individuals, nicotine; Grant et al., 2005 ) . 14% were classifi ed with dependence on or abuse Individuals with co-occurring SAD/SUD have of both alcohol and illicit drugs, 17% illicit drugs more severe cases, including higher psychiatric only, and 69% alcohol exclusively (SAMHSA). comorbidity rates, than individuals with SAD Specifi c illicit drugs associated with the highest alone (Grant et al., 2005 ; Thomas, Thevos, & past-year dependence or abuse rates were mari- Randall, 1999 ) . Further, people with comorbid juana (19%), pain relievers (8%), and cocaine SAD/SUD appear more likely to relapse after (5%) (SAMHSA). The annual cost of SUDs in alcoholism treatment compared to people with an the United States was estimated at $180.9 billion SUD alone (Kushner et al., 2006 ) . Overall, in 2002 and has been increasing annually since fi ndings suggest that individuals with comorbid 1992 (ONDCP, 2004) . While research on natural SAD/SUD have more severe and complicated recovery from SUDs (primarily focused on presentations and suffer from poorer prognoses alcohol) has shown that a signifi cant number of than individuals with SAD or SUD alone. substance users recover without treatment (see Smart, 2007 for a review), the majority do not. Further, relapses are more common among those Posttraumatic Stress Disorder who recover without treatment than those who and Substance Use Disorders recover with treatment (Moos & Moos, 2006 ) . Unfortunately, only approximately 11% of indi- PTSD is another chronic and debilitating condi- viduals with an SUD received needed treatment tion (Kessler, 2000 ) which can develop following in the past year (SAMHSA, 2010 ) . a variety of traumatic events, including natural disasters, combat, and interpersonal violence (Kessler, Sonnega, Bromet, Hughes, & Nelson, Social Anxiety Disorder 1995 ) . The vast majority of people exposed to a and Substance Use Disorders traumatic event develop acute symptomatic reactions, and while the majority of people recover Social anxiety disorder, also known as social without intervention, a substantial minority will phobia, is a common and debilitating condition continue to experience posttraumatic stress symp- involving a marked and persistent fear of one or toms (Gilboa-Schechtman & Foa, 2001 ) . PTSD more social (e.g., conversations, dates) and/or is diagnosed when an individual experiences an performance (e.g., public speaking, writing in event characterized by perceived threat that elic- front of others) situations in which the person its overwhelming fear, helplessness, or horror, faces possible scrutiny and/or embarrassment followed by persistent (lasting for at least 1 (APA, 2000 ) . The feared social situations are month) posttraumatic stress symptoms that result avoided or endured with intense anxiety. SAD in functional impairment. Four types of symp- symptoms must result in signi fi cant functional toms characterize PTSD: (1) reexperiencing impairment and/or marked distress, which often aspects of the traumatic event (e.g., intrusive include lower educational attainment, as well as thoughts, recurrent dreams, fl ashbacks); (2) higher rates of work and social impairment, avoidance of traumatic event cues (i.e., avoiding comorbidity, and suicidal ideation (Grant et al., thoughts and reminders of the event); (3) emo- 2005 ; Ruscio et al., 2008 ) . SAD typically begins tional numbing (e.g., detachment, loss of interest, by adolescence, has a chronic course, and does restricted affect); and (4) hyperarousal (e.g., sleep not remit without treatment (Grant et al., 2005 ) . disturbance, irritability, dif fi culty concentrating; Epidemiological reports have estimated that Elhai et al., 2009 ; King, Leskin, King, & SAD has a lifetime prevalence of 12.1% (Kessler Weathers, 1998 ) . et al., 2005 ) . Among individuals with a lifetime Among nationally representative samples, SAD diagnosis, 48.2% had an alcohol use disorder Kessler et al. (2005 ) found a lifetime estimate of 18 Substance Abuse and Anxiety Disorders: The Case of Social Anxiety Disorder and PTSD 287

7.8% for PTSD. When examining Veteran Self-Medication populations, PTSD lifetime estimates increase to 18.7% (Dohrenwend et al., 2006) . A number According to the self-medication hypothesis of cross-sectional studies have documented ele- (Khantzian, 1985 ) , similar to tension reduction vated odds of substance use among individuals (Conger, 1956 ) and stress-response dampening with a diagnosis of PTSD compared to individu- (Sher & Levenson, 1982 ) models of alcohol use, als without PTSD (Blumenthal et al., 2008 ; substance use functions as a means to reduce dis- Chilcoat & Breslau, 1998 ; Kessler et al., 1995 ) . tress and manage unpleasant psychological states. Comorbid PTSD/SUD is associated with Self-medication and related models assume a increased impairment compared to PTSD or causal model where the presence of a disorder SUD alone. Individuals with co-occurring leads to the development of the other. When PTSD/SUD experience greater emotional applying the self-medication hypothesis to anxi- difﬁ culties and receive less social support than ety disorder/SUD comorbidity, one would predict individuals with only SUD or SUD and another that individuals suffering from a primary anxiety Axis I disorder (Ouimette, Ahrens, Moos, & disorder, such as SAD or PTSD, develop an SUD Finney, 1997 ) . Compared to individuals who after repeated attempts to relieve or reduce their do not use drugs/alcohol to manage emotions, anxiety through substance use (Quitkin, Rifkin, individuals who report active substance use to Kaplan, & Klein, 1972 ) . medicate their PTSD symptoms have reduced health-related quality of life (Leeies, Pagura, Sareen, & Bolton, 2010 ) . Further, PTSD and High-Risk SUD appear to be independent predictors of suicidal ideation and attempts (Ullman & The high-risk model, commonly referred to as Brecklin, 2002 ) and comorbid PTSD/SUD the substance-induced anxiety hypothesis, states report a higher number of lifetime suicide that pathological substance use serves to promote attempts than either PTSD or SUD alone the development of an anxiety disorder (see (Moylan, Jones, Haug, Kissin, & Svikis, Kushner et al., 2000 for a review). One explana- 2001 ) . Additionally, studies support the notion tory mechanism for such a pathway is that sub- that individuals with co-occurring PTSD/SUD stance dependence and withdrawal symptoms, fare worse in treatment compared to people particularly when considering alcohol, can cause with either disorder alone (Brown, Read, & neurobiological changes (e.g., reduced levels of Kahler, 2003 ; Brown, Stout, & Mueller, 1996 ; g-aminobutyric acid benzodiazepine receptors in Ouimette et al., 1997 ) . the case of alcohol and depressants) that result in acute or chronic anxiety symptoms (e.g., George, Nutt, Dwyer, & Linnoila, 1990 ) . Models of Anxiety Disorder/Substance Use Disorder Comorbidity Common Etiology Three models are presented that propose: (1) anxiety disorders promote SUD (i.e., self-medication In the common variable theory, it is assumed that hypothesis), (2) SUD promotes anxiety disorders a third variable may account for an individual’s (i.e., high-risk model), or (3) a common variable increased risk for developing both disorders and promotes both SUD and anxiety disorders (i.e., that no causal relationship exists between the dis- common etiology). While the models presented orders (see Kushner et al., 2000 ; Stewart & here are condensed to provide a general overview, Conrod, 2008 for reviews). Possible candidates a more in-depth analysis is available in Kushner, for such common variables include personality Abrams, and Borchardt (2000 ) and Stewart and predispositions or a common genetic basis under- Conrod (2008 ) . lying the two disorders. 288 L.S. Ham et al.

Data Supporting Models rate fi ndings in directionality could be explained by considering the age of onset and temporal Supporting the self-medication hypothesis, ordering for specifi c anxiety disorders and SUDs. National Comorbidity Survey follow-up data For instance, Falk, Yi, and Hilton ( 2008 ) found con fi rmed that baseline panic, speci fi c phobia, that while the onset of SAD and specifi c phobia separation anxiety, PTSD, and SAD were each tended to precede the onset of alcohol depen- predictive of at least one form of substance dence or alcohol abuse, the age of onset for panic dependence 10 years later (Swendsen et al., disorder and generalized anxiety disorder was 2010 ) . Several longitudinal studies based on epi- much later than the onset for both types of alco- demiological samples have found that baseline hol use disorders. Therefore, self-medication and SAD symptoms (e.g., Buckner et al., 2008 ; high-risk models may play more or less promi- Swendsen et al., 2010; Zimmerman, Wittchen, nent roles depending upon anxiety disorder type. Pfi ster, Kessler, & Lieb, 2003) or PTSD symp- Support for the common etiological model has toms (e.g., Cottler, Compton, Mager, Spitznagel, been found in research examining a shared & Janca, 1992 ; Leeies et al., 2010 ; Swendsen genetic basis or personality predispositions in et al., 2010 ) in particular predict later SUD diag- comorbid anxiety and SUDs. For example, noses. For example, the presence of PTSD more Merikangas, Stevens, and Fenton ( 1996 ) found than tripled the odds of developing alcohol depen- that relatives of individuals, who were alcohol- dence (OR = 3.2) and illicit drug dependence dependent and/or had an anxiety disorder, were at (OR = 3.9) across a 10-year follow-up period an increased risk (ORs = 2.0Ð3.7) for developing (Swendsen et al.). In people with SAD, epidemi- alcohol dependence (but not alcohol abuse) and/ ological estimates suggest that self-medication or an anxiety disorder themselves. It has been with substance use is present between 7.9% (pub- suggested that anxiety sensitivity, a personality lic speaking subtype) and 21.2% (Bolton, Cox, predisposition characterized by fear of the conse- Clara, & Sareen, 2006 ; Robinson, Sareen, Cox, quences of anxiety symptoms (Taylor, 1999 ) , & Bolton, 2009 ) . Individuals who report fre- might be important in the development of both quently using alcohol to cope with social anxiety anxiety disorders and SUDs (Stewart & Kushner, also drink more and have greater alcohol depen- 2001 ; Stewart & Conrod, 2008 ) . Despite support dency symptoms than those who do not use alco- for the common etiology model, additional hol to cope with social anxiety (Carrigan, Ham, research is needed to better understand the impact Thomas, & Randall, 2008 ) . Further, experimental of personality predispositions and genetics on the data have found that socially anxious and non- comorbidity of anxiety and SUDs. anxious individuals demonstrate greater levels of Importantly, the processes involved in perpet- alcohol use (see Battista, Stewart, & Ham, 2010 uating a comorbid anxiety disorder/SUD condi- for a review) following a social stressor, suggest- tion may not be those implicated in the onset of ing that social stressors confer a higher risk for the comorbid condition. Instead, both anxiolytic alcohol use. When considering PTSD, Leeies (i.e., self-medication) and anxiogenic (i.e., high- et al. ( 2010 ) have shown that approximately 20% risk) processes may be at play in maintaining of individuals with PTSD use substances (alco- comorbid anxiety and SUDs, as proposed by hol, drugs, or both) in an attempt to self-medicate. Kushner et al. ( 2000 ; “feed-forward” model) and Overall, these data suggest that individuals diag- Stewart and Conrod (2008 ; “mutual mainte- nosed with SAD or PTSD commonly self-medi- nance” model). While processes consistent with cate and are more likely to develop an SUD. either the self-medication or high-risk models Data also support a high-risk (substance- might be key in the development of the co-occurring induced anxiety) model. Studies indicate that the condition (e.g., self-medication in SAD and onset of SUD symptoms often precedes anxiety PTSD), both model processes eventually interact in disorder onset (Breslau, Novak, & Kessler, 2004 ; a reciprocal nature and maintain both substance Semple, McIntosh, & Lawrie, 2005 ) . The dispa- use and anxiety symptoms. Thus, it is important 18 Substance Abuse and Anxiety Disorders: The Case of Social Anxiety Disorder and PTSD 289 to recognize that both processes may be occur- and an SUD. Challenges related to differential ring in these comorbid conditions, contributing to diagnosis, cognitive de fi cits, and secondary gain the complexities in treating a person with an anx- are reviewed below. iety disorder and SUD. Differential diagnosis . First, symptoms of SUDs (particularly withdrawal) and substance intoxica- Factors That Contribute to Complexity tion can overlap with symptoms of anxiety disorders. For instance, the effects of substance An individual with a comorbid SAD/SUD or intoxication and withdrawal from a substance PTSD/SUD presents a particularly compli- may mimic anxiety symptoms or include unpleas- cated picture when considering assessment ant symptoms that infl uence anxiety levels. and treatment. As described previously, people Intoxication, withdrawal, and adaptation to absti- with the comorbid condition present with more nence may have temporary or permanent effects severe cases (e.g., Grant et al., 2005; Ouimette on psychological, cognitive, and psychomotor et al., 1997 ) and have poorer prognoses (e.g., functioning (Clark, 1999 ) . Indeed, it may be Brown et al., 2003 ; Kushner et al., 2006 ) than diffi cult to ascertain whether or not anxiety symp- people diagnosed with one disorder. This sec- toms are in fact temporary (e.g., substance- tion highlights several aspects contributing to induced anxiety disorder) or independent anxiety the complexities in assessment and treatment syndromes. For example, effects of intoxication of individuals with comorbid SAD/SUD or (e.g., stimulants) and withdrawal (e.g., alcohol, PTSD/SUD. depressants) from several substances result in hyperarousal and increased anxiety. These effects could appear similar to hyperarousal symptoms Assessment present in PTSD. Further, individuals experiencing withdrawal might appear to meet some crite- The presence of an anxiety disorder might be ria for SAD due to concerns about appearing overlooked in individuals completing treatment anxious and/or being negatively evaluated when in a substance treatment facility and vice versa. experiencing observable withdrawal symptoms For example, El-Sayegh, Fattal, and Muzina (e.g., tremors, shaking). Given these dif fi culties ( 2006) found that SAD went unrecognized in a in distinguishing substance-induced anxiety from psychiatric evaluation for 94% of addiction treat- an independent anxiety disorder, a minimum of 4 ment-seeking patients with substance depen- weeks of abstinence is recommended prior to dence. One way to address this problem in SUD giving an individual a diagnosis of an anxiety dis- contexts is to provide training and education in order in addition to an alcohol use disorder (APA, anxiety disorders as well as to encourage assess- 2000; Clark, 1999 ) . The abstinence period for ment of anxiety symptoms and motives for drink- other substances has not been established empiri- ing (e.g., self-medication-related motives) in any cally, but there is agreement that a drug-free client presenting with an SUD. Similarly, clini- period is necessary to determine whether anxiety cians in anxiety disorder treatment contexts symptoms represent intoxication, withdrawal should be aware of the possibility of a co-occur- symptoms, a substance-induced anxiety disorder, ring SUD and routinely assess substance use, or an independent anxiety disorder. including substance use as a safety behavior. Determining length of sobriety may be accom- While a lack of awareness among clinicians about plished using self-report, collateral report(s), the need to assess for the co-occurring disorders behavioral observation, and/or a biological drug is one factor contributing to problems in identify- test. Self-report information from substance users ing individuals with the comorbid condition, is generally reliable and accurate when collected in there are many additional factors that complicate a confi dential setting while the individual is sober assessment in cases involving an anxiety disorder (e.g., Sobell & Sobell, 1990 ) . Thus, ensuring 290 L.S. Ham et al. sobriety at the time of assessment is critical. Cognitive abilities. Cognitive defi cits may interfere A biological test, such as urine drug screening, with assessment and treatment participation. blood tests, or alcohol breath tests (e.g., Allen & Individuals with an SUD in particular are likely to Litten, 2001; Goldberger & Jenkins, 1999 ) is pre- experience cognitive de fi cits given the neurotoxic ferred, particularly if there are concerns that the effects of the substance, traumatic brain injury individual is intoxicated at the time of the assess- occurring while intoxicated, or severe malnutrition ment and/or is dishonest about his or her last use. associated with SUDs (Bates, Bowden, & Barry, However, there are potential drawbacks to this 2002 ; Tarter & Kirisci, 1999 ) . Though some neu- method (e.g., cost, varying drug metabolite rocognitive de fi cits related to chronic alcohol use half-lives). Generally, the most cost effective and may improve over time (Goldman, 1986 ) , perma- least invasive methods for assessing sobriety is nent defi cits have been observed even in heavy through the use of self-report, collateral reports social drinkers (e.g., Oscar-Berman, Shagrin, (e.g., a signi fi cant other, family member), and Evert, & Epstein, 1997 ) . Therefore, a clinician behavioral observations of signs of use (e.g., assessing a substance-using client must consider unsteady gait, pupil dilation) or withdrawal the possibility of short-term or long-term cognitive (e.g., tremors, sweating). de fi cits. In the case of PTSD, for example, sub- For many reasons it may be dif fi cult to attain stance use-related cognitive de fi cits could be over- the goal of sobriety prior to or during the assess- looked if memory problems are attributed to ment process. Achieving this goal can be partic- avoidance of trauma-related memories. As such, ularly challenging when the anxiety disorder and substance users may require a neuropsychological SUD interact reciprocally (i.e., the “feed-for- evaluation, with consideration of time since last ward” or “mutual maintenance” models; Kushner use, length and pattern of use, medical history, as et al., 2000; Stewart & Conrod, 2008) making it well as history of anxiety and SUD symptoms. diffi cult for the client to abstain from the substance without another method to cope with fear- Secondary gain. There are several possible sec- related substance using cues and anxiogenic ondarily reinforcing factors, also referred to as withdrawal effects. Often, assessment occurs secondary gain, for clients undergoing an assess- before the client has achieved the recommended ment for co-occurring anxiety disorder and SUD. period of sobriety. When working with an indi- For example, assessment results could have vidual with an SUD who is currently using or implications for compensation related to level of has recently initiated a period of abstinence, it is functional impairment and distress (e.g., disabil- important to consider the potential intoxication ity claims, worker’s compensation), in which the and withdrawal effects of the abused substance(s) individual may be motivated to overreport symp- when evaluating anxiety symptoms. Furthermore, toms. In some situations, the likelihood of receiv- the clinician should establish a chronology in the ing compensation and/or insurance benefi ts for development and maintenance of symptoms, treatment of psychological diagnoses might be which is best accomplished through the combi- increased if the individual has an anxiety disor- nation of client and collateral reports (e.g., der (or other non-SUD diagnosis) compared to Lingford-Hughes, Potokar, & Nutt, 2002 ) . The an SUD. In addition, the assessment might be use of multimodal assessments (e.g., previous motivated by a desire to avoid or reduce the medical records, substance and psychological severity of legal consequences. Conversely, some history, self-report assessments, self-monitoring, individuals may be motivated to avoid receipt of collateral reports, behavioral observations, and diagnoses. In addition to concerns about the gen- biological substance use tests), multiple assess- eral social stigma of the label(s), individuals may ment points, and medical examinations to assess be concerned about whether the diagnoses affects for withdrawal effects are strategies that can be eligibility for certain types of employment (e.g., implemented to improve diagnostic accuracy. military and other governmental service), future insurance coverage, or access to a treatment 18 Substance Abuse and Anxiety Disorders: The Case of Social Anxiety Disorder and PTSD 291 program that excludes individuals with co- in therapy and potentially feeling vulnerable in a occurring anxiety or SUDs. Given these potential therapeutic setting threatening) may promote motivators for over- or underreporting symp- avoidance of therapy. toms, it is important that the clinician asks the Treating a client with comorbid anxiety disor- client (and collateral sources or agencies as der/SUD may be impacted by his or her willing- applicable) about his or her expectations and ness to participate in common aspects of addiction beliefs about the assessment process as well as the treatment. For example, individuals with SAD desired outcomes. may avoid SUD treatment or attend but not actively participate in treatment, which often involves group settings. Indeed, socially anxious substance Treatment Barriers abusers report that social anxiety symptoms interfere with willingness to talk to a therapist, speak in Only about 24% of NESARC respondents with a group setting, attend 12-step programs, and ask comorbid SAD/alcohol use disorder sought treat- someone to be a 12-step sponsor (Book, Thomas, ment for SAD and 26% for an alcohol use disor- Dempsey, Randall, & Randall, 2009 ) . der (Schneier et al., 2010 ). This leaves a large Withdrawal from substance use often leads to proportion of individuals with the comorbid con- increased anxiety and arousal. Thus, another condition without treatment for SAD, an alcohol use sideration in the treatment of individuals with disorder, or both. Recent reports suggest that only comorbid anxiety/SUD is problems in discontinu- 13.3% of individuals with PTSD had ever received ing substance use or refusal to stop using anxi- treatment (Davis, Ressler, Schwartz, Stephens, & olytic medications during exposure-based Bradley, 2008 ) . Further, previous fi ndings sug- treatments for anxiety disorders. Research suggest that PTSD is underdiagnosed in SUD sam- gests that alcohol and other depressants (e.g., ben- ples (Dansky, Roitzsch, Brady, & Saladin, 1997 ) zodiazepines) interfere with certain learning resulting in numerous individuals not receiving processes, which is particularly critical in expo- adequate treatment. Reasons for the lack of treat- sure-based therapies (Morissette, Spiegel, & ment can be classifi ed as client-related, systemic, Barlow, 2008 ) . Furthermore, depressant use and clinician-related factors. among individuals receiving exposure-based treatment for PTSD has been associated with higher Client-related factors. Avoidance behaviors pres- dropout rates (van Minnen, Arntz, & Keijsers, ent in anxiety disorders generally, and for SAD 2002 ) . A related problem involves intoxication in and PTSD in particular, may impact treatment- therapy. Clinicians should discuss rules about seeking and participation in both anxiety and intoxication in the clinical setting before therapy SUD treatment. Fear avoidance could result in begins so that the client is aware of the conse- avoidance of speci fi c therapy components or the quences of arriving to therapy intoxicated. therapy process more generally. The prospect of engaging in feared situations as part of exposure- Systemic factors . One critical barrier to treatment based interventions may lead many clients to in individuals with comorbid anxiety disorder avoid anxiety-related treatments, particularly and SUD is the lack of availability or access to when the individual is also attempting to abstain effi cacious treatments focused on the comorbid from substances that have been used to cope with conditions. This often leaves clients with both an such fears. In the case of a client with SAD, the anxiety disorder and an SUD to seek treatment prospect of placing a telephone call to make an that focuses on just one disorder. Such treatments appointment, social interactions in the waiting typically do not include consideration of the co- room, and social interactions in treatment set- occurring disorder and the functional relations tings might deter treatment-seeking. Similarly, between the two disorders. Many treatment pro- PTSD-related hypervigilance and dif fi culty with grams/providers require that potential clients trust (which may make the prospect of engaging obtain treatment for the SUD prior to anxiety 292 L.S. Ham et al. disorder treatment. This is unfortunate because providing treatment for the co-occurring disorder, some individuals may not desire SUD treatment leading them to ignore the co-occurring disorder if substance use is viewed as a coping mechanism or refer the client elsewhere. for anxiety, rather than an independent problem. In sum, several factors complicate the picture Secondly, SUD treatment may not be as effective for clinicians when encountering an individual when disorder-speci fi c triggers for substance use with comorbid SAD/SUD or PTSD/SUD. remain (Ouimette, Moos, & Finney, 2003 ) . Third, Challenges related to differential diagnosis, cog- disorder-speci fi c fears might interfere with SUD nitive abilities, and secondary gain may make treatment participation (as discussed above). identifi cation of individuals with these comorbid Finally, there is evidence that psychosocial or conditions dif fi cult. Furthermore, client-speci fi c, pharmacological treatment targeting SAD only in systemic, and clinician-related barriers contrib- individuals with SAD/SUD may experience a ute to the dif fi culties in treating clients with a co- clinically signi fi cant reduction in SAD with limited occurring anxiety disorder and SUD. changes in substance use (Book, Thomas, Randall, & Randall, 2008 ; McEvoy & Shand, 2008 ) . Thus, the standard practice of requiring Treatment Approaches SUD treatment prior to anxiety disorder treatment may be problematic in certain cases. After presenting treatment elements common to In the context of treatment for an anxiety dis- SUD treatments more generally, this section will order and an SUD separately, it is also possible cover specifi c treatment approaches for SAD and that one type of treatment could interfere with SAD/SUD as well as treatment approaches for another form of treatment. For example, benzodi- PTSD and PTSD/SUD. A case study is presented azepines, often prescribed for anxiety symptoms, for each set of comorbid conditions to illustrate can interfere with the learning process within treatment implementation for these co-occurring exposure-based therapies for anxiety and increase disorders. the likelihood of attrition (Morissette et al., 2008 ; Treatment for SUDs often involves group set- van Minnen et al., 2002 ) . Benzodiazepines also tings in which social support is an important aspect have a high potential for abuse and could be of the therapeutic environment. Clinicians often dangerous if mixed with other substances (Back encourage clients with an SUD to participate in & Brady, 2008 ) . 12-step groups such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), which may Clinician factors. Clinicians may be hesitant to be accomplished using a manualized treatment implement exposure-based therapies in an indi- (Twelve-Step Facilitation [TSF]; Nowinski, Baker, vidual with an SUD due to concerns of relapse or & Carroll, 1992 ) . Motivational enhancement ther- attrition from therapy as a result of introducing a apy (MET), cognitive-behavioral therapy (CBT), potential substance use trigger (i.e., a feared situ- and combined behavioral intervention (CBI) are ation). Indeed, some clinicians may be reluctant currently the leading psychosocial interventions to use exposure therapy in general (see Richard involved in the treatment of alcohol use disorders & Gloster, 2007 for a review), and in individuals (Randall, Book, Carrigan, & Thomas, 2008 ) . MET with PTSD in particular (see Ruzek & Rosen, refers to an approach in which the therapist 2009 for a review), due to concerns that the anxi- employs motivational strategies, such as active lis- ety-inducing techniques central to exposure may tening techniques, to encourage the client to cause excessive distress for the client. Clinicians develop his or her own plan for changing drinking treating an anxiety disorder may avoid treating an behaviors (Miller, Zweben, DiClemente, & SUD due to concerns about client attrition Rychtarik, 1995 ) . CBT is founded on the integra- because the client might not share the goal of tion of both behavioral and cognitive interven- treating the SUD. Further, clinicians may not tions, which are each based on the assumption that have suf fi cient training or feel competent in prior learning is having maladaptive consequences. 18 Substance Abuse and Anxiety Disorders: The Case of Social Anxiety Disorder and PTSD 293

Accordingly, CBT aims to reduce distress or reuptake inhibitors [SSRIs]) interventions for the unwanted behavior by undoing learning or by treatment of SAD (Hofmann & Smits, 2008 ; proving new, more adaptive learning experiences Randall et al., 2008 ; Stewart & Chambless, 2009 ) ; (Kadden et al., 1995 ) . CBI incorporates techniques however, these studies have largely excluded from both MET and CBT in addition to encourag- participants with an SUD. Consequently, the ing clients to participate in support groups and literature provides few evidence-based treatment including family members in the treatment plan options for individuals presenting with co-occur- (Longabaugh, Zweben, LoCastro, & Miller, 2005 ) . ring SAD/SUD. Despite this gap in the literature, Although this chapter does not cover pharmaco- previous studies have highlighted important logical treatment, it should be noted that pharma- characteristics of treatment that increase the like- cotherapy continues to be an important part of lihood of a positive outcome when treating an SUD treatments (Vocci, Acri, & Elkashef, 2005 ) . individual with co-occurring SAD/SUD. Research on the treatment of SUDs and its co-occurrence with SAD has largely focused on alcohol use Social Anxiety Disorder and Substance disorders speci fi cally; however, treatment options Use Disorder Comorbidity for SUDs more generally will be discussed when data are available. SAD treatment aims to reduce social fears and There are currently three general approaches avoidance of feared situations. Several forms of to the treatment of co-occurring SAD/SUD, cognitive-behavioral approaches (i.e., cognitive namely, sequential, concurrent, and integrated therapy, exposure therapy, CBT, social skills methods. Traditionally, clinicians have utilized a training, and relaxation training) appear effective sequential treatment approach for treating indi- in the treatment of SAD (Book & Randall, 2002 ; viduals with comorbid SAD/SUD, treating the sub- Clark et al., 2006 ; Randall et al., 2008 ; Rapee, stance use problem fi rst and then treating the Gaston, & Abbott, 2009 ) ; however, exposure SAD. Concurrent treatment is an approach in therapy has been argued to be the critical compo- which the client receives treatment for both dis- nent in reducing SAD symptoms (Clark et al., orders simultaneously; however, there is no con- 2006 ) . Exposure therapy is an approach in which sideration given to the relations between the two the client is encouraged to expose themselves to disorders. With strong evidence-based treatment the feared situation while using skills learned in options for each disorder individually, Kushner therapy to reduce anxiety symptoms. Cognitive et al. ( 2000) argued that the lack of success therapy is largely focused on challenging errone- when treating clients with comorbid SAD/SUD ous beliefs (e.g., cognitive restructuring) after the may suggest that together these disorders form client identi fi es his or her own problematic a “hybrid condition” that requires an entirely thoughts, behaviors, or emotions. Relaxation different treatment option than that seen for training refers to a technique in which the client either condition alone. As such, it is possible is taught to control the amount of physical ten- that a “hybrid” or integrated treatment model sion in his or her body in order to reduce anxiety. would be a more ef fi cacious approach. In an SAD may be associated with defi cits in social integrated model, both SAD and SUD are treated performance; therefore, social skills training tar- and monitored simultaneously by a single indi- gets behavioral skills for social interactions. With vidual qualifi ed to treat both disorders. This model the integration of each of these approaches, CBT attempts to demonstrate to clients how problems has consistently shown signifi cant and long-last- are interrelated rather than approaching them ing treatment effects for anxiety disorders (see separately, as done in sequential or concurrent Stewart & Chambless, 2009 for a review). models. Many well-controlled clinical trials have highlighted the effi cacy of both psychosocial and Ef fi cacy. One clinical case study examined a pharmacologic (primarily selective-serotonin sequential approach to treating SAD/SUD. 294 L.S. Ham et al.

Buckner et al. ( 2008) examined the utility of SSRI pharmacotherapy (n = 47) or a psychosocial combining MET with CBT in treating a client relapse prevention treatment only (n = 49). Results with comorbid SAD and an alcohol use disorder. indicated that the concurrent treatment was effec- The authors found that the use of a brief MET tive in reducing anxiety symptoms; however, it intervention prior to individual CBT for SAD had no signifi cant effect on alcohol relapse rates. provided a useful skill (e.g., alcohol-related Concurrent treatment approaches for comorbid change plan) that decreased the risk of using SAD/SUD may reduce anxiety symptoms, but alcohol to cope with the increased anxiety levels not alcohol use. experienced in CBT treatment. Following 19 ses- In a preliminary study, Courbasson and sions of MET and CBT, and at 6-month follow- Nishikawa (2010 ) found that a modi fi ed SAD up, the client no longer met criteria for SAD or cognitive-behavioral group therapy (CBGT) the alcohol use disorder. resulted in decreased social anxiety-related symp- Two studies examined a concurrent treatment toms from pre- to posttreatment among 26 clients approach to treating SAD and alcohol depen- with co-occurring SAD and SUDs. Though the dence. In one randomized controlled trial, protocol was primarily based on Heimberg and researchers utilized a concurrent individual treat- Becker’s (2002 ) CBGT for SAD, it also included ment model in the treatment of alcoholics with explicit discussions of the link between SAD and SAD (Randall, Thomas, & Thevos, 2001 ) . substance use, making it an integrated treatment Participants were randomly assigned to alcohol to a degree. The effect size of the social anxiety treatment only (n = 44) or combined alcohol and reduction (d = 0.85) was similar to that of studies SAD treatment (n = 49). Both 12-week treatments consisting of clients with SAD only. Unfortunately, were individual, manual-guided, and CBT ori- substance use was not assessed, so treatment out- ented. Interestingly, the group receiving CBT for comes related to substance use are unknown. alcohol dependence yielded slightly better alco- Other important limitations of the study include hol-related and equivalent SAD treatment out- the lack of a control group and the high (56%) comes when compared to the group that received attrition rate. Nonetheless, the results provide concurrent SAD/alcohol dependence CBT evidence for additional research to explore the treatment. A high dropout rate in the concurrent speci fi city of these effects in this population. treatment group is a possible explanation for Importantly, this is the only known study to fi ndings that were inconsistent with hypotheses examine treatment of SAD/SUD for substances (i.e., the dual-treatment approach would lead to other than alcohol (i.e., cocaine, cannabis, opi- less SAD and drinking, compared to the alcohol ates, or prescription drugs). only treatment). It is possible that exposure to Finally, one study has provided support for an feared situations without the aid of alcohol or integrated treatment approach. In a recent alternative coping strategies could have led to National Institute on Alcohol Abuse and greater anxiety levels and thus lower treatment Alcoholism (NIAAA)-funded study, researchers adherence (Randall et al., 2008 ) . Methodological examined a new integrated treatment, the Brief care concerning attrition and third variable effects Intervention for Socially Anxious Drinkers may be bene fi cial in future clinical trials examin- (BISAD), which combined CBT strategies for ing treatment for SAD/alcohol use disorder. social anxiety and hazardous drinking (PI: Tran; Schade et al. ( 2005 ) demonstrated similar Grant No. R21AA014014). A pilot study pro- results while examining a concurrent treatment vided evidence for the ef fi cacy of BISAD (n = 21) for individuals with comorbid alcohol depen- in reducing heaving drinking, social anxiety, and dence and an anxiety disorder (SAD or agora- alcohol-related negative consequences at 1- and phobia). In this randomized controlled trial, 4-month follow-ups, compared to alcohol psy- participants were assigned to either a combined choeducation (n = 20) (Tran, 2008 ) . The success intensive psychosocial alcohol relapse prevention of this integrated approach may be attributed to program with anxiety-focused CBT and optional the focus on the links between anxiety and alco- 18 Substance Abuse and Anxiety Disorders: The Case of Social Anxiety Disorder and PTSD 295 hol use. Future well-controlled, randomized abstaining from alcohol while working in his job treatment outcome studies are necessary to in a factory assembly line. Alex reported that, examine the effi cacy of such interventions for prior to this treatment episode, he typically drank individuals with coexisting SAD/SUD. before work, during breaks, and during the lunch Taken together, these studies have been lim- hour on a daily basis to control his anxiety (in ited by small sample sizes and a paucity of work addition to evening drinking, for a total of 12Ð15 examining treatment of substance use problems standard drinks on a typical day). On the day he other than alcohol. Nonetheless, based on the lapsed, Alex reported that he was informed that a case study examining a sequential treatment for supervisor would be evaluating the assembly line SAD and alcohol use disorders, it seems that this employees over the next week. Alex reported that treatment might be effi cacious in reducing symp- his anxiety about being scrutinized at work toms of SAD and alcohol-related outcomes increased substantially and he felt he needed to (Buckner et al., 2008 ) . Evidence from two ran- drink to “calm [his] nerves.” Subsequently, Alex domized controlled trials does not support con- drank three 12-oz beers at lunch. He noted that current SAD and alcohol dependence treatments some of his co-workers regularly drank 1Ð2 beers in improving alcohol-related outcomes, and the over the lunch hour. fi ndings related to SAD reduction were mixed Assessment included a set of self-report (Randall et al., 2001 ; Schade et al., 2005 ) . Finally, measures, portions of a well-established semi- two studies examined integrated treatments for structured diagnostic interview, an unstructured SAD/SUD. The uncontrolled (Courbasson & clinical interview, and a review of an assessment Nishikawa, 2010 ) and the randomized controlled report from a previous addiction-focused evalua- pilot study (Tran, 2008 ) of integrated intervention. Alex previously attended court-ordered tions found successful reductions in anxiety Alcoholics Anonymous (AA) meetings related to symptoms. There were also successful reductions a DUI charge 2 years earlier. He reported no pre- in alcohol-related outcomes in the pilot study vious treatment for SAD. Related to SAD, Alex (Tran); however, it is unknown whether the inte- reported that he experienced SAD symptoms for grated intervention used in the Courbasson and “as long as [he] could remember.” Alex reported Nishikaway (2010 ) study affected substance use that he fi rst consumed alcohol at age 14 and began outcomes as these dependent variables were not abusing alcohol around age 16. Alex noted that, assessed. Overall, it seems that the results related as a teenager, he began using alcohol to cope with to integrated treatments for SAD/SUD are the anxiety about social interactions, particularly most promising. interactions with women that he found attractive. After graduating from high school, his drinking Clinical case study. What follows is a case exam- escalated. Alex reported he moved from a small, ple of a client diagnosed with co-occurring SAD rural community to a larger community where and alcohol dependence. “Alex” is a 27-year-old, he experienced increased anxiety as he was White man who was treated in an addiction thera- repeatedly faced with interacting with unfamiliar peutic community setting. His entry into the ther- people. At the time of the initial assessment, apeutic community was precipitated by a driving Alex reported that his SAD symptoms interfered under the in fl uence (DUI) legal charge and short- with his ability to engage in treatment as well as term inpatient treatment primarily focused on in daily activities inherent in living with others in detoxifi cation. Three days following admission the therapeutic community setting. He reported into the therapeutic community, Alex experi- that, in the past, he fi gured out ways to mask enced a drinking “lapse.” The facility’s addiction his drinking so that he could go to work and counselor referred Alex to the therapeutic com- attend AA meetings while intoxicated. Alex was munity’s mental health provider to address co- particularly concerned about negative evaluation occurring anxiety symptoms identifi ed as relapse at work, but also reported that he avoided dating triggers. Speci fi cally, he reported dif fi culty situations and interactions with members of 296 L.S. Ham et al. the opposite sex due to his SAD symptoms. as well as the need to assess for SAD in addic- The initial evaluation supported a diagnosis of tion settings. comorbid SAD and alcohol dependence. Alex completed the therapeutic community’s standard addiction treatment, primarily com- PTSD and Substance Use Disorder prised of a 12-step facilitation approach. Comorbidity Concurrent to addiction treatment, he was offered weekly individual treatment to target As above for comorbid SAD/SUD treatment, SAD and the relations between SAD and arguments have been made for sequential, con- drinking behavior. The SAD intervention was current, and integrated treatment methods. based on the Managing Social Anxiety manual Historically, clinicians have considered sequen- (Hope, Heimberg, & Turk, 2006 ) , which tial treatment of co-occurring PTSD/SUD as the includes psychoeducation about SAD, cogni- most clinically indicated method. Treatment of tive restructuring, and graduated exposure to the SUD is typically considered fi rst and then feared situations. Three components were PTSD treatment if clinically indicated. This integrated into the manualized SAD treatment method can be advantageous in that reduced sub- to address comorbidity: (1) psychoeducation stance use may result in increased emotional sta- focused on the association between SAD and bility and greater ability to benefi t from PTSD alcohol use (and its reciprocal nature), (2) treatment. Moreover, PTSD symptoms may remit self-monitoring of alcohol use urges, and (3) following successful SUD treatment (Dansky, cognitive restructuring examining Alex’s Brady, & Saladin, 1998 ) . However, such patients biased beliefs about his ability to perform and may be medicating their PTSD symptoms with cope with anxiety in social situations without drugs. In this scenario, delaying PTSD treatment the use of alcohol. Special attention was paid in favor of SUD treatment may increase the prob- to feared situations that interfered with addic- ability of an addiction relapse as PTSD-related tion treatment (e.g., AA meetings, interacting triggers for substance use remain (Ouimette et al., with housemates, refusing to drink alcohol 2003) . Alternatively, congruent with the self- with co-workers) in planning and implement- medication hypothesis of co-occurring PTSD/ ing exposures. SUD (see Stewart & Conrod, 2003 ) , if individu- Following completion of 20 cognitive- als are using drugs to manage PTSD symptoms, behavioral treatment sessions, Alex completed it seems rational to fi rst treat PTSD and then offer self-report measures and a targeted semi-structured SUD treatment if clinically indicated. This option clinical interview. The interview revealed that also has a number of potential faults. Effective Alex still experienced SAD symptoms, but treatments for PTSD require rational examina- that these symptoms were in the subclinical tion of trauma memories and experiencing nega- range. Self-report measures suggested a clini- tive emotions. Increased exposure to such cally signifi cant reduction in SAD symptoms. stressors could trigger increased substance use. Alex remained abstinent from alcohol accord- Previous research has found that individuals who ing to self- and collateral reports. He reported continue alcohol use or benzodiazepine use dur- increased attendance and involvement at AA ing PTSD treatment are more likely to drop out meetings, including active involvement with an of treatment early compared to individuals absti- AA sponsor. At discharge from the therapeutic nent from anxiolytic substances (van Minnen community and 2 months after treatment comet al., 2002 ) . Additionally, continued substance pletion, Alex continued to experience improve- use during PTSD treatment could block or limit ments in SAD symptoms and had not consumed learning, which is a key mechanism in the effec- alcohol. This case study illustrates the importance tive treatment of PTSD. Such fi ndings suggest of considering both SAD and the alcohol use that PTSD treatment without consideration of disorder in treating the comorbid condition, SUD complexities may hinder treatment effects. 18 Substance Abuse and Anxiety Disorders: The Case of Social Anxiety Disorder and PTSD 297

Second, clinicians can consider treating both address concurrent disorders. For example, in an disorders concurrently. For example, a patient might uncontrolled study, Seidel, Gusman, and Abueg receive prolonged exposure (PE) for PTSD, while ( 1994 ) examined the effect of inpatient treatment at the same time receive cognitive-behavioral incorporating cognitive modifi cation, exposure, coping skills training targeting the SUD. This and coping skills training for Veterans with method may be limited in that each treatment is co-occurring PTSD/alcohol abuse. Cognitive provided without consideration of the other. modi fi cation appears to have targeted general Considering evidence suggesting a strong functional belief systems as opposed to precise dysfunc- relation among co-occurring disorders (Coffey, tional beliefs related to a specifi c traumatic event. Stasiewicz, Hughes, & Brimo, 2006 ; Smith, They also applied an exposure-based therapy; Feldner, & Badour, 2011 ) , concurrent treatment however, the description of the exposure elements without consideration of the functional relations suggests that the participants engaged in a more between the two conditions may be limited. general discussion of military experiences as Third, clinicians can provide integrated treat- opposed to targeting a particular memory for ment for co-occurring disorders. In this method, repeated prolonged exposure. Finally, relapse the same provider treats the PTSD and SUD at prevention strategies were applied. The authors the same time. Speci fi c focus is paid to the func- reported that greater than 60% of the participants tional relationship between the co-occurring dis- remained abstinent at 3 months posttreatment. orders. This option matches well with client Change in PTSD-relevant functioning was not preferences (Brown, Stout, & Gannon-Rowley, reported. Although it is dif fi cult to draw any fi rm 1998 ) and addresses a more comprehensive set of conclusions about treatment mechanisms, this intertwined functional relations within a client. study provided a base from which future studies could expand upon. Ef fi cacy. Since the mid-1990s, researchers have In 2000 , Triffl eman reported fi ndings of a small been designing and testing programs focused on controlled examination of Substance Dependence treating the complexities associated with co- PTSD Therapy (SDPT ), an integrated treatment occurring PTSD/SUD. A variety of procedures designed to address the unique needs of individu- have been implemented; however, there have als with co-occurring PTSD/SUD. Participants been several key elements common in these pro- were randomly assigned to either SDPT or TSF. grams including education, SUD treatment, TSF focuses specifi cally on eliminating substance PTSD treatment, and relapse prevention. use, but does not directly address PTSD symp- Education typically focuses on increasing under- toms. In the active treatment condition, partici- standing of the basic components of SUD and pants fi rst engaged in abstinence-focused SUD PTSD and how they relate to each other. Coping treatment (i.e., coping skills training). During this skills training for SUD focuses on increasing phase, they also received education on the interac- effi cacy and ability to manage emotions and tion of PTSD symptoms and addiction. The sec- behaviors related to addiction (Kadden et al., ond phase applied stress inoculation therapy 1995 ) . Elements of coping skills training include (Meichenbaum & Cameron, 1983) while continu- craving management, assertiveness training, ing to address addiction concerns. Cognitive relaxation training, anger management, and man- modifi cation, in vivo exposure (as long as can be agement of time and social life. Effective PTSD tolerated), and coping skills training were the pri- treatments examined thus far in the co-occurring mary treatment components. All participants PTSD/SUD literature typically include exposure improved equally across groups indicating no dif- procedures. Currently there are a limited number ference between SDPT treatment protocol and of studies examining effective methods of treat- TSF in treating co-occurring PTSD/SUD. Small ing co-occurring PTSD/SUD. sample size (n = 19) may have limited the ability Early investigations combined treatment pro- to detect true differences, or perhaps mechanisms cedures found to be effective for each disorder to present in each treatment (e.g., common factors 298 L.S. Ham et al. such as regular sessions, empathetic therapist) of concurrent treatment of PTSD/alcohol depen- may have driven the null outcome. dence comorbidity (PI: Foa; Grant No. RO1 Donovan, Padin-Rivera, and Kowaliw (2001 ) AA012428). Preliminary data from this random- provided preliminary data from an uncontrolled ized controlled trial was presented previously at study showing that “Transcend,” a group-based meetings of the International Society for treatment program for co-occurring PTSD/SUD, Traumatic Stress Studies (Riggs et al., 2003) and can have a positive effect on relevant symptom the Association for Advancement of Behavior pro fi les. “Transcend” included a variety of treatment Therapy (Riggs, Pai, Volpicelli, Imms, & Foa, procedures stemming from a diverse collection of 2004 ) . Cognitive-behavioral treatment and medi- theoretical backgrounds including constructiv- cation management were provided for alcohol ist, psychodynamic, and cognitive-behavioral. dependence while PE was provided for PTSD. Coping skills training and TSF were provided Participants were randomly assigned to PE/No for addiction concerns and unstructured exposure PE for PTSD and Naltrexone/Placebo for alcohol to memories of traumatic events was included for dependence. Findings suggested that individuals PTSD. Participants reported statistically receiving active treatment components reported signifi cant decreases in all PTSD symptoms and signifi cant reductions in PTSD and SUD symp- in addiction severity. However, as noted by Riggs toms compared to control participants. Similar to and Foa ( 2008 ) , the magnitude of treatment gains the fi ndings reported by Coffey et al. (2006 ) , indi- was marginal, suggesting limited clinical impact. viduals receiving PE reported reduced alcohol Further, it is diffi cult to determine the active cravings. These preliminary data suggest that in mechanisms responsible for treatment effects addition to the fi ndings from Brady et al.’s ( 2001 ) given the variety of program components. integrated treatment study, concurrent treatments In an attempt to investigate more speci fi c are also a promising avenue for treatment of co- treatment mechanisms, Back, Dansky, Carroll, occurring PTSD/Alcohol dependence. Foa, and Brady ( 2001 ) designed an integrated Najavits (2002 ) developed an integrated treat- treatment for co-occurring PTSD and cocaine ment package for co-occurring PTSD/SUD enti- dependence. Substance use treatment focused on tled Seeking Safety. This package purposely omits coping skills training, whereas PTSD symptoms exposure therapy elements for PTSD to limit the were targeted through PE therapy. Treatment potential for relapse triggered by exposure-related occurs across 16, 90-min sessions, twice weekly. negative effect. Seeking Safety incorporates cog- The fi rst fi ve sessions focused on coping skills nitive, behavioral, and interpersonal elements to training to provide some stabilization and educa- increase ability to manage and cope with PTSD tion concerning the functional relation between and substance use diffi culties. While this therapy PTSD and addiction. PE is initiated in session has shown promise in terms of client acceptance, six. In an uncontrolled study, Brady, Dansky, reduced suicidal threat, improved emotion man- Back, Foa, and Carroll (2001 ) reported that treat- agement, and reduced substance use (Najavits, ment completers (n = 15 out of 39 initially Weiss, Shaw, & Muenz, 1998 ) , treatment out- enrolled) experienced statistically signifi cant come investigations have generally produced reductions in intrusive, avoidance, and hyper- equivocal results in terms of PTSD outcomes. arousal symptoms from baseline measurements. Previous reports have failed to fi nd differences in Additionally, depression diffi culties improved, as PTSD symptoms compared to educational and did addiction symptoms. Effect size data sug- relapse prevention control groups (Hien, Cohen, gested clinically signifi cant improvement in Miele, Litt, & Capstick, 2004 ; Hien et al., 2009 ) . PTSD (Glass’s delta = 1.80) and substance use Researchers have suggested that PE may be (Glass’s delta = 1.26) symptoms at posttreatment contraindicated for individuals with severe anger and 6-month follow-up. diffi culties and suicidal/self-harm tendencies Riggs and Foa (2008 ) summarize data from a (e.g., Foa, Hembree, & Rothbaum, 2007 ) or indi- recent NIAAA-funded study examining the effect viduals for whom exposure becomes emotionally 18 Substance Abuse and Anxiety Disorders: The Case of Social Anxiety Disorder and PTSD 299 overwhelming (Coffey, Dansky, & Brady, 2003 ) . processing therapy (CPT: Resick & Schnicke, As a preliminary attempt to address some of these 1992) has also received considerable empirical concerns, Najavits, Schmitz, Gotthardt, and support as an effective treatment for PTSD. In a Weiss (2005 ) applied Seeking Safety to address direct comparison, Rizvi, Vogt, and Resick (2009 ) dif fi culties in emotion regulation and included an compared PE with CPT for women with PTSD. exposure element in the treatment co-occurring Interestingly, they found that younger women PTSD/SUD (n = 5). Findings indicated improve- appeared to benefi t more from CPT, whereas older ments in addiction and PTSD symptoms, in addi- women received more benefi t from PE. Such tion to suicidal risk. Such fi ndings suggest that fi ndings suggest that speci fi c treatment proce- the inclusion of Seeking Safety with exposure dures for PTSD may evidence differential effi cacy therapy for PTSD may be a viable treatment as a function of client characteristics. The debili- option to address the complexities associated tating effects and complex nature of this relatively with co-occurring PTSD/SUD. common co-occurrence have provided necessary Current data provide promising avenues of support for continued large-scale clinical trials exploration to address the clinical complexities examining various treatments targeting co-occur- associated with PTSD/SUD co-occurrence. ring PTSD/SUD. Future well-controlled treatment Brady et al. (2001 ) and Riggs and Foa (2008 ) outcome studies are necessary to rigorously exam- both provide preliminary data supporting concur- ine the effects of such interventions in order to rent and integrated treatment models utilizing determine what treatments work best for which cognitive-behavioral coping skills training and clinical scenarios. exposure therapy for PTSD. Additionally, preliminary evidence suggests that Seeking Safety may be an effective adjunct to exposure therapy Clinical Case Study in the treatment of PTSD/SUD. Although we have detailed studies resulting in promising treat- The following is a case example of a Veteran with ments, there are numerous areas to examine fur- co-occurring PTSD, cannabis dependence, alco- ther. The National Institute on Drug Abuse hol dependence, and cocaine dependence in full (NIDA) has funded a randomized controlled remission. “Joe” is a 55-year-old, African study to replicate and extend previous fi ndings American combat Veteran who was treated in a (Brady et al.) examining the impact of concurrent VA PTSD/addiction treatment program. He CBT for SUD and PE for PTSD in OEF/OIF served in Vietnam for 12 months. During this Veterans (PI: Back, Grant No: RO1 DA030143). time, he experienced several combat-related trau- NIDA has also funded a randomized controlled matic events and exhibited functional diffi culties project focused on examining the impact of PE in stemming from PTSD symptoms for years. Joe the concurrent treatment of PTSD/SUD which had been unable to maintain regular employment incorporates biological and emotion regulation and had dif fi culties related to family and friends elements in hopes of uncovering speci fi c media- due to his PTSD symptoms. He avoided crowds tors of treatment change (PI: Hien, Grant No: and other social activities due to anxiety stem- RO1 DA023187). Additionally, in response to ming from trauma reminders. Joe frequently lost relatively high attrition rates (e.g., Brady et al.), his temper, was constantly irritable, and had trou- the NIAAA has funded a randomized controlled ble sleeping due to frequent, disturbing trauma- trial examining the impact of MET on treatment related nightmares. retention for exposure-based treatment of co- Although Joe experienced several events occurring PTSD/SUD (PI: Coffey, Grant No: meeting the PTSD criteria for a trauma, he was RO1 AA016816). able to identify the memory that intruded most Currently, the co-occurring PTSD/SUD treat- frequently and had the greatest impact on current ment literature has focused mostly on exposure- daily functioning. This particular event occurred based treatment for PTSD. However, cognitive when he was serving on a ship off the coast of 300 L.S. Ham et al.

Vietnam. He and several friends were originally coping skills training included education about ordered to participate in a specifi c operation. addiction and PTSD, craving management, However, at the last minute he was ordered to cognitive modi fi cation, problem solving, substance stay back while several of his friends boarded refusal skills, lapse management, assertiveness the helicopter and departed the ship. He then training, anger management training, and witnessed a missile strike the helicopter down. motivational enhancement training. Just prior to and during this incident, he reported Following completion of the residential treat- extreme fear. Following this incident, Joe reported ment phase, Joe transitioned into an integrated feelings of helplessness, anger, disgust, and sad- CPT/cognitive-behavioral coping skills outpa- ness. In the years following, he kept considering tient treatment program aimed at treating PTSD things he could/should have done to prevent this and preventing relapse. The coping skills relapse incident. He has repeatedly blamed himself for prevention training focused on management of this incident for approximately the past 40 years. social life, time management, and managing Joe was referred to the PTSD/addiction internal and external triggers in addition to moti- treatment program following his most recent vational enhancement. This treatment occurred in relapse. Joe completed an initial evaluation, a group setting for 1 h each week. Consideration which consisted of several questionnaires, an of the relation between substance use and PTSD unstructured interview, and a drug screen. Joe symptoms was incorporated into group discus- reported two previous addiction treatments. sions. Additionally, Joe participated in individual Each lasted 1 month and occurred in a residen- outpatient CPT, which aims to correct inaccurate tial treatment facility focused specifi cally on interpretations concerning the selected trauma treatment of SUDs. Following each treatment, event. Joe completed all 12 CPT sessions. In Joe reported several months of sobriety; how- addition to directly examining faulty beliefs sur- ever, he stated that he eventually returned to rounding Joe’s trauma, CPT skills were used to substance use in order to cope with his trauma target and modify biased beliefs concerning Joe’s memories. Joe had not received treatment for perception of the connection between PTSD his PTSD symptoms previously. Joe’s responses symptoms and his substance use. on self-report measures were suggestive of Following completion of all 12 CPT sessions, PTSD and depressive symptoms in the moder- there was a clinically signi fi cant drop in PTSD ately severe range. Joe was drinking 12 12-oz symptoms and depressive symptoms, as well as beers and smoking 3Ð4 marijuana joints daily. no substance use. These gains were maintained at He reported a history of regular cocaine use; a 3-month follow-up assessment. His drug screens however, he denied use in the past 7 years. His con fi rmed his self-report. This case study illustrates initial drug screen was positive for cannabis. the successful use of CPT combined with Baseline results yielded initial diagnoses of cognitive-behavioral coping skills training in the PTSD, cannabis and alcohol dependence, treatment of co-occurring PTSD/SUD. These depressive disorder NOS, and cocaine depen- fi ndings also lend support for the integration of dence in full remission. PTSD and SUD elements across treatment. Given Joe’s initial level of substance use, it was determined that immediate PTSD treatment would offer limited bene fi t. Therefore, our initial goal was Conclusion and Future Directions to reduce substance use to a level that would allow for effective PTSD treatment. He was offered treat- Though there is considerably more work focused ment in a 4-week dual diagnosis residential treat- on interventions for PTSD/SUD than SAD/ ment program, which integrates educational SUD, there remain important gaps in the assess- elements of the relation between SUD and PTSD ment and treatment knowledge base for both and provided cognitive-behavioral coping skills combinations of diagnoses. It also is notable training for SUD treatment. Cognitive-behavioral that anxiety disorder/SUD comorbidity rates are 18 Substance Abuse and Anxiety Disorders: The Case of Social Anxiety Disorder and PTSD 301 dramatically higher when considering drug Despite the high prevalence, the resulting neg- dependence (OR = 6.2) in comparison to alcohol ative impact, and the complicating factors involved dependence (OR = 2.6; Grant et al., 2004 ) . Given this in the assessment and treatment of these comorbid backdrop, it is surprising that most researchers anxiety and SUD conditions, relatively little is have focused on evaluating treatments for known about the optimal ways to serve individuals co-occurring anxiety disorders and alcohol with co-occurring SAD/SUD or PTSD/SUD. dependence. There is a paucity of research Additional empirical attention to developing examining interventions for co-occurring anxi- ef fi cacious treatments for clients with these co- ety disorders and drug dependence. Future occurring conditions is clearly warranted. research should address this gap. Further, more research is warranted that Acknowledgments This chapter is the result of work examines the ef fi cacy of integrated treatment supported with resources and the use of facilities at the protocols for co-occurring anxiety disorders and G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS. The views expressed here represent those of the SUDs. This is particularly lacking in the case of author and do not necessarily represent the views of the SAD/SUD, despite evidence that integrated treat- Department of Veterans Affairs or the University of ments might result in improved SAD and drink- Mississippi Medical Center. ing outcomes (PI: Tran; Grant No. R21AA014014; Tran, 2008 ) and that ef fi cacious integrated treatments are available for treating individuals with References co-occurring PTSD/SUD (e.g., Brady et al., 2001 ; Riggs et al., 2003, 2004 ) . Allen, J. P., & Litten, R. Z. (2001). 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Cross Developmental Complexities Treatment of Comorbid Anxiety Disorders Across the Life span 1 9

Caleb W. Lack, Heather Lehmkuhl Yardley, and Arpana Dalaya

The fourth edition of the Diagnostic and Statistical The high rates of overlap among anxiety Manual for Mental Disorders (DSM-IV; American disorders have numerous implications across the Psychiatric Association [APA], 1994 ) lists 12 research and practice realms. One of the most diagnostic categories for anxiety disorders, lead- important is that many clinical trials for treatment ing to over 25 distinct anxiety diagnoses on Axis of disorders restrict the types of participants, par- I (Norton, 2008 ) . Decades of research on these ticularly excluding those with highly complex disorders have found very high rates of comor- comorbid conditions (e.g., psychosis or bipolar bidity (i.e., co-occurrence of disorders within an disorder) and instead focusing on “pure” clients. individual), both for mood disorders and other As a result, our current empirically supported anxiety disorders (Brown, Campbell, Lehman, treatments may not be generalizable to a large Grisham, & Mancill, 2001 ; Kessler, Chiu, portion of clients—those with comorbid condi- Demler, & Walters, 2005 ) . In fact, a substantial tions (Goldenberg et al., 1996 ) . Over the last 15 body of research suggests that presentation of a years, considerable effort has been put forth to single anxiety disorder, with no comorbidity, is examine how comorbidity in fl uences treatment, the exception and not the norm (Brown, Di as well as how treatment can infl uence comorbid- Nardo, Lehman, & Campbell, 2001; Davis, ity. Does the presence of a comorbid disorder Barlow, & Smith, 2010 ) , even for those disorders make treatment more diffi cult? Will treating a with the lowest comorbidity rates (Goisman, primary disorder impact the comorbid disorder? Goldenberg, Vasile, & Keller, 1995 ) . This infor- The focus of the current chapter will be to review mation is not completely surprising, given the this research, particularly focusing on how such overlap in both etiology and diagnostic symp- knowledge can allow psychologists and other toms across these disorders (see Lawrence & mental health practitioners to more effectively Brown, 2008 for a review). treat clients who present with multiple, comorbid anxiety disorders.

Anxiety Disorders and Comorbidity C. W. Lack, Ph.D (*) • A. Dalaya, B.A. Department of Psychology , University of Central As mentioned, epidemiological- and community- Oklahoma , 100 N. University Drive , Box 85, based research have found high rates of comorbid- Edmond, OK 73034 , USA e-mail: [email protected] ity for persons with an anxiety disorder, even when compared to other categories of mental disorders H. L. Yardley, Ph.D Nationwide Children’s Hospital, (Toft et al., 2005 ) . In terms of speci ﬁ c rates, research 700 Children’s Drive, Columbus, OH 43205, USA has shown differential patterns of comorbidity for

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 309 DOI 10.1007/978-1-4614-6458-7_19, © Springer Science+Business Media New York 2013 310 C.W. Lack et al. the different anxiety disorders. For the below information, the fi rst disorder named would be consid- Impact of Comorbidity on Disorder ered the primary diagnosis, with the following Severity being the most typically comorbid diagnoses. Generalized anxiety disorder (GAD) has General clinical and research consensus is that, shown high rates of comorbidity with several compared to someone presenting with only a sin- other anxiety disorders, with estimates from 66 to gle anxiety disorder, those persons who meet 83% (Goldenberg et al., 1996 ; Wittchen, Zhao, diagnostic criteria for multiple anxiety disorders Kessler, & Eaves, 1994 ) . For persons with pri- tend to have more severe symptoms. In terms of mary GAD, the most commonly seen anxiety dis- course, single anxiety disorders have a later onset orders are social and speci fi c phobias (Borkovec, and are more likely to remit on their own than co- Abel, & Newman, 1995 ; Davis et al., 2010 ) , occurring disorders (Bruce, Machan, Dyck, & panic disorder, and posttraumatic stress disorder Keller, 2001 ; Goldenberg et al., 1996 ) . Research (PTSD; Kessler et al., 2005 ) . For panic disorder examining social phobia has found more severe (with or without agoraphobia), the most com- pretreatment symptoms in both the primary (social monly co-occurring anxiety disorders are specifi c phobia) and comorbid disorders (Erwin, Heimberg, phobias, social phobias, and generalized anxiety Juster, & Mindlin, 2002 ; Mennin, Heimberg, & ( Brown, Campbell et al., 2001 ; Kessler et al., Jack, 2000 ) . Similar fi ndings have been seen with 2005 ) . In persons with PTSD, high rates of social generalized anxiety (Belzer & Schneier, 2004 ; phobias are seen (Zayfert, Becker, Unger, & Nutt, Argyopoulos, Hood, & Potokar, 2006 ; Shearer, 2002 ) , as well as panic disorder (Kessler Wittchen et al., 1994 ) . In one study examining et al., 2005 ) , although the most commonly co- PTSD in a noncombat population, comorbid anxi- occurring disorders are non-anxiety ones (e.g., ety disorders were not related to PTSD severity major depression and substance abuse; Brady, (Zayfert et al., 2002 ) , although a later study found Killeen, Brewerton, & Lucerini, 2000 ) . that those with PTSD and a comorbid diagnosis of Social anxiety disorder (also known as social social phobia were more clinically severe than phobia) is highly comorbid with GAD, obsessive- those with PTSD or social phobia alone (Zayfert, compulsive disorder (OCD; Davis et al., 2010 ) , DeViva, & Hofmann, 2005 ) . agoraphobia, specifi c phobias, and panic disorder There are, however, mixed outcomes in primary (Kessler et al., 2005 ) . Obsessive-compulsive dis- panic disorder diagnoses, with some studies fi nding order has some of the highest comorbidity rates, higher symptoms (Allen et al., 2010 ) and some with almost half of persons being diagnosed with fi nding no differences in symptoms between per- a co-occurring anxiety problem (Weissman et al., sons who did and did not have comorbid disorders 1994 ), most commonly panic disorder, phobias, (Tsao, Mystkowski, Zucker, & Craske, 2005 ) . One or generalized anxiety (Brown & Barlow, 1992 ; study in particular that studied comorbid GAD and Davis et al., 2010 ; Kessler et al., 2005 ) . For those panic disorder found that those with both had with a primary diagnosis of a speci fi c phobia, signi fi cantly less satisfaction in personal relation- much lower rates of comorbidity exist compared ships, lower functioning, and lower emotional to other anxiety disorders (Brown, Di Nardo health (Massion, Warshaw, & Keller, 1993 ) . et al., 2001 ) ; however, for those with a different primary anxiety disorder, speci fi c phobias are the most common co-occurring disorder (Sanderson, Anxiety Comorbidity and Treatment Di Nardo, Rapee, & Barlow, 1990 ). Given the Impact low incidence rates of persons with only a specifi c phobia presenting for treatment (Silverman & There has been a substantial body of research Kearney, 1992 ) , though, it is more likely that a devoted to examining the treatment implications speci fi c phobia will be a comorbid, non-primary of comorbidity. Overall, the presence of comor- diagnosis in someone presenting for treatment. bidity does not appear to diminish the bene fi ts of 19 Comorbid Anxiety Disorders 311 empirically supported treatments. For example, and will be outlined below: transdiagnostic Brown, Antony, and Barlow ( 1995 ) found that treatments and treatments designed to speci fi cally the presence of comorbid conditions in primary treat speci fi c combinations of disorders. panic disorder did not impact short- or long-term outcome for panic symptoms. Most research has yielded similar results about panic symptoms Transdiagnostic Approaches (e.g., Tsao et al., 2005 ) , but not all studies have con fi rmed such fi ndings. One replication instead Transdiagnostic treatments are predicated on found comorbidity was associated with less like- three notions (Norton, 2008 ) . First, that anxiety lihood of treatment response (Tsao, Lewin, & disorders may not be independent from one Craske, 1998 ) . another; second, that treatments for speci fi c anxi- Results are more mixed with other anxiety ety disorders are robust; and fi nally, that some disorders. Treatment outcome for primary GAD diagnoses may lead to other diagnoses. Given with or without any comorbid conditions has these ideas, treatment geared toward the primary shown no differences in short-term treatment diagnosis should then generalize to the comorbid response (Mennin et al., 2000 ) , although others diagnoses as well. Due to the fact that there is no have shown comorbid anxiety disorders to one “transdiagnostic treatment,” but are instead decrease remission rates in the long term (Bruce treatments for speci fi c disorders, below are sum- et al., 2001 ) . In contrast, GAD comorbid with maries of research into transdiagnostic therapies, OCD or panic disorder has been linked to attenu- arranged by the primary diagnosis treated. ated treatment response (Steketee, Chambless, & Tran, 2001 ) . Primary social phobia treatment out- Social Phobia : One example of transdiagnostic come has not been negatively impacted by comor- treatment is cognitive-behavioral group therapy bid anxiety disorders (Brown et al., 1995 ) . (CBGT; Juster & Heimberg, 1994 ; Heimberg, Research on OCD is also mixed. Having pri- 1991 ; Heimberg & Juster, 1994 ) . This type of mary OCD with comorbid PTSD has been found treatment was fi rst developed for use with indi- to decrease response rate (Gershuny, Baer, Jenike, viduals with social phobia and has been adapted Minichiello, & Wilhelm, 2002 ) , while OCD and for transdiagnostic groups as discussed below. comorbid GAD were shown to increase dropout Cognitive-behavioral group therapy begins with rates and decrease treatment response (Steketee providing individuals with a cognitive framework et al., 2001 ) . In contrast, others have shown no for understanding the link between faulty beliefs negative impact on OCD treatment from comor- about and anxiety during social interactions. bid anxiety problems in adults (Steketee, Eisen, Restructuring activities are then employed to help Dyck, Warshaw, & Rasmussen, 1999 ; Storch participants identify negative automatic thoughts, et al., 2010 ) or children (Storch et al., 2008 ) . begin to classify them by cognitive distortion type, dispute negative thoughts using Socratic questioning and challenging of underlying Treatment Approaches for Comorbid assumptions, and fi nally developing coping self- Anxiety Disorders statements. The behavioral component follows cognitive therapy. Individuals develop concrete As discussed above, research has begun to examine goals (i.e., measurable, observable, attainable) the impact of treatment approaches for comorbid for exposures. Further, participants are given anxiety disorders with mixed results. As reviewed “homework” assignments to complete exposures below, recent literature has demonstrated decreases between sessions. Since CBGT is conducted in a in symptom severity and number of comorbid con- group setting, this improves access to care and ditions following treatment for certain disorders, helps normalize symptoms of social phobia. but not for others. Two distinct approaches to treating Mennin et al. (2000 ) examined the ef fi cacy of comorbid anxiety disorders have been developed CBGT in 122 adults with social phobia with and 312 C.W. Lack et al. without GAD. Results indicated signi fi cant desensitization therapy (Goldfried, 1971 ) requires improvement in social phobia symptoms as well individuals to practice relaxation skills in response as the comorbid GAD symptoms. They proposed to exposure to anxiety-producing stimuli and wor- that pretreatment GAD symptoms exacerbate the ries. Participants are taught to use pleasant imag- avoidance, fear, and worry associated with social ery, diaphragmatic breathing, and progressive phobia, thus treatment of social phobia may gen- muscle relaxation. They are then instructed to use eralize to the overlapping symptoms in GAD these skills when cued to by an anxiety provoking (Mennin et al., 2000) . This seemed to be situation. Additionally, cognitive therapy also con fi rmed by their fi ndings. been examined. As discussed previously, cognitive therapy for anxiety involves identifi cation of Speci fi c Phobias : A one-session cognitive-behav- negative automatic thoughts, systematic evalua- ioral treatment has been developed for specifi c pho- tion of anxious thoughts, and restructuring tech- bias (Ost, 1989, 1997 ) . It is predicated on the belief niques to make thoughts more adaptive. Speci fi c that individuals experience catastrophic thinking to GAD, cognitive therapies typically include dis- related to the feared stimuli which leads to avoid- cussion of intolerance of uncertainty, poor prob- ance. Therapy uses exposure to allow the individual lem-solving, and avoidance. Finally, CBT adds to have positive experiences with the feared stimuli behavioral exposure to cognitive training. which allow individuals to collect experiences that Following cognitive training, participants are contradict their faulty assumptions about the stimu- encouraged to use skills in real-world situations lus. Treatment is conducted in a single session that with clear goals for each exposure. may last up to 3 h. Participants are gradually Newman, Przeworski, Fisher, and Borkovec exposed in vivo to the feared stimuli. Cognitive ( 2010) compared a treatment combination of strategies are not used by the therapist during ses- self-monitoring, active anxiety reduction, and sion, but participants are encouraged to draw con- homework assignment in a sample with GAD clusions based on the positive experiences. With and comorbid anxiety disorders. Results indicate each step in the graduation, the participant must that psychotherapy for primary GAD led to a experience a reduction in anxiety of at least 50%. reduction in number and severity of comorbid In two studies, Ollendick, Ost, Reuterskiold, anxiety disorders at both posttreatment and fol- and Costa (2010 ) and Ost, Svensson, Hellstrom, low-up. Borkovec et al. ( 1995 ) reported similar and Lindwall ( 2001 ) report that youth undergo- results in a sample of adults with GAD. ing this therapy experienced not only a signifi cant Participants experienced a reduction in primary drop in symptoms of the primary anxiety disor- GAD as well as signi fi cantly fewer comorbid der (speci fi c phobia) but also reductions in clini- diagnoses following successful treatment of cal severity of other comorbid phobias and GAD. Ladouceur et al. ( 2000 ) examined a cogni- anxiety disorders. They attribute this to increased tive treatment for GAD. Results suggest that self-effi cacy following treatment of and “con- focusing on GAD speci fi c elements of cognitive quering” a speci fi c phobia. therapy lead to reductions in comorbid anxiety disorders. Speci fi cally, they reported that partici- Generalized Anxiety Disorder: Different combi- pants had more than a 50% decrease in number of nations of treatments have shown success in treat- comorbid illnesses which were maintained at ing GAD and comorbid anxiety disorders. follow-up 1 year later. However, some common elements of treatment are shared by those found to be the most effective Panic Disorder : Panic disorder treatment has also in reducing GAD and other comorbid diagnoses. been shown to impact comorbid conditions. Each of the proposed treatments involve self- Typically, treatment of PD uses cognitive-behav- monitoring of symptoms and cues, employing ioral methods developed by Craske and Barlow active strategies to reduce anxiety, and practice (Panic Control Treatment, 1993 ) . First, individu- using skills between sessions (Newman & als are provided with a physiological explanation Borkovec, 1995 ) . For example, self-control for panic symptoms; then, they are taught cognitive 19 Comorbid Anxiety Disorders 313 restructuring techniques to combat overestima- includes (1) cognitive restructuring techniques tions of risk related to these symptoms. Next, to respond to catastrophizing and overestimation participants learn breathing retraining for use of trauma, (2) interoceptive exposure to physio- when hyperventilation occurs during a panic epi- logical symptoms of panic and in vivo exposure sode. Individuals are then gradually exposed to to reminders (cues) to trauma, and (3) additional internal and external cues to panic using intero- cognitive work involving exposure to the trauma ceptive (internal) and in vivo (external) exposure. via writing and reading aloud about the initial Self-monitoring of anxiety and home practice are trauma. also required between treatment sessions. Research has shown MCET to be effective Several authors have examined the effect of over a wait list control (Falsetti, Erwin, Resnick, this treatment in PD with comorbid diagnoses Davis, & Combs-Lane, 2003 ) as well as a mini- (e.g., Brown et al., 1995 ; Tsao et al., 2005 ) . mal attention control (Falsetti et al., 2005 ) . Brown et al. (2001 ) reported a dramatic decrease Falsetti, Resnick, Davis, and Gallagher ( 2001 ) in number and severity of comorbid conditions used the above model in 22 women in a group at posttreatment. However, in contrast to other format. They reported reductions in the number of research, participants had returned to pretreat- women meeting diagnostic criteria for PTSD, ment levels of comorbidity at 2-year follow-up panic attacks and symptoms, fear of having and were more likely to seek additional treat- another attack, as well as reduction in the interfer- ment between follow-ups. Tsao et al. (2005 ) ence associated with attacks that were present and found that participants experienced signifi cant symptoms of depression. Additionally, Falsetti reductions in both PD symptoms and comorbid et al. (2003 ) reported improved function in a sam- diagnoses. Interestingly, the reduction in comor- ple of female trauma victims following MCET. bid diagnoses in this sample was not signi fi cant Participants experienced reduced symptoms of until follow-up (9 months), which is a departure PTSD and panic attacks and experienced improve- from other research. However, severity of ment in functioning in work, marriage, and gen- comorbid diagnoses did decrease from pre- to eral functioning. Reductions were maintained at posttreatment. 3- and 6-month follow-ups. Treatment gains have been shown to extend past the 6-month follow-up as well (Falsetti, Resnick, & Davis, 2008 ) . Speci fi c Therapies A second specifi c therapy has been developed for individuals with GAD and comorbid panic In contrast to transdiagnostic therapies, there are disorder with agoraphobia (PDA; Labrecque, two therapies that have been designed to treat Dugas, Marchand, & Letarte, 2006 ) . This treat- specifi c clusters of anxiety disorders. For exam- ment method is based on the notion that available ple, multichannel exposure therapy (MCET) was cognitive-behavioral therapies of the individual developed to treat posttraumatic stress disorder disorders shared common components that could (PTSD) and comorbid panic attacks (Falsetti, be used in treating both disorders together. Resink, & Davis, 2005 ) . This treatment combines Labrecque et al. ( 2006 ) combined features from aspects of cognitive processing therapy (Resick other available treatments for panic (Craske & & Schnicke, 1993) and panic control treatment Barlow, 1993 ; Marchand & Letarte, 1993 ) and (Barlow & Craske, 1994 ) . Treatment in MCET GAD (Dugas & Ladouceur, 2000 ; Ladouceur targets symptoms of both PTSD and panic attacks et al., 2000 ) . One major tenant of combining the through physiological, cognitive, and behavioral treatments is to help individuals tolerate the uncer- channels. Initially, participants in MCET are tainty/discomfort that accompanies both GAD introduced to the idea that panic attacks and and PDA. Treatment components include provid- symptoms are conditioned responses to condi- ing psychoeducation to participants about anxiety tioned stimuli related to the initial unconditioned and specifi c diagnoses, information regarding trauma. Following from this explanation, treatment symptoms and maintenance of panic, breathing 314 C.W. Lack et al. retraining, cognitive restructuring, confronting Her symptoms began interfering with academic, beliefs, interoceptive and in vivo exposures, expo- social, and family functioning at this time. sure to worries, training in problem orientation, Speci fi cally, teachers noticed that assignments and relapse prevention. Results of preliminary were completed only after long delays and that studies have demonstrated a reduction in symp- she was not spending time with peers during free tom presentation of both GAD and PDA at post- periods. At home, Leah spent considerable treatment and follow-up (Labrecque et al., 2006 ; amounts of time organizing and straightening her Labrecque, Marchand, Dugas, & Letarte, 2007 ) . room. For example, each time she needed to put clean laundry away, she would refold all clothes in the same container/drawer. Case Study In terms of panic symptoms, Leah began having panic attacks (PA) once per month after her 15th Leah (a pseudonym) was a 16-year-old Caucasian birthday. She experienced her fi rst PA at home female referred by her psychiatrist for evaluation while relaxing. This attack lasted approximately and treatment of obsessive-compulsive disorder, 15 min and involved increased heart rate, sweat- panic disorder without agoraphobia, and major ing, shaking, nausea, and derealization. In response depressive episode, recurrent. Speci fi c symptoms to the PA, Leah became concerned with having of both anxiety disorders are listed below. Leah another panic attack and worried that she was received her initial diagnoses from her psychia- “going crazy.” Hence, she limited social interac- trist according to the DSM-IV-TR ( APA, 1994 ) at tions due to these concerns. Leah also experienced the age of 14 years. Leah was referred for treat- symptoms of MDD, likely as a result of OCD and ment due to increased anxiety in numerous situa- PD. Specifi cally, Leah reported feeling depressed tions, ritualistic behaviors (i.e., excessive cleaning mood and anhedonia. These mood disturbances and organizing), and impairment in social and appeared to result from her combination of OCD academic functioning. Based on her symptoms, and PD, speci fi cally her functional impairment impairment, and results of clinical evaluation, (e.g., lack of social interactions and limited range Leah was given the above diagnoses. Leah was of pleasurable activities). She was sleeping more otherwise typically developing aside from hypo- than 11 h per night, felt lethargic, and reported thyroidism which was managed by a pediatric extreme indecisiveness. This was differentiated endocrinologist and stable at treatment entry. She from indecisiveness related to anxiety by the was in a regular classroom and during periods of nature of content (i.e., minor decisions rather than lower anxiety was performing above average aca- related to organizing or just right phenomena). demically and had several friends.

Treatment Assessment of Anxiety Symptoms Leah presented for 14 sessions of CBT with expo- Leah began exhibiting a signi fi cant number of sure and response prevention. Therapy was based ritualistic and avoidant behaviors around the age on the model proposed by March and Mulle ( 1998 ) of 14 years. Speci fi cally, these included contami- and validated in several studies (e.g., POTS, 2004 ; nation concerns, avoidance of contaminated items Storch et al., 2007 ) . Treatment was conceptualized (e.g., public areas), excessive cleaning/washing as a transdiagnostic approach and included addi- (i.e., items in the home such as books as well as tional sessions in which physiological symptoms her person), concerns about organization, exces- of panic were targeted using CBT principles. sive list making, and other just right phenomena Sessions one and two focused on an introduc- (i.e., evening things out, repeating tasks until they tion to therapy, psychoeducation, and fear hierar- felt just right). Leah reported feeling increasingly chy construction. Leah was asked to begin anxious when prevented from engaging in rituals. monitoring her thoughts between sessions and 19 Comorbid Anxiety Disorders 315 recording them using a thought record. Leah between fl oors until her heart rate was elevated at completed this easily and brought back a least three times during a shopping trip and signi fi cant number of thought records between remain at mall for a minimum of 30 min follow- sessions. Hierarchy items included contamination ing exposure or until habituation occurs. We also related items (e.g., showering and cleaning exces- continued to review cognitive strategies at the sively) and numerous organization/just right phe- end of each session. nomena (e.g., list making, reorganizing bedroom Relapse prevention and preparation for ter- and clothes). Leah’s fi nal hierarchy consisted of mination were covered in session 12. 25 items, the majority of which were related to Psychoeducation was provided regarding possi- avoidance and organizing. Initial cognitive work ble triggers for Leah’s symptoms to return, for was begun in the second session; this involved example, increased stress or less attention paid having Leah begin to differentiate between “typi- to returning symptoms. The importance of con- cal” and “OCD” worries and concerns. tinued exposure and cognitive work at home Sessions three through eight primarily con- was reinforced. Leah was asked to prepare any sisted of exposure and response prevention work. questions to be discussed with the therapist in As an example of an exposure, Leah was required the fi nal session. Session 14 was conducted 3 to “disorganize” her wallet, backpack, or com- weeks after session 13 to allow Leah to have puter fi les while in session. Exposures were con- additional time to work on symptoms at home. tinued until habituation to the feared stimuli was In the fi nal session, termination was discussed achieved and her anxiety was greatly decreased. and relapse prevention reviewed. Leah initially resisted some of the exposures, stating that they were not relevant to her treatment. However, over the course of treatment, Assessment Leah began to acknowledge that habituation in session and during homework was generalizing Leah completed the Children’s Yale-Brown to more naturalistic, real-world situations and, Obsessive Compulsive Scale (CY-BOCS; thus, was valuable. Exposures were conducted Scahill et al., 1997 ) at pre- and posttreatment during each session with increasing dif fi culty. (session 13). At pretreatment, Leah received a Due to Leah’s PA symptoms, particular attention severity rating of 20, indicating moderately severe was given to the physiological symptoms of anx- OCD symptoms. At the fi nal session, Leah’s iety during exposures. Other tasks during this CY-BOCS score had reduced to 3, which is well portion of treatment involved reviewing home- within normal limits. Although Leah has not work from between sessions, which typically returned for a follow-up assessment, per her psy- included additional exposures in the home as chiatrist she continues to maintain posttreatment well as continued cognitive work. Leah also levels of anxiety. Prior to treatment, Leah was reviewed and practiced coping statements and experiencing monthly PA with worry about hav- cognitive restructuring in session. ing one on a daily basis. After the fi rst month of Sessions 9–12 focused on continued exposure treatment, during which time Leah had one PA, with the introduction of interoceptive exposures Leah did not experience any further PAs. Worry for panic symptoms. As Leah had been primed to about her attacks decreased over the course of attend to physical symptoms in earlier exposures treatment, so that at her 14th appointment Leah and to actively use coping statements, she was reported only minimal worry (1 out of 10) and receptive to this type of exposure. Leah was noted that this only occurred occasionally. assigned additional interoceptive exposures in Although there was no speci fi c measure of MDD places and at times which were related to her PA symptoms, anecdotally, Leah reported increased (e.g., at school, the mall). For example, one engagement in activities with friends, improved homework assignment was to go to a shopping mood, decreased sleep, and she obtained a job at center in the area and walk up and down the steps a coffee shop which she enjoyed. 316 C.W. Lack et al.

both disorders simultaneously are superior to Future Directions those treating disorders separately in discrete sessions (Reinecke & Hoyer, 2010 ) . Although much has been learned over the last 20 A thorough understanding of the mechanisms years regarding comorbidity in anxiety disorders, that facilitate improvement of comorbid disorders many questions are still unanswered. Currently, may assist in determining whether diagnosis- the most pressing need for research concerns speci fi c or combined treatments are more effec- fi nding the most effective and effi cient treatment. tive. The answer may depend on the type and As mentioned above, many studies investigating relatedness of the comorbid disorders (Reinecke the treatment of anxiety disorders use participants & Hoyer, 2010 ) or the components within the without comorbid or complex presentations, treatment (Labrecque et al., 2007 ) . Approaches undermining the ability of the results to general- that emphasize commonalities across disorders ized to the majority of clients (Goldenberg et al., signifi cantly reduce comorbid disorders (McEnvoy 1996) . Evidence suggesting that frequency and et al., 2009 ) . For example, Labrecque et al. (2007 ) severity of comorbidity does not predict CBT found that treatments that identi fi ed intolerance of treatment outcome (Davis et al., 2010 ; Storch bodily sensations for PDA and intolerance of et al., 2010 ) implies that exclusion criteria for uncertainty for GAD as vulnerability factors were CBT research studies no longer need to include preferred by participants. The authors suggest comorbid anxiety disorders. treatment models that address intolerance may be Future research needs to establish whether effective regardless of which disorder is the main focusing treatment on the primary diagnosis is diagnosis. Another study found that the more per- superior to combining treatments for primary and ceived control participants reported on a post- comorbid diagnoses into one treatment (Labrecque treatment anxiety control questionnaire, the et al., 2007 ) . Studies have found treatments focus- greater the decrease in comorbidity (Craske et al., ing on the primary diagnosis not only effectively 2007) . It is also possible, however, that decreases treat the primary diagnosis but also signi fi cantly in comorbid disorders occur because clients apply decrease the frequency and severity of comorbid techniques learned in treatment to their comorbid disorders (Newman et al., 2010 ; Ollendick et al., disorders (McEnvoy et al., 2009 ) . Given that 2010 ) . There is, however, evidence that combining effective treatments for various anxiety disorders treatments for both the primary and comorbid tend to share common features (e.g., exposure diagnosis is effective (Labrecque et al., 2007 ) , with response prevention, cognitive restructuring, which has led to the development of transdiagnos- relaxation training), this seems likely. tic treatments (such as those as reviewed above) The optimal intensity of treatment also remains that emphasize commonalities across disorders to unclear, as one study reduced the clinical severity treat the primary and comorbid diagnoses concur- of comorbid anxiety disorders, which are typi- rently (McEnvoy, Nathan, & Norton, 2009 ) . Future cally treated with 12–16 sessions of CBT, using research should directly compare diagnosis- only one 3-h session to treat youth with speci fi c speci fi c (e.g., MCET) and transdiagnostic treat- phobias (Ollendick et al., 2010 ) . It is unknown if ments to determine each method’s effect on other intensive treatments (e.g., multiple times outcome variables such as diagnosis-speci fi c weekly, extended therapy sessions) for different symptoms, higher-order and common factors (e.g., primary disorders would have the same impact. negative affectivity, locus of control, emotion reg- Future research also needs to identify the mecha- ulation), nonspeci fi c factors (e.g., therapeutic alli- nisms leading to optimal outcomes and ascertain ance, group cohesion), treatment compliance and if the same effects occur for these disorders when attrition, and duration of treatment effects and they are more severe or when they are the pri- remission rates on primary and comorbid diagnoses mary disorder rather than the comorbid one. (Storch et al., 2010 ) . 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Heather L. Smith-Schrandt , Casey D. Calhoun , Marissa A. Feldman , and Eric A. Storch

Most clinicians and researchers agree that child Rocher Schudlich & Cummings, 2003 ) and adjustment be viewed through a contextual lens, family dysfunction predicts anxiety treatment with the family environment being the fi rst, and outcomes (e.g., Crawford & Manassis, 2001 ) . potentially most formative, backdrop affecting Yet, family confl ict is often neglected in theoreti- children. Heriditability estimates suggest familial cal formulations of anxiety development, and aggregation of anxiety (for review, see Hettema, family confl ict studies too infrequently consider Neale, & Kendler, 2001 ) , but genetic contribu- anxiety apart from depression. As no review tions are not large enough to account for all has singularly focused on family confl ict and variability, suggesting family environment also pediatric anxiety, the chapter synthesizes the two be considered (Murray, Creswell, & Cooper, literatures in hopes of inspiring increased attention 2009 ) . Anxious children are more likely than less to family con fl ict and its implications for pediat- anxious peers to have a dysfunctional family ric anxiety. (Pagini, Japel, Vaillancourt, Côté, & Tremblay, Parenting practices, particularly psychologi- 2009 ) , and family factors such as cohesion, adapt- cal control and intrusiveness, are implicated in ability, parenting, stress and social support, and anxiety development and maintenance (McLeod, marital quality have been associated with various Wood, & Avny, 2011 ) . Some recent reviews of pediatric anxiety disorders (Côté et al., 2009 ; family matters in pediatric anxiety suggest that Lange et al., 2005; Peleg-Popko & Dar, 2001, other aspects of family life, including family 2003 ) . Moreover, family con fl ict and dysfunction confl ict, are also relevant (Bögels & Brechman- may partially account for interfamilial transmission Toussaint, 2006; Bögels & Phares, 2008 ; of anxiety (e.g., Drake & Kearney, 2008 ; Du Chorpita & Barlow, 1998 ; Elizabeth et al., 2006 ; Hughes & Gullone, 2008 ; Murray et al., 2009 ; Weich, Patterson, Shaw, & Stewart-Brown, 2009) . For example, family chaos at age four This chapter bene fi ted from the clinical involvement and predicts anxiety in middle childhood (Asbury, expertise of Maria dePerczel Goodwin, Department of Dunn, & Plomin, 2006 ) . Con fl ict within families Psychology, University of South Florida. is ubiquitous, normative, unavoidable, and when H. L. Smith-Schrandt (*) ¥ M. A. Feldman ¥ E. A. Storch infrequent and effectively resolved, typically is Department of Psychology , University of South Florida , not harmful (Adams & Laursen, 2007 ; 4202 E. Fowler Avenue , PCD4118G , Tampa , Montemayor, 1983 ) . However, frequent, intense, FL 33620 , USA e-mail: [email protected] and poorly resolved con fl ict can be detrimental for families and children (see Fincham & C. D. Calhoun Department of Psychology , University of North Carolina , Osborne, 1993 ) . Given that families are complex Chapel Hill , NC 27599 , USA and transactional (Eichelsheim, Deković, Buist,

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 321 DOI 10.1007/978-1-4614-6458-7_20, © Springer Science+Business Media New York 2013 322 H.L. Smith-Schrandt et al.

& Cook, 2009 ) , con fl ict can pervade families (see Table 20.1 ), they do not provide information such that dysfunction and chaos spreads through- regarding the nature or direction of the relation- out. Thus, while we examine dyadic con fl ict ship. Interparental con fl ict may serve to produce, separately, namely, interparental confl ict, par- maintain, or exacerbate anxious impairment in entÐchild confl ict, and the role of siblings, we children. Longitudinal evidence suggests that the highlight reciprocal effects and potential mecha- marital relationship, and IPC in particular, can nisms of infl uence, including the interrelation- lead to later internalizing symptoms (e.g., ship between interparental con fl ict and Cummings, Schermerhorn, Davies, Goeke- parentÐchild con fl ict. Following a brief consid- Morey, & Cummings, 2006 ; Harold, Shelton, eration of family con fl ict beyond adolescence, Goeke-Morey, & Cummings, 2004 ; Nomura, we conclude with recommendations for the next Wickramaratne, Warner, Mufson, & Weissman, generation of research, discussion of treatment 2002) . For example, IPC has been found to pre- considerations, and an illustrative case study. dict internalizing symptoms 5 years later (Gerard, Krishnakumar, & Buehler, 2006 ) . Speci fi cally considering anxiety, a distressed marital relation- Interparental Confl ict ship has been associated with adolescent-reported anxiety 8 years later, even after controlling for Various conceptualizations and examinations of maternal psychopathology (Spence, Najman, interparental confl ict (IPC) exist, ranging from Bor, O’Callaghan, & Williams, 2002 ) . domestic violence to everyday squabbles between In a prospective study, family discord (family couples. Although IPC is associated with a wide cohesion, divorce, marital, and parentÐchild range of adjustment dif fi culties, including but not relationships) was associated with the child limited to internalizing symptoms, results from developing an anxiety disorder within 10 years meta-analyses suggest that not all children who (Nomura et al., 2002 ) . Results demonstrated a witness IPC are negatively impacted (see fourfold increase in anxiety disorders when fam- Table 20.1 for summary of meta-analyses). ily discord was present in families without However, witnessing domestic violence, an parental depression. This study may be the stron- extreme form of IPC, is associated with pediatric gest evidence that the family factors and marital anxiety and posttraumatic stress symptoms (for relationship are related to clinical anxiety. reviews, see Guille, 2004 ; Margolin & Gordis, However, the study did not examine IPC 2000 ) . A recent meta-analysis suggests a moder- speci fi cally or potential associations between ate effect between family violence and internal- family discord and parental depression. Hence, izing symptoms and a slightly stronger association family con fl ict may mediate the relationship with posttraumatic stress symptoms (Chan & between parental psychopathology and internal- Yeung, 2009 ) . Moreover, an earlier meta-analysis izing symptoms. In support of this possibility, found children exposed to interparental violence Drake and Kearney ( 2008 ) found that family experience levels of internalizing symptoms sim- environment and con fl ict mediated the relation- ilar to physically abused children (Kitzmann, ship between parent and child anxiety sensitiv- Gaylord, Holt, & Kenny, 2003 ) . Meta-analytic ity. Similarly, a depressive con fl ict style observed results specifi c to IPC indicate a small-to-moderate during a martial con fl ict problem-solving task relationship between marital con fl ict and inter- mediated parent’s depressive symptoms and nalizing symptoms and a slighter strong relation- child’s internalizing symptoms (Du Rocher ship with externalizing disorders (Beuhler et al., Schudlich & Cummings, 2003 ) . 1997 ) . As anxious and depressive symptomology While meta-analysis specifi c to child anxiety regularly co-occur, meta-analysis of these effects is pending, longitudinal data suggest a directional speci fi c to anxiety has yet to be conducted. link from the marital relationship and IPC to child While meta-analyses suggest a moderate asso- internalizing symptoms. While most studies ciation between IPC and internalizing symptoms examine anxiety and depressive symptoms 20 Family Confl ict and Anxiety 323

Table 20.1 Summary of family con fl ict meta-analyses Citation Family con fl ict Outcome Effect size (r ) Beuhler et al. (1997 ) IPC Internalizing symptoms 0.15 Externalizing symptoms 0.19 Chan and Yeung (2009 ) Family violence (IPC and child abuse) Internalizing symptoms 0.22 Posttraumatic stress 0.35 symptoms Erel and Burman (1995 ) IPC Parenting behaviors 0.22 Kitzmann et al. (2003 ) Interparental violence Internalizing symptoms 0.17 Posttraumatic stress 0.25 symptoms Krishnakumar and Beuhler IPC Parenting behaviors 0.30 ( 2000 ) Rhoades (2008 ) Affective reaction to IPC Internalizing symptoms 0.31 Cognitive reaction to IPC 0.34 Self blame 0.36 Percieved threat 0.40 Physiological reaction to IPC 0.14 Behavioral reaction to IPC 0.24 Child involvement in con fl ict 0.29 Avoidance 0.26 Affective reaction to IPC Externalizing symptoms 0.15 Cognitive reaction to IPC 0.21 Self blame 0.28 Perceived threat 0.21 Physiological reaction to IPC 0.11 Behavioral reaction to IPC 0.14 Child involvement in con fl ict 0.15 Avoidance 0.04 Note . Some effect sizes were converted from Cohen’s d to r for ease of comparison IPC interparental con fl ict

conjointly, some do report signi fi cant associa- Interparental Confl ict and Child tions between IPC and anxiety speci fi cally (e.g., Anxiety: Process-Level Research El-Sheikh & Elmore-Staton, 2004 ; Dewit et al., 2005 ; Kerig, 1998 ) . Yet, anxiety and depression Children are not merely passive receivers of their may be diffi cult to disentangle as they frequently environment, so it is important to consider how co-occur, with 25Ð50 % of depressed youth also children’s processing of con fl ict is associated having an anxiety disorder (Axelson & Birmaher, with internalizing symptoms. A recent meta- 2001 ) . As such, incremental effects speci fi c to analysis (Rhoades, 2008 ) found moderate asso- anxiety may be dif fi cult to detect, especially if ciations between children’s internalizing both anxiety and depression are related to family symptoms and their affective, cognitive, behav- confl ict. While the fi eld may still be short of a ioral, and physiological reactions to IPC (see defi nitive link between IPC and child anxiety, Table 20.1 ). Cognitive, affective, and behavioral, process-level research provides a more specifi ed but not physiological, reactions had greater asso- and nuanced understanding. ciations with internalizing than externalizing 324 H.L. Smith-Schrandt et al. problems. Regarding internalizing symptoms, the could exacerbate anxious symptoms. Second, effect sizes were larger for cognitive and affec- repeated exposure to IPC may sensitize a child such tive, compared to behavioral and physiological, that emotional responses, and felt insecurity, are reactions. Thus, children’s reactions to IPC likely heightened (Davies & Cummings, 1994 ) . Similarly, determine whether internalizing symptoms posttraumatic stress disorder includes heightened develop. Viewed differently, children with inter- sensitivity to trauma-related cues and diminished nalizing symptoms may be more likely to experi- regulation ability (Meiser-Stedman, 2002 ) , and ence maladaptive reactions to IPC. We group our emotional security has been found to mediate the discussion of mechanisms into three broad cate- relationship between IPC and posttraumatic stress gories: (1) emotional processes and physiological symptoms (El-Sheikh et al., 2008 ) . reactions, (2) cognitive processes and behavioral reactions, and (3) family processes and parent- Cognitive processes and behavioral reactions to ing. One additional mechanism, the interplay of con fl ict. The cognitive-contextual framework rec- interparental and parentÐchild con fl ict, will be ognizes the role of emotion but suggests that chil- discussed in the later section focusing on parentÐ dren’s cognitive appraisals of con fl ict are more child con fl ict. proximally responsible for child adjustment (Grych & Fincham, 1994 ) . The theory postulates Emotional processes and physiological reactions . that threat perceptions, coupled with low coping The emotional security hypothesis (Davies & ef fi cacy, are related to anxiety and feelings of Cummings, 1994 ; see also the speci fi c emotions helplessness, while self-blame is associated with model Crockenberg & Langrock, 2001 ) posits guilt, shame, and sadness. Several studies have that negative emotional reactions to IPC over implicated appraisals of self-blame and perceived time result in a more chronic state of emotional threat in the relationship between IPC and inter- insecurity. Emotional security refers to a child’s nalizing symptoms (e.g., El-Sheikh & Harger, “felt security,” or perception of safety, with 2001 ; Gerard, Buehler, Franck, & Anderson, respect to their family. Both concurrent and lon- 2005) , affective well-being (e.g., Xin, Chi, & Yu, gitudinal support has been provided for the emo- 2009 ) , and anxiety speci fi cally (e.g., Kerig, 1998 ) . tional security hypothesis as an explanatory Meta-analysis reveals internalizing symptoms are mechanism for the development of internalizing moderately associated with self-blame and per- symptoms in the context of IPC (e.g., Cummings ceived threat (Rhoades, 2008 ; see Table 20.1 ). A et al., 2006 ; El-Sheikh, Cummings, Kouros, relationship between internalizing symptoms and Elmore-Staton, & Buckhalt, 2008 ; Harold et al., children’s cognitive processing of IPC seems clear, 2004 ; Shelton & Harold, 2007 ) . but less is known about how self-blame and threat The emotional security hypothesis suggests perceptions are linked to anxiety speci fi cally. implications for understanding child anxiety. First, Similar to the cognitive-contextual model of anxiety may result from witnessing IPC if children IPC, cognitive models of anxiety development are less able to manage their emotional and physio- posit that prolonged, repeated, and early exposure logical reactions (Davies & Cummings, 1994) . The to events perceived as uncontrollable leads to a ability to regulate physiological arousal, as indi- diminished sense of control (e.g., “uncertain help- cated by vagal tone, has buffered children exposed lessness”) resulting in a consistent affective state to IPC from developing internalizing symptoms of anxious arousal (Chorpita & Barlow, 1998 ) . (El-Sheikh, Harger, & Whitson, 2001) . Moreover, Interparental confl ict could certainly represent an physiological reactivity is a stable trait of anxiety early, and likely repeated and prolonged, negative (Olatunji & Cole, 2009) , and anxious children expe- life event that could be perceived as uncontrolla- rience and express heightened negative emotions in ble, and thus lead to anxiety. Pediatric anxiety is response to negative events (e.g., Suveg et al., 2008 ) . associated lower coping ef fi cacy and cognitive Thus, anxious children will likely have dif fi culty bias to interpret ambiguous, and even benign, situ- regulating physiological reactions to IPC, which ations as threatening (e.g., Bögels & Zigterman, 20 Family Confl ict and Anxiety 325

2000; Creswell & O’Connor, 2006 ; Kortlander, Some children try to distract parents in confl ict Kendall, & Panichelli-Mindel, 1997 ; Lester, Seal, by diverting the attention onto themselves. Meta- Nightingale, & Field, 2010 ) . It follows that anx- analysis reveals a moderate effect between chil- ious children will be especially likely to interpret dren’s involvement in confl ict and internalizing threat to less ambiguous events, such as IPC, that symptoms (Rhoades, 2008; see Table 20.1 ). could pose an imagined or real threat to their well- While acting out is perhaps more characteristic being (e.g., separation from parent, divorce, or of externalizing disorders, its use in the context change in schools), since anxious children display of IPC has been associated with increases in hypervigilant attention to external threat cues (e.g., later internalizing symptoms (Schermerhorn, Schultz & Heimberg, 2008 ; Meiser-Stedman, Cummings, & Davies, 2005 ) . While anxious 2002 ) . Children, more so if anxious, may look to children may not regularly display these behav- their parents to determine whether an IPC poses a iors, children that do employ behavioral dysregu- threat (e.g., Creswell & O’Connor, 2006 ; Lester lation in the context of IPC develop internalizing et al., 2010 ) . Anxious parents, and parents of anx- symptoms. It is possible, but not yet considered, ious children, may be more likely to inadvertently that anxious children attempt other distraction display threat cues or overtly convey threat infor- strategies (e.g., rituals, somatic complaints). mation (e.g., Murray et al., 2009 ) . Thus, IPC could Conversely, anxious children may be more likely contribute to anxiety development if the child to withdraw and anxiously ruminate on the poten- interprets the event as uncontrollable and threaten- tial threat the argument poses for the family unit ing. Moreover, anxious children are especially (Riskind, 2005 ) . Meta-analysis reveals a moder- likely to perceive IPC as threatening. ate association between avoidance and internal- While appraisals of self-blame are thought to izing symptoms (Rhoades, 2008 ; see Table 20.1 ). be more related to depression than anxiety, they While both avoidance and involvement are asso- remain signifi cantly correlated with anxiety, ciated with internalizing symptoms, more specifi c albeit to a lesser degree, when depressive symp- research is needed to determine the frequency or toms are controlled (Matheson & Anisman, 2003 ) impact of these strategies for anxious children. and general self-blaming tendencies have been associated with adult anxiety (e.g., Kelly, Tyrka, Family processes and parenting. Interparental Price, & Carpenter, 2008 ) . Children are more confl ict is embedded in a larger family context so likely to self-blame when IPC is child-centered that other family factors infl uence the impact of (Grych & Fincham, 1994 ) , and child-centered IPC. Early researchers supposed that parental sep- confl ict has been tied to internalizing symptoms aration and divorce would result in internalizing (e.g., Gordis, Margolin, & John, 2001 ) and anxi- diffi culties. Yet, fi ndings suggest that the effects ety specifi cally (Snyder, Klein, Gdowski, of divorce are largely a by-product of IPC (for Faulstich, & LaCombe, 1988 ) . Parenting an anx- review, see Amato & Keith, 1991 ) . For example, ious child can be stressful for families (Kalra, family con fl ict (combined couple, parentÐchild, Kamath, Trivedi, & Janca, 2008 ; Lange et al., and sibling) predicts anxiety symptoms 1 year 2005 ; Storch et al., 2009 ) , and this stress could later, but divorce does not (Noller, Feeney, potentially result in increased family confl ict. For Sheehan, Darlington, & Rogers, 2008 ) . The rela- example, parents’ stress over accommodating tionship between family confl ict and child anxiety obsessive-compulsive symptoms and child dis- is likely multifaceted and family factors, such as tress over refusal to accommodate are associated parental psychopathology, attachment, family with increased family confl ict (Peris et al., 2008 ) . cohesion, and relationship quality, are supported Thus, the presence of an anxious child in a family as process-level mediators (e.g., El-Sheikh & may contribute to increased stress and child- Elmore-Staton, 2004 ; Owen, Thompson, Shaffer, related con fl ict, which could in turn exacerbate Jackson, & Kaslow, 2009 ) . Illustrative of the inter- child anxiety, especially if the child blames play of multiple family factors, Shelton and themselves. Harold ( 2008) found that parent depressive 326 H.L. Smith-Schrandt et al. symptoms increased IPC, which was associated predicted children’s fear reactions, and children’s with the child perceiving rejection by their parent distress was then associated with child internal- and development of internalizing symptoms. izing symptoms (Cummings, Goeke-Morey, & While multiple family factors likely infl uence the Papp, 2003; Davies, Sturge-Apple, Winter, impact of IPC, we focus on parenting, social Cummings, & Farrell, 2006 ) . If parents use learning, and dysfunctional family roles or alli- avoidant or withdrawn strategies to cope with ances, namely, parentifi cation and triangulation. confl ict in their marriage, children may model these strategies and generalize their use to other Parenting and spillover effects. By far, the family situations, particularly if a parent’s avoidance of factor that has received the most attention regard- confl ict results in de-escalation (Bussell et al., ing IPC and internalizing symptoms is parenting. 1999 ; Crockenberg & Langrock, 2001 ) . In fact, The “spillover” hypothesis suggests that disagree- adolescents’ con fl ict resolution style with sib- ment between parents may result in dysfunction in lings is predicted by methods employed by their the parentÐchild relationship, which is the proxi- parents during IPC, and modeling of parent’s mal force related to child adjustment (see Erel & avoidance is associated with internalizing symp- Burman, 1995 ) . Interparental con fl ict may be toms (Dadds, Atkinson, Turner, Blums, & emotionally draining and result in diminished abil- Lendrich, 1999 ) . ity or desire to engage with and parent children. Parent’s interpretations of, and comments dur- For example, maternal emotional reactivity (as ing, IPC represent information transfer and could measured by cortisol) to IPC is subsequently increase a child’s threat perception and anxious related to suboptimal parenting (Sturge-Apple, reactions. For instance, parents’ explanations Davies, Cicchetti, & Cummings, 2009 ) . Meta- absolving the child of blame may reduce fear, analysis (Erel & Burman, 1995 ; Krishnakumar & whereas explanations implicating the child may Buehler, 2000 ) provides support for the “spillover” result in more distress (see Fincham & Osborne, hypothesis, fi nding a moderate association between 1993 ) . Parents of anxious children, regardless of IPC and parenting practices (see Table 20.1 ). parental anxiety levels, make more catastrophiz- Several studies fi nd parenting “spillover” effects ing comments and engage in less explanatory dis- from IPC to internalizing symptoms (e.g., cussion of emotion during conversational tasks El-Sheikh & Elmore-Staton, 2004 ; Kaczynski, with their children (Moore, Whaley, & Sigman, Lindahl, Malik, & Laurenceau, 2006 ) . In fact, par- 2004 ; Suveg et al., 2008 ; Whaley, Pinto, & enting practices important to anxiety development, Sigman, 1999 ) and may also do so during dis- namely, psychological control and intrusiveness, agreements with their spouse. Moreover, anxious mediate the relationship between IPC and internal- children may be especially tuned into their par- izing symptoms (e.g., Benson, Buehler, & Gerard, ent’s interpretations of events (e.g., Creswell & 2008 ; Buehler, Benson, & Gerard, 2006 ) . Maritally O’Connor, 2006 ; Lester et al., 2010 ) and may distressed fathers, more than their female partners, integrate their parents’ interpretation into their may withdraw from children and parenting respon- own understanding of the situation, in turn creat- sibilities, which is unfortunate as fathers seem to ing or perpetuating a fearful or anxious pattern of play a specialized role in pediatric anxiety by facil- responding. itating child autonomy (for a review, see Bögels & Phares, 2008 ) . Parenti fi cation and triangulation . The “compensatory” hypothesis, an alternative to the “spill- Social learning. In addition to indirect effects over” theory, posits that parents may become through parenting, social learning, modeling, and over-involved and particularly invested in the information transfer can occur. Regarding model- parentÐchild relationship due to their dissatisfac- ing, the type of con fl ict resolution employed by tion with their marriage (Erel & Burman, 1995 ) . parents might infl uence whether anxiety is expe- While the compensatory hypothesis may not be rienced. For example, parents’ use of withdrawn, pertinent for most families, it may hold relevance or avoidant, strategies reported by daily diary for a subset of more dysfunctional families or 20 Family Confl ict and Anxiety 327 families characterized by anxious parenting control during the teen years. If anxious adolescents practices (e.g., intrusiveness). For example, inter- resist overcontrolling parents, they might experi- nalizing symptoms have been related to feeling ence higher levels of parentÐadolescent con fl ict. closer with one parent than the other (Grych, However, anxious hesitation and doubting may Raynor, & Fosco, 2004 ) . Two dysfunctional pat- debilitate anxious adolescents, such that they are terns of parentÐchild relations, parentifi cation less likely or unable to seek typical levels of and triangulation, may be considered compensa- autonomy. While anxious adolescents may or tory processes relevant to pediatric anxiety. may not combat parental overcontrol, efforts Parentifi cation , de fi ned as a child’s felt responsi- aimed at independence are likely benefi cial and bility to provide emotional support to their par- could reduce anxiety, as increased autonomy ent, has been linked to IPC and increased threat seeking and independent decision-making over perceptions, as well as anxiety and overdepen- time improve emotional functioning (Qin, dence, but mediation has not been tested Pomerantz & Wang, 2009 ) . (Mayseless & Scharf, 2009 ; Peris, Goeke-Morey, Evidence, albeit limited, suggests that parentÐ Cummings, & Emery, 2008 ) . Triangulation refers child confl ict is related to, exacerbates, and has to involving the child in IPC by forming a coali- implications for the pathogenesis of child anxiety tion with the child against the other parent. (e.g., Caples & Barrera, 2006 ; Krishnakumar, Triangulation has been found to mediate the Buehler, & Barber, 2003 ) . Supporting this con- impact of IPC on internalizing symptoms through nection, treatment reduction in child anxiety, children’s self-blame, threat perception, and cop- whether or not con fl ict is speci fi cally addressed, ing ef fi cacy (Grych et al., 2004 ) . However, one is associated with reduced parentÐchild con fl ict study found that triangulation was associated (Silverman, Kurtines, Jaccard, & Pina, 2009 ) . with a negative parentÐchild relationship and Perhaps the most de fi nitive evidence comes from child maladjustment, but not internalizing symp- a prospective longitudinal study using growth toms (Kerig, 1995 ) . While parenti fi cation and curve modeling to test a diathesis-stress model. triangulation are less studied, future examination In this study, Rueter, Scaramella, Wallace, & of compensatory processes linked to IPC in clini- Conger ( 1999) found that over time parentÐado- cally anxious families may yield interesting lescent disagreements exacerbated anxiety symp- fi ndings. toms and ultimately triggered the onset of an anxiety disorder. However, another longitudinal study found that parentÐadolescent con fl ict was Parent–Child Confl ict associated with life dissatisfaction, but not anxiety, in young adulthood (Overbeek, Stattin, Somewhat surprisingly, relatively few studies Vermulst, Ha, & Engels, 2007 ) . Thus, con fl ict have examined whether anxious children experi- with parents may exacerbate anxiety in predis- ence more or less con fl ict with their parents composed adolescents, but not necessarily lead to pared to their non-anxious peers. ParentÐchild increased anxiety for all adolescents. This high- con fl ict is thought to naturally increase during lights the importance of process-level research. adolescence in response to adolescent autonomy seeking, especially if parents are reluctant to grant independence (for a review, see Steinberg, Parent–Child Confl ict and Anxiety: 2001) . Parents’ psychological autonomy granting Process-Level Research protects against anxiety development (Gray & Steinberg, 1999 ) . In fact, the converse parenting While the literature has not advanced to examine practice, psychological control or intrusiveness, many potential mechanisms related to parentÐ is more characteristic of families of anxious ado- child con fl ict and anxiety, process-level vari- lescents (see McLeod et al., 2011 ) . It is unclear how ables would illuminate how parentÐchild con fl ict anxious adolescents respond to psychological is linked to anxiety and which children are at 328 H.L. Smith-Schrandt et al. greatest risk for developing anxiety as a result of ParentÐchild confl ict may be either a full or con fl ict with their parents. For example, rela- partial mechanism explaining the relationship tionship quality may be more predictive of between IPC and child anxiety (e.g., Gerard et al., internalizing symptoms than frequency of parentÐ 2006 ; Krishnakumar et al., 2003 ) . For example, adolescent confl ict (Adams & Laursen, 2007 ) . Chung, Flook, and Fuligni (2009 ) employed a Similar to IPC, it is likely the child’s processing diary method and found that both IPC and par- and coping are important to consider. For exam- entÐadolescent confl ict were associated with ple, parentÐadolescent con fl ict is more predic- daily increases in anxious and depressed symp- tive of externalizing symptoms unless the toms. Moreover, parentÐadolescent confl ict par- adolescent uses destructive confl ict resolution tially mediated the relationship between IPC and strategies, which are then more predictive of internalizing symptoms. Thus, IPC may be tied internalizing symptoms (Branje, van Doorn, van to anxiety directly and indirectly as a function of der Valk, & Meeus, 2009 ) . Avoidant coping confl ict between parent and adolescent. strategies leave confl icts unresolved, which may Additionally, the combination of both stressors, induce or perpetuate anxious worry (e.g., Caples interparental and parentÐadolescent confl ict, & Barrera, 2006 ; Riskind, 2005 ) . An extreme might serve to increase risk for anxiety. ParentÐ form of confl ict avoidance, namely, “exiting child confl ict accounts for additional variance in statements” (e.g., “I have told my parents I never child-report of internalizing symptoms after want to talk with them again”), has been associ- accounting for IPC (El-Sheikh & Elmore-Staton, ated with internalizing symptoms (Wijsbroek, 2004) . Similarly, the combination of IPC and par- Hale, Van Doorn, Raaijmakers, & Meeus 2010 ) . ent hostility towards the child represents a cumu- While little process-level research exists, rela- lative risk factor for boys’ internalizing symptoms tionship quality and con fl ict resolution style (Gordis et al., 2001 ) . seem important, and confl ict between parent and child is also related to IPC. Role of Siblings Interparental confl ict and parentÐchild confl ict intertwined . The parentÐchild relationship and Sibling con fl ict in the context of child anxiety has the marital relationship are interdependent. In received little attention. In one cross-sectional addition to undermined parenting ability, discord study, anxious children were found to engage in in the marriage may lead to increased parentÐ more con fl ict with their siblings than non-anxious child confl ict, especially if one parent attempts to peers (Fox, Barrett, & Shortt, 2002 ) . As a poten- form a coalition with the child against the other tial explanation, mothers of anxious children are parent (e.g., Buehler & Gerard, 2002 ; Kerig, reported to be much more involved, controlling, 1995 ; Grych et al., 2004 ) . For example, parents and protective of their anxious child, as compared are 50 % more likely to have negative interac- to their other children (Barrett, Fox, & Farrell, tions with their child the day after an IPC 2005 ; Hudson & Rapee, 2002 ) . This differential (Almeida, Wethington, & Chandler, 1999 ) . This treatment could lead the sibling to believe he or may be a result of parents feeling more irritable she is being treated unfairly due to the anxious or emotionally drained (El-Sheikh et al., 2001 ) . child’s need for attention. As a result, the sibling Parents may also not be supportive of each oth- could develop feelings of jealousy and resent- ers’ parenting decisions, and this lack of unity ment towards the anxious child, and con fl ict may and social support may lead to more parentÐchild develop between the two children. con fl ict. This may be especially true for families In a longitudinal study of the in fl uence of sib- parenting anxious children, as parents of children ling relationships, sibling con fl ict at baseline pre- with emotional and anxiety disorders report less dicted childhood anxiety 2 years later (Stocker, social support, including less support from within Burwell, & Briggs, 2002 ) . Sibling con fl ict the family (Lange et al., 2005 ) . accounted for a unique and signi fi cant proportion 20 Family Confl ict and Anxiety 329 of the variance in child anxiety, even after con- 2010) . Lastly, both anxiety and dysfunctional trolling for maternal hostility and IPC. This family processes can be “inherited” (transmitted, important preliminary fi nding suggests that sib- modeled, or replicated) from family of origin to ling confl ict could be more infl uential, than inter- the nuclear family (Dadds et al., 1999 ; Hettema parental and parentÐchild con fl ict, in predicting et al., 2001 ) resulting in a cycle of anxiety, dis- later anxiety symptoms. On the other hand, some tress, and dysfunction. In fact, approximately studies have shown that siblings can serve a posi- 60 % of men who perpetuate domestic violence tive function for children with anxiety. One study experienced familial violence in their childhood found that a supportive sibling relationship pro- (Delsol & Margolin, 2004 ) . tected a child from developing adjustment problems that may result from IPC (Jenkins & Smith, 1990 ) . Another study (Lockwood, Gaylord, Summary, Future Directions, Kitzmann, & Cohen, 2002 ) found that siblings and Implications may act as a buffer between family stress and peer rejection, which is also a major source of While the implications of family confl ict for anxiety for children and adolescents (Storch, pediatric anxiety are not yet fully known, evi- Masia-Warner, Crisp, & Klein, 2005 ) . This evidence supports the likely possibility of a bidirec- dence suggests that a child with anxiety may tional relationship between these two factors. bene fi t from having a sibling to provide social Meta-analysis and longitudinal studies support support in times of stress, perhaps after exposure an association between IPC and internalizing to interparental or parentÐchild con fl ict. symptoms, but specifi city to anxiety is less certain as most researchers combine anxiety and depression. As stress and caregiver burden seem Effects Beyond Adolescence to be more substantial when parenting an anxious child (Storch et al., 2009 ) , reciprocal effects While the focus of this chapter has been on fam- related to child-centered con fl ict may be present. ily confl ict and childhood, this is not meant to Increased attention should be given to social suggest family confl ict only relates to children’s learning models, including parents’ modeling of anxiety. As previously discussed, parenting an avoidant coping and information transfer during anxious child can lead to confl ict within the cou- confl ict. ParentÐchild and sibling confl ict have ple relationship. There is a vast literature, beyond received less empirical attention, but connections the scope of this chapter, on the detrimental and relevance to anxiety are suggested. As such, impact of relationship con fl ict, domestic vio- the fi eld is in need of more rigorous process-level lence, and divorce on each partner’s health, mood, design and longitudinal examination of parentÐ life satisfaction, and anxiety (see Howard, child confl ict and pediatric anxiety, as well as the Trevillion, & Agnew-Davies, 2010 ; Kiecolt- role of siblings. For example, it remains to be Glaser & Newton, 2001; Robertiello, 2006 ; seen whether anxious adolescents combat, or Whisman & Uebelacker, 2006 ) . Further, family cede to, parental over control or whether specifi c con fl ict experienced as a child can have long- con fl ict tactics impact anxiety course. As the sib- lasting effects present in adulthood. For example, ling relationship can function as risk or protective women with panic disorder retrospectively report factor for child anxiety, speci fi c dyadic relation- more con fl icted family environments during ship qualities might clarify fi ndings. Finally, childhood than non-anxious adult women (Laraia, more studies with clinical samples would be Stuart, Frye, Lydiard, & Ballenger, 1994 ) . bene fi cial for understanding the distinct relation- Similarly, higher stress reactivity is seen in adult ships between family factors and individual anxi- men who experienced greater childhood confl ict, ety disorders. It is certainly possible that some and this reactivity then predicts adult onset of anxiety disorders are more infl uential for, and mood and anxiety disorders (McLaughlin et al., affected by, family confl ict than others or that 330 H.L. Smith-Schrandt et al. disorder-speci fi c family con fl ict processes exist. breathing irregularly, “freezing up,” and crying As examples, a family’s lack of accommodation when called on in class). Hector was otherwise of obsessive-compulsive symptoms may result in typically developing, successful academically, parentÐadolescent confl ict, and separation anxi- and socially adept. Hector lived at home with his ety may be perpetuated if a child fears divorce mother, father, brother (7 years), and sister (3 after overhearing parents arguing. years). According to this information obtained Regardless of causal potential, as confl ict during the assessment process, Hector met diag- occurs in all families, it is also present in many nostic criteria for generalized anxiety disorder families with anxious children. As such, it is (see American Psychiatric Association, 2000 ) . important to consider how IPC affects an anxious Considering best practice, the treating clini- child and whether it might impede treatment or cian implemented an evidence-based treatment amelioration of anxiety symptoms. There is not approach for managing symptoms of anxiety. de fi nitive evidence that including parents or sib- Using a cognitive behavioral model, and the lings in treatment of pediatric anxiety is war- “Coping Cat” manual (Kendall & Hedtke, 2006 ) ranted (see Lewin, 2011 ) . However, as illustrated as reference, Hector was taught affective educa- in the case study presented below, family inter- tion, awareness of anxious thought patterns, rec- vention may be more appropriate, or even neces- ognition/reduction of worry, and relaxation sary, when the family also presents with confl ict training. Relaxation training was coupled with a considering that family dysfunction has been biofeedback computer “game” in which “points” associated with poorer anxiety treatment out- were awarded coupled with visual stimuli (e.g., a comes (e.g., Crawford & Manassis, 2001 ; Merlo, gray and white picture of a rainbow slowly col- Lehmkuhl, Geffken, & Storch, 2009 ) . Alterna- ored in) for a relaxed demeanor (slow and steady tively, there is some evidence that amelioration of heart rate). Hector responded positively and child anxiety symptoms will reduce family quickly to treatment. After nine sessions, it was con fl ict and dysfunction (e.g., Silverman et al., determined that Hector was ready to terminate 2009 ; Storch et al., 2007 ) , due to a bidirectional therapy. This readiness was based on Hector link between child impairment and family func- experiencing remission of many anxiety symp- tioning. Thus, a primary consideration may be toms (including sleep dif fi culties and somatic determination of family’s willingness and desire complaints), as well as demonstrating compe- to concurrently address family con fl ict. tency in using coping tools to reduce anxiety, replacing catastrophic thinking with more adaptive appraisals of situations, and exposure to age- Case Study appropriate risk-taking behaviors with minimal anxiety (e.g., amusement park rides previously Hector (a pseudonym) was a bright, creative, and avoided due to fear). However, 5 months after humorous 9-year-old Latino male exhibiting termination, Hector’s parents initiated services multiple symptoms of anxiety including exces- again at Hector’s request. sive worry (e.g., concern about “ fl unking” a standardized test that he passes every year, fearing consequences of presenting an expired coupon), Anxiety Treatment in the Context catastrophic thinking (e.g., fear someone would of Interparental Con fl ict be hit by car if they walked too close to the street), perseveration (e.g., “not letting things go”), trou- Upon returning to treatment, Hector reported he ble falling asleep, and somatic complaints (e.g., was experiencing school-related “stress”. stomach aches). Hector’s mother sought evalua- Although he was reporting somatic complaints tion and treatment for her son due to school (e.g., stomachaches) and emotional distress, avoidance (e.g., frequent trips to the nurse, lower many of Hector’s anxious symptoms (e.g., sleep attendance) and emotionality at school (e.g., diffi culties) were in remission, and most coping 20 Family Confl ict and Anxiety 331 strategies (e.g., relaxation, cognitive restructur- tion and divorce, treatment took place over the ing) were retained. In fact, since leaving therapy, course of approximately 10 months (20 ses- Hector made a successful transition to a new sions) with maintenance sessions (e.g., 2Ð4 school (feared event reported during initial treat- weeks between sessions) as symptoms improved ment) without debilitating anxiety, sleep and family circumstances stabilized. Unlike tra- diffi culties, or somatic complaints. Despite these ditional family therapy, Hector remained the gains, Hector’s experience of distress was con- identi fi ed client and treatment focused on his cerning enough for him to seek treatment. At this functioning and processing of IPC. While his point in time, Hector also reported frustration siblings’ coping was assessed and discussed, with his younger brother and frequent sibling because they did not demonstrate maladaptive confl ict over minor daily events (e.g., sharing). coping or functional impairment, they were not Lastly, Hector’s parents reported marriage primary participants in treatment. Marital dis- dif fi culties, which ultimately resulted in Hector’s cord (outside of effects on children) was not parents planning a temporary separation, which directly addressed, but the treating clinician was achieved by one parent taking a job that provided a referral for couples counseling. required an extended period overseas. The par- In collaboration with the family, the follow- ent’s absence was explained to the children in ing treatment objectives were established: (1) terms of a career opportunity rather than explain- monitor Hector’s anxiety and reinforce learned ing the marriage dif fi culties. anxiety reduction techniques, (2) bolster While the domestic disputes were not known Hector’s coping skills and self-ef fi cacy beliefs, to be physical in nature, or even intense, Hector, (3) ensure communication and maintain a pos- who was hypervigilant to potential danger (as itive relationship with the parent who was anxious children tend to be), had observed paren- away, and (4) decrease sibling con fl ict and tal disagreements, less parental cohesion, and improve the sibling bond. Lastly, when a deci- occasional changes in his parents’ sleeping loca- sion for divorce was made, treatment included tions. Hector admitted fearing a potential divorce helping parents communicate this decision and and that some “stress” was related to his parents’ co-parent their children through, and after, this arguments. However, the degree to which he transition. attributed his stress to his family’s circumstances As Hector previously responded well to was minimal. Similarly, both parents were most cognitive behavioral methods, a similar comfortable not directly addressing the IPC and approach to individual sessions was taken to were uncertain how much or what information to monitor symptoms, maintain previous treat- share with their children. ment gains, and bolster anxiety reduction skills. As family confl ict, parental separation, and Because Hector underestimated his coping potential divorce complicated this case and ability and tended towards “worse case” inter- likely contributed to exacerbation in Hector’s pretations or perceptions of threat, a positive anxiety symptoms, individual therapy focused strength-based component (e.g., identifying solely on addressing child anxiety was role models, defi ning successful coping, insuffi cient. Based on evaluation of family func- exploring own strengths, parental praise of tioning (parents’ willingness and motivation to coping efforts) was included to improve coping work together for the sake of their children) and self-effi cacy and encourage positive expecta- Hector’s symptom presentation, treatment tions regarding the future. Hector also created included extensive family involvement (individ- a “coping cheat sheet” listing ways to cope ual, sibling, parent [separate and joint], and with IPC (e.g., remove self from situation, family sessions), psychoeducation regarding the journal, seek support) and then recorded nega- interplay between family confl ict and anxiety, tive events and coping attempts (and effective- and a strength-based focus on coping ability. ness of strategy selected) in daily logs. Due to the unfolding process of parental separa- Problem-solving, relationship maintenance, 332 H.L. Smith-Schrandt et al. and communication (e.g., daily feelings journal including things to share with the absent parent) References exercises were used to ensure the maintenance of a strong relationship with the absent parent. Adams, R. E., & Laursen, B. (2007). The correlates of Sibling con fl ict was addressed with con fl ict con fl ict: Disagreement is not necessarily detrimental. 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Adam B. Lewin, Jessie Menzel, and Michael Strober

In this chapter we describe the complications that Second, the common emergence of OCD and ensue from the phenotypic overlap between anxiety phenotypes prior to onset of weight con- anorexia nervosa (AN) and obsessive–compulsive cerns and dieting (Bulik, Sullivan, Fear, & Joyce, disorder (OCD) and consider how to approach the 1997 ) and persistence of anxiety states following evaluation and treatment of their comorbidity; to weight restoration (Pollice, Kaye, Greeno, & aid the discussion we present two illustrative case Weltzin, 1997 ) further support of the OCD-AN examples. The theoretical signifi cance of this link. Third, strong familial aggregation of OCD association lies in recent speculation that the dis- and multiple anxiety phenotypes, as well as com- tinguishing phenotypic characteristics of AN, pulsive personality, in AN (Strober, Freeman, phobic avoidance of normal body weight and Lampert, & Diamond, 2007 ) and evidence from grossly distorted appraisal of bodily image, twin studies of a common genetic architecture express a broad array of heritable traits, including in fl uencing liability to both anxiety and eating anxiety and fear proneness and disturbances in disorder (Keel, Klump, Miller, McGue, & Iacono, reward and habit circuitry, also linked to the 2005 ; Silberg & Bulik, 2005 ) bridge these pathophysiology and clinical features of OCD. two impairing neuropsychiatric syndromes. Empirical support for the notion that AN and Commonalities between the diagnostic features of OCD overlap is strong, based on evidence of, fi rst, AN and the behavioral phenomenology of anxiety a strikingly high lifetime comorbidity of AN with states and obsessional illness are notable. They anxiety disorders, OCD in particular (Godart, include anticipatory fear, hypervigilance, phobic Flament, Perdereau, & Jeammet, 2002 ; Kaye, avoidance, the incorrigible resistance of dietary Bulik, Thornton, Barbarich, & Masters, 2004 ) . restriction to reason or logic, and compulsiveness of weight checking, dieting, exercise, and counting of calories—features similar in character to the worry-driven, compulsive error checking and A. B. Lewin , Ph.D., ABPP (*) • J. Menzel , M.A. inability to inhibit perseveration of compensatory Department of Pediatrics , Rothman Center for goal-directed action characteristic of OCD. Neuropsychiatry, University of South Florida College of Medicine , 880 6th Street South, Child Rehabilitation Notably, despite these associations, AN is gener- and Development Center, Suite 460, Box 7523, ally not considered an obsessive–compulsive St. Petersburg, FL 33701, USA spectrum disorder, per se (DSM-IV Workgroup; e-mail: [email protected] Hollander, Braun, & Simeon, 2008 ) . M. Strober , Ph.D. The common association of OCD and AN Department of Psychiatry & Biobehavioral Sciences , complicates their presentation, prognosis, assess- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of ment, and the interventions required for these California , Los Angeles , CA 90095 , USA often chronic, treatment refractory syndromes.

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 337 DOI 10.1007/978-1-4614-6458-7_21, © Springer Science+Business Media New York 2013 338 A.B. Lewin et al.

In this regard, the presence of comorbid OCD stimuli (Altman & Shankman, 2009 ) with compul- symptoms in individuals with eating disorders sive acts aimed at reducing alarm and distress confers greater severity and persistence of eating occasioned by these intrusive ideas (Buree, disorder symptoms (Jimenez-Murcia et al., 2007 ; Papgeorgis, & Hare, 1990 ; Rachman & Hodgson, Milos, Spindler, Ruggiero, Klaghofer, & Schnyder, 1980 ; Tynes, White, & Steketee, 1990 ) . While the 2002 ) as well as increased overall levels of associ- content of the most pervading aversive thoughts ated anxiety and depression (Sallet et al., 2010 ) . differs across the two syndromes, the con fl uence of fear and alarm and behavioral acts reinforced by their avoidance-related function fi gure promi- Anorexia Nervosa (APA, 2000 ) nently in each. Even when classic obsessions and compulsions are lacking in persons with AN, over- Anorexia nervosa is an illness of undetermined lap with the phenomenology of OCD is striking— etiology whose onset, typically during adoles- impaired inhibition of intrusive ideas, rigid habit cence, confers high risk of medical and psycho- behaviors that resist change, and avoidance of the logical morbidity, premature early death, and fear instantiated by ingestion of food. Much like extreme economic burden. The illness is charac- the patient with OCD, persons with AN experi- terized not simply by an avoidance of normal ence these preoccupying thoughts as (at times) body weight (at or less than 85% of normal or deeply upsetting, dif fi cult to inhibit, and interper- ideal body weight for age or height) but rather an sonally disruptive. Accordingly, adherence to inexplicable indifference to the emaciation that abnormally extreme rules governing food choices, results and steadfast resistance to its correction frequent weighing, purging, and body checking because of the intense fear of being “fat.” have been likened to compulsive actions which Accompanying these features is an apparent dis- function to reduce anxiety related to eating or turbance in how weight is perceived and judged weight gain (Kaye, 2004 ) . Potentially a contrast to (believing oneself to be overweight even when obsessions in OCD is the degree perfectionism emaciated), an undue in fl uence of weight or and rigid standards for oneself can appear ego- shape on self-worth, and amenorrhea in postme- syntonic in AN (vs. an ego-dystonic presentation, narchal females (APA, 2000 ) . The full syndromic at least typically, in OCD). Anorexia nervosa is presentation of AN is not common; its lifetime likely to have a strong temperamental foundation occurrence estimated to be under 1% (Hudson, as perfectionism accompanied by intolerance for Hiripi, Pope, & Kessler, 2007 ) , occurring pre- personal imperfections, unrelenting self-standards, ponderantly in females. However, the public and harm avoidance which often appear early in health signifi cance of AN is signifi cant, as it is development (Hildebrandt, Bacow, Markella, & among the most lethal of all psychiatric disorders Loeb, 2012 ; Strober, 2004, 2010 ) . (Hudson et al.) with a mortality rate of approximately 5% per decade (Sullivan, 1995 ) . Prevalence

Phenomenological Overlap (Palmer & Evidence from comorbidity studies attests to the Jones, 1939 ) strength of the OCD and AN association. In clinical populations, the estimated co-occurrence The overlap in cognitive, affective, and behavioral ranges widely, with ﬁ gures ranging from 10 to aspects of OCD and AN has long been noted 60% (Godart et al., 2002 ; Halmi et al., 2003 ) . (Altman & Shankman, 2009 ) . Palmer and Jones In mixed populations of adolescents and adults (1939 ) noted that rigidity, compulsive perfectionism, with AN, the lifetime prevalence of OCD ranges and obsessional personality were inherent to AN. from 24.3 to 35% with a point prevalence of Both disorders are distinguished by perseverative 16.8% in adolescents (Salbach-Andrae, Lenze, thoughts centered on fear- or anxiety-inducing Simmendinger, Klinkowski, Lehnkuhl, & 21 OCD and Eating Disorders 339

Pfeiffer, 2008 ) to 17.8% in older adolescents/ (Fahy, Osacar, & Marks, 1993 ) , and symptoms adults (Godart et al., 2003 ). Conversely, in clini- of OCD typically persist after weight recovery cal samples of OCD, lifetime comorbidity with (Morgan, Wolfe, Metzger, & Jimerson, 2007 ; eating disorders are lower, in the range of 2.4– von Ranson, Kaye, Weltzin, Rao, & Matsunaga, 13% for AN but as high 18% when including 1999 ; Wentz, Gillberg, Anckarsater, Gillberg, subthreshold AN (du Toit, van Kradenburg, & Rastam, 2009 ) . Niehaus, & Stein, 2001; LaSalle et al., 2004 ; Familial studies supporting a shared underpin- Rubenstein, Pigott, L’Heureux, Hill, & Murphy, ning of AN and OCD have shown that the life- 1992 ; Sallet et al., 2010 ) . For a detailed review time prevalence of OCD is elevated among of comorbidity studies, see Swinbourne and ﬁ rst-degree relatives of AN probands compared Touyz ( 2007 ) . to relatives of non-AN controls (Bellodi et al., Further support for phenotypic overlap is evi- 2001 ; Lilenfeld et al., 1997, 1998 ; Stein et al., dence of a greater number of non-eating disor- 1999; Strober et al., 2007 ) though there is also dered obsessive thoughts and compulsions in evidence to the contrary (Bienvenu et al., 2000 ; individuals with eating disorders compared to Nestadt et al., 2000 ) . Twin studies of anxiety dis- either psychiatric or healthy controls (Cassidy, orders and eating disorders suggest shared genetic Allsopp, & Williams, 1999 ; Claes, Vandereycken, & susceptibility (Silberg & Bulik, 2005 ) . Notably, Vertommen, 2002 ; Halmi et al., 2003 ; Hirani, Keel et al. ( 2005 ) found that within monozygotic Serpell, Willoughby, Neiderman, & Lask, 2010 ; twin pairs discordant for eating disorders, the Matsunaga et al., 1999 ; Roberts, 2008 ; Sassaroli prevalence of anxiety in the non-eating disor- et al., 2008; Strober, 1980 ) . For example, con- dered twins was greater than in controls; contamination, aggressive and somatic obsessions, versely, for monozygotic twin pairs discordant as well as checking and ordering/arranging for anxiety disorder, the non-anxiety disordered rituals are common in youth with AN (Hirani twins were more likely to express eating pathol- et al., 2010 ) . Notably, some evidence also sug- ogy than were control subjects (Keel et al., 2005 ) . gests that obsessional symptoms decrease with While these twin studies did not examine OCD weight restoration in AN patients (Ehrlich et al., speci ﬁ cally, a convergence of evidence on this 2010 ) in accord with the known association area suggests at least some shared liability between obsessional behavior and severe malnu- between OCD and AN. trition (e.g., see Keys, Brozek, Henschel, Mickelson, & Taylor, 1950 ) . Putative Neurobiological Mechanisms

Etiology and Genetic Studies Anorexia nervosa and OCD have been linked to common abnormalities in neurobiological sub- Detailed considerations of a potential shared strates involving, in particular, serotonergic pathophysiology in eating disorders and OCD (5-HT) systems that regulate fear learning and have been offered (Stein & Lochner, 2008 ) . extinction, habit actions, and frontal modulation Considering the typical developmental trajec- of limbic emotion-generating circuits (Kaye, tory and chronology of disease onset within this 2008) . The attention on 5-HT function has been comorbidity, it can be argued that OCD may based on the role of this broadly distributed sys- represent a risk factor for the later emergence of tem in synaptogenesis, appetite regulation, and AN (Bulik et al., 2003 ; Kaye et al., 2004 ) as the impulse regulation. In eating disorders, abnor- illness precedes onset of AN in upwards of malities in 5-HT function are not limited to acute two-thirds of comorbid patients (Bulik et al., illness alone (Jimerson et al., 1997 ) but are found 2003 ; Godart, Flament, Lecrubier, & Jeammet, post-morbidly as well (Frank et al., 2002 ; Kaye, 2000; Kaye et al., 2004) , early age of onset of Fudge, & Paulus, 2009 ; Kaye, Wagner, Fudge, & OCD has been linked to later eating disorders Paulus, 2011 ) . 340 A.B. Lewin et al.

Evidence linking defects in 5-HT systems to that chronic stress, highly associated with anxious OCD is better developed and has been well states generally, alters neural morphology medi- reviewed (Goodman, McDougle, & Price, 1992 ; ating fear learning, emotional memory consoli- Stein, 2000 ; Westenberg, Fineberg, & Denys, dation, and the regulation of emotion (Duman, 2007 ) . Notably, a wide range of studies have Malberg, & Thome, 1999; Kaufman, Plotsky, reported increased 5-HT metabolic activity and Nemeroff, & Charney, 2000; Sapolsky, 2003 ; decreased levels of 5-HT transporter protein in Vyas, Jadhav, & Chattarji, 2006 ) , thus suggesting OCD patients compared to non-patients (Arora & that individuals prone to early onset of anxious Meltzer, 1991 ; Insel, Mueller, Alterman, Linnoila, states may acquire a hyperresponsiveness to sig- & Murphy, 1985 ; Marazziti et al., 1997 ; nals of novelty and become impaired in the abil- Marazziti, Hollander, Lensi, Ravagli, & Cassano, ity to discriminate safe from threatening 1992 ) , Reductions in cerebrospinal ﬂ uid levels of environments well in advance of the emergence 5-HT metabolites have been correlated with of puberty. These characteristics, also prominent decreases in obsessive–compulsive symptom features of OCD, may thus confer risk for the severity (Thoren, Asberg, Cronholm, Jornestedt, eventual development of AN (Anderluh, & Traskman, 1980 ) , and evidence exists for Tchanturia, Rabe-Hesketh, & Treasure, 2003 ; pharmacological treatment studies which consis- Kaye et al., 2004; Olatunji, Tart, Shewmaker, tently ﬁ nd that serotonin reuptake inhibitors Wall, & Smits, 2010 ) and are consistent with the (SRIs) produce positive treatment outcomes in antecedence of anxiety and OCD in persons with patients with OCD (Abramowitz, Taylor, & AN (Hsu, Kaye, & Weltzin, 1993 ; Kaye et al., McKay, 2009 ; Watson & Rees, 2008 ). 2004 ; Kaye, Weltzin, & Hsu, 1993 ) .

A Putative Model of Etiological Assessment and Treatment Overlap The phenotypic overlap between AN and OCD From a young age, persons with AN are uncom- has important assessment and treatment implica- promisingly rigid and compulsive, show exagger- tions. In the following sections, we offer some ated worry about inconsequential mistakes, are considerations for how to view differential diag- distressed by the anticipation of change, avoid nosis as well and how to approach treatment novelty, and their life decisions are governed by options. the avoidance of even the slightest possibility of threat (Strober, 2010 ) . Strober and colleagues recently proposed a neurodevelopmental model Differential Diagnosis of AN emphasizing a heritable predisposition towards obsessional anxiety- and stress-engendered As anxiety and compensatory behavior are central impairment of circuitry involved in fear learning psychological features of AN and OCD alike, and the regulation of affective arousal as core ele- dietary restriction, ritualistic eating patterns, and ments (Strober, 2004 ; Strober et al., 2007 ) . These eating-induced fear can be seen in both disorders. neuroatypicalities (also associated with obses- Just as the patient with AN steadfastly restricts sional illness) are offered as a mechanistic expla- caloric intake due to weight phobia, OCD can nation for the sudden onset of perceived threat present as an avoidance of certain foods based on and avoidance of weight change that emerge in fears of contamination or disgust. As such, care- concert with physical, hormonal, and social/ ful ascertainment of the core rationale for ritual- developmental changes that accompany pubertal istic behaviors and the underlying worry is maturation. Preclinical and clinical studies are fundamental to accurate differentiation as we supportive of this speculative model, showing have seen classic OCD accompanied by low body 21 OCD and Eating Disorders 341 weight due to food contamination fears. Generally, (Kaplan & Howlett, 2010 ; Keel & McCormick, obsessions and rituals experienced in OCD tend 2010 ) . Nevertheless, there is no single, empiri- to be ego-dystonic, while in eating disorders they cally well-supported approach at this time. are largely ego-syntonic (Bastiani et al., 1996 ) . Pharmacological interventions have also been Also in contrast to patients with OCD, obsessive widely used, but without robust fi ndings. Two thoughts in the early stages of AN are not com- studies examined the use of fl uoxetine in treating monly experienced as intrusive or inappropriate, AN and neither found signifi cant effects on and attempts to neutralize/suppress/ignore weight gain or eating disorder psychopathology intrusive thoughts are rare (Olatunji et al., 2010 ) . relative to placebo (Attia, Haiman, Walsh, & Thus, insight can assist in the differential diagnosis Flater, 1998 ) . Overall, AN is largely considered as individuals with AN do not experience their resistant to pharmacological interventions obsessions surrounding food or the related com- (Kaplan & Howlett, 2010 ) and pharmacotherapy pulsions, such as excessive exercise, calorie in the absence of psychotherapy is not recom- counting, or ritualistic eating, to be irrational mended for AN (Bulik, Berkman, Brownley, (Halmi et al., 2003 ) . By contrast, most individu- Sedway, & Lohr, 2007 ) . Unfortunately, no stud- als with OCD experience their obsessions and ies from a dismantling perspective have been compulsions as odd, irrational, and intrusive and conducted to determine which interventions easily characterize them in these terms. account for the greatest variance in improvement Descriptively and clinically, differences nor is there a set of guidelines for sequencing between the two syndromes have been noted and treatment by different modalities. may assist in their separation. Specifi cally, AN Neither is there strong empirical support for has been associated with greater perceived inef- the broad effi cacy of psychosocial interventions fectiveness and poorer interoceptive awareness for AN. Psychological treatments that have been (Jimenez-Murcia et al., 2007 ) , whereas contami- studied include various family therapies, cogni- nation fears, sexual obsessions, and cleaning tive-behavioral therapy (CBT), interpersonal compulsions tend to be more common in pure therapy (IPT), and psychodynamic therapy (Bulik OCD (Bastiani et al., 1996 ; Halmi et al., 2003 ) . et al., 2007 ) . Despite some support for CBT in Lastly, OCD has an earlier age at onset than AN maintaining normal body weight after discharge and other eating disorders (Kaye et al., 2004 ) from a CBT-based inpatient treatment setting underscoring the importance of careful assessment (Pike, Walsh, Vitousek, Wilson, & Bauer, 2003 ) , of the temporal chronology of symptom develop- one acute treatment trial (McIntosh et al., 2005 ) ment in relationship to signifi cant weight loss bear- that compared CBT, interpersonal psychotherapy, ing in mind the effect of malnutrition on obsessional and supportive psychotherapy found that after a thought (Keys et al., 1950 ; Pollice et al., 1997 ) . course of 20 visits, women randomized to the Following these timelines is of critical importance nonspecifi c supportive psychotherapy arm fared in identifying true comorbidity bearing in mind better than those assigned to either CBT or IPT. that comorbid OCD usually precedes AN in A recent long-term follow-up (mean 6.7 years) of upwards of 65% of cases (Speranza et al., 2001 ) . this sample found no differences in severity of illness across the three conditions (Carter et al., 2011 ) . Unfortunately, few well-designed and Treatment of the Comorbid Patient adequately powered randomized controlled treatment studies of AN exist (see Bulik et al., 2007 Treatments for anorexia nervosa . The treatment for a review). The strongest support is for a of AN consists of a blend of treatment modalities behavioral family therapy approach for adoles- (individual, group, family) and approaches cents, which emphasizes parent control of re- (interpersonal, CBT, psychodynamic) requiring nutrition during an initial phase of treatment a comprehensive and multidisciplinary approach (Eisler et al., 2000 ) . 342 A.B. Lewin et al.

During this acute phase, health stabilization is ing, and ingesting only small amounts (Kennedy, the primary outcome with hospitalization gener- Katz, Neitzert, Ralevski, & Mendlowitz, 1995 ) . ally advocated in cases of more extreme malnu- Several studies have evaluated the ERP model trition (e.g., BMI < 15) or when a course of by exposing patients to binge eating but preventing outpatient care fails to achieve weight gain the compensatory vomiting behavior. Results have (Fairburn, 2008 ) . Anorexia nervosa is associated shown a reduction in binge and purge episodes with a range of physical health complications (Gray & Hoage, 1990 ; Kennedy et al., 1995 ; such as arrhythmia, electrolyte disturbance, loss Rossiter & Wilson, 1985 ) , but the durability of of menses, dehydration, and bone disease, and as these effects has never been demonstrated and two malnutrition progresses the patient’s mental state studies that compared the effectiveness of CBT worsens, diminishing the patient’s capacity to with and without ERP found that the addition of bene fi t from psychotherapy. Accordingly, psy- ERP did little to enhance the effects of CBT alone chotherapy has limited chances of succeeding (Bulik, Sullivan, Carter, McIntosh, & Joyce, 1998 ; when the body is in a starved state (Bulik et al., Wilson, Eldredge, Smith, & Niles, 1991 ) . 2007 ) , and frequent physician assessments and Nevertheless, experts have argued that ERP is inher- nutritional rehabilitation are necessarily central ent to therapies applied to AN given the following: to improving health and achieving desired treat- (1) the marked role of anxiety/avoidance in the ment outcomes (APA, 2006 ; Pomeroy, 2004 ) . pathogenesis and presentation of AN (Hildebrandt et al., 2012 ) and (2) fear-learning-based models Treatments for obsessive– compulsive disorder . consistent with the maintenance of AN that resem- There are two primary approaches for treating ble the presentation of OCD (Steinglass & Walsh, OCD: CBT with exposure and response prevention 2006 ; Sysko, Walsh, Schebendach, & Wilson, (ERP) and pharmacotherapy with SRIs. A discus- 2005 ) . This suggests that exposure and habituation sion of these approaches is found elsewhere in this to food-, eating-, and weight-related cues promote volume and in several recent reviews (Abramowitz change via negative reinforcement of avoidance et al., 2009 ; Lewin & Piacentini, 2009 ) . behaviors and fear extinction. Weekly weight checks, refeeding with a variety of foods, and nat- Treatment of eating disorders using OCD behav- uralistic exposures (where precise caloric and fat ioral therapies . Unfortunately, no treatment stud- values are not available) mirror the ERP strategies ies have targeted individuals with comorbid OCD employed for OCD treatment. and AN. The need for this line of research is highlighted in a recent cross-sectional analysis of Treatment of comorbid OCD and eating disor- 508 inpatients with an eating disorder (half of the ders. In treating the comorbid patient, weight sample also had OCD) that suggests a bidirectional must fi rst be restored to an adequate level for and reciprocal relationship between the symptom medical stability and to maximize the patient’s complexes (Olatunji et al., 2010 ) wherein change in ability to both comprehend and participate in one mediated improvement in the other. However, psychotherapy. Fairburn (2008 ) recommends that isolated reports have examined the effects of ERP if comorbid OCD is present, the clinically more techniques where the goal is to reduce anxiety severe disorder should take precedence in pre- associated with eating certain foods or reduce scribing the treatment approach. However, it is binge eating/purging. An initial model of ERP sometimes feasible to pursue both treatments applied by Rosen and Leitenberg ( 1982 ) to bulimia simultaneously as psychotherapy for AN can aid nervosa had patients eat “forbidden” foods until the fl exibility required for ERP with OCD symp- they felt the urge to vomit while being prevented toms. As discussed above, with less severely ill from doing so (Rosen & Leitenberg). A slightly patients with AN, ERP can be applied to aspects different version of the technique involved of the eating pathology (Fairburn, 2008 ) . While preventing binge eating by exposing patients to treatment of AN with ERP alone is not indicated “forbidden” foods through licking, touching, smell- (Shapiro et al., 2007 ) , ERP can logically be 21 OCD and Eating Disorders 343 combined with cognitive therapies to treat a range infection, which included tapping foods, limiting of speci fi c intrusive obsessions and compulsions and repeating food choices (she ate only berries (McCabe & Boivin, 2008 ) , including obsessions at breakfast), eating only half of food portions, concerning risky foods and the subsequent use of and refusing to watch food being cleared from compensatory behaviors such as compulsive the table. Her abnormal eating behaviors were exercise, laxative use, and purging. ERP can also accompanied by other rigidities, including be used to address obsessions of weight or shape, restricting the clothes she would wear, the devel- compulsive weighing, body checking, avoidance opment of bedtime routines, following a rigid of mirrors and revealing clothing, food avoid- daily schedule, and refusal to be touched by any ance, and dietary restriction. sticky substances. Signi fi cant weight loss Still, there are caveats for psychotherapy with occurred over the period of a year, yet Kendra the comorbid AN/OCD patient to keep in mind. denied fear of weight gain, disturbance in her First, when challenging the core psychopathology perception of weight and shape, or a desire to of AN—fear of gaining weight/fatness and the maintain her low body weight. To the contrary, undue in fl uence of weight/shape on self-evalua- she stated she wished she could eat and knew tion—use of cognitive techniques is probably that she needed to eat more in order to be healthy, essential for achieving and maintaining good ther- yet she was unable to explain why she was engag- apeutic outcomes (Shapiro et al., 2007 ) . Second, it ing in these behaviors, only that something in her is important to take into account the age of the head told her that she must and that she needed individual. While the addition of CBT techniques to eat less. may be essential for adults and older adolescents, In spite of her statements, Kendra was initially involvement of the family is essential in treating diagnosed with, and treated for, AN. However, children and younger adolescents (Lewin, 2011 ; she stated that what her treatment team told her Lock, 2001 ; Lock & Le Grange, 2001 ) . made little sense as the characteristics of people We now present two cases that highlight the with this illness did not apply to her. After 4 importance of differential diagnosis and treat- weeks of treatment for an eating disorder, Kendra ment selection. In the case of Kendra, OCD underwent another psychiatric evaluation which symptoms are misdiagnosed as AN but subse- resulted in a primary diagnosis of OCD. quently respond well to ERP. In the case of Zoe, From this point on, Kendra’s treatment who presents with severe comorbid AN and included a course of pharmacotherapy with the OCD, weight restoration is the primary goal. Zoe SSRI fl uoxetine, dietary support for weight gain, remains treatment resistant and her history is and behavioral therapy initially focused on her noteworthy for several inpatient hospitalizations. eating behaviors. Kendra’s tapping and eating in Once her weight is stabilized, she is better able to halves responded rapidly to behavior therapy, but participate in ERP for OCD, but dramatic charac- her other eating-related oddities continued. As a ter changes are unlikely. result, she underwent an intensive, 3-week course of CBT with ERP targeting the entire range of her obsessions and compulsions. Exposure practices Case Illustrations included watching food being cleared from the table, participating in clearing food from the Case 1. Kendra was a 10-year-old Caucasian table, “contaminating” hands with leftover food female who presented for treatment of obses- from meals and food from the table, and covering sive–compulsive symptoms and presumed eating hands in sticky substances. An essential part of disorder. The only daughter of divorced parents, this phase was preventing Kendra from engaging she lived with her mother and grandmother, in her usual avoidance responses, such as fl eeing enjoyed sports, and was very diligent about her the table and being able to wash her hands. The school work. At age 8 years, Kendra developed ERP therapy proved effective in helping her abnormal eating behaviors following a strep reduce her anxiety and she resumed normal 344 A.B. Lewin et al. eating behaviors and was successful in restoring has been able to return to school; she struggles and maintaining a normal body weight. socially and with family due to her obsessional fears, and her marked rigidity has persisted. Case 2. Zoe was a 27-year-old Caucasian woman with a bachelor’s degree from an Ivy League university and was on medical leave from a Conclusions competitive MBA program at the time she presented for inpatient treatment of AN. She had also been The frequent co-occurrence and shared phenom- a superior student and was on an athletic scholar- enology between AN and OCD, and the familial- ship for track while in college. Zoe was hospital- ity of anxiety symptoms in AN, suggest the two ized twice before for severe emaciation, at ages syndromes may share risk factors that impact 17 and 23 years. Preceding this current hospital neural systems regulating emotional and habit admission, she restricted her daily intake to under behavior in common. Nevertheless, at this time 300 calories and followed a rigid exercise routine. translational and clinical evidence linking these On admission she described a marked ‘fear of syndromes is limited and no research-driven fat,’ an extreme fear of weight gain, and marked guidelines for managing the comorbid patient distortion of body image. Zoe’s rigidity and exist. Even so, several rational principles apply to infl exibility extended beyond her disordered responsible management: (1) medical stability eating. She was unable to tolerate uncertainty or must be a fi rst aim; (2) a multidisciplinary perceived imperfections and resisted any devia- approach is crucial for integrating the manage- tions from her usual daily routine. In addition to ment of medical, psychological, and nutritional fears about weight gain and appearance, she components of the psychopathology; (3) while worried that foods, and other people, were “con- research support exists for use of ERP techniques taminated.” She incessantly questioned staff in treating OCD symptoms and these same tech- regarding the preparation and origin of all foods and niques may also aid in the reduction of certain fl uids, washed her hands repeatedly, and avoided abnormal eating disorder behaviors, other psy- removing her raincoat due to a belief that it pro- chotherapeutic techniques will be required in the tected her from environmental contaminants. core features of AN; and (4) involvement of the Zoe’s treatment initially focused on medical family cannot be ignored when treating eating stability and weight restoration. As her cognitive pathology in children and adolescents. capacity improved, intensive psychotherapy for AN was initiated. 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Nicole M. Cain, Emily B. Ansell, and Anthony Pinto

Over the past two decades, tremendous strides personality disorder (OCPD), and dependent have been made in the treatment of anxiety personality disorder (DPD). We discuss the disorders, with both psychopharmacological and impact of these PDs on the presentation, clinical cognitive-behavioral therapies (CBT) demonstrat- course, and treatment outcome for speci fi c anxiety ing signifi cant effi cacy (e.g., Barlow & Lehman, disorders as well as review two personality mod- 1996; Lydiard, Brawman-Mintzer, & Ballenger, els that help to clarify the underlying mechanisms 1996; Mennin & Heimberg, 2000 ) . However, despite that contribute to treatment complexity. We also a number of positive outcomes, many individuals review treatment approaches that address the nuances with anxiety disorders continue to exhibit chronic associated with having comorbid cluster C person- impairment with low rates of recovery that appear ality features and use a clinical case presentation to to be worsened by certain comorbid psychiatric illustrate the challenges of treating an anxiety conditions (Bowen, Senthilselvan, & Barale, disorder along with comorbid OCPD. Finally, we 2000 ; Bruce et al., 2005 ; Yonkers, Bruce, Dyck, conclude with recommendations for future & Keller, 2003 ) . This chapter reviews the treatment research to address these treatment complexities. complexities associated with having an anxiety disorder and a comorbid cluster C personality disorder (PD), which includes avoidant person- Cluster C Personality Disorders ality disorder (AVPD), obsessiveÐcompulsive The Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition Text Revision N. M. Cain , Ph.D. (*) ( DSM-IV; American Psychiatric Association, Department of Psychology , New York-Presbyterian 2000 ) diagnostic criteria for AVPD describe a Hospital, Weill Cornell Medical College , White Plains , NY , USA pattern of social inhibition, feelings of inade- e-mail: [email protected] quacy, and hypersensitivity to negative evaluation Department of Psychology , Long Island via four or more of the following characteristics: University—Brooklyn Campus , avoids occupational activities that involve inter- Brooklyn , NY , USA personal contact due to fears of criticism, disap- E. B. Ansell , Ph.D. proval, or rejection; is unwilling to develop Department of Psychiatry , Yale University relationships unless certain of being liked; is School of Medicine , New Haven , CT , USA restrained in intimate relationships due to fears of A. Pinto , Ph.D. being shamed or ridiculed; is preoccupied with Department of Psychiatry , Columbia University being criticized or rejected; is inhibited in new College of Physicians and Surgeons, New York State Psychiatric Institute , interpersonal situations due to feelings of inade- New York , NY , USA quacy; views self as socially inept, unappealing,

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 349 DOI 10.1007/978-1-4614-6458-7_22, © Springer Science+Business Media New York 2013 350 N.M. Cain et al. or inferior; and/or is reluctant to take personal for unpleasant or aversive tasks; feeling discomfort risks or engage in new activities because they or helplessness when alone due to excessive may result in embarrassment. Prevalence in fears of being unable to take care of oneself; outpatient settings is around 15% (Zimmerman, urgent seeking of a new relationship to provide Rothschild, & Chelminski, 2005 ) and in the gen- care and support when a previous relationship eral population is between 2 and 5% (Grant et al., ends; and/or unrealistic fears of preoccupation 2004 ; Torgersen, Kringlen, & Cramer, 2001 ) . with being left to take care of oneself. Prevalence Individuals with an AVPD diagnosis present as in outpatient settings is estimated at 1.4% aloof, apprehensive, and guarded while internally (Zimmerman et al., 2005 ) and in the general pop- experiencing feelings of inadequacy ( Ansell & ulation between 0.5 and 1.5% (Grant et al., 2004 ; Grilo, 2007 ). Torgersen et al., 2001 ) . OCPD (APA, 2000) is a pattern of orderliness, It is important to note that cluster C PDs share perfectionism, and rigid control that interferes many of the same psychometric limitations as with effi ciency, task completion, and social inter- other Axis II PDs due to the structure of DSM- actions. Diagnostic criteria require four or more IV’s categorical classifi cation system (Clark, of the following: preoccupation with details, rules, 2007; Widiger & Trull, 2007 ) . Criticisms of the lists, schedules, and organization to the extent that system include excessive co-occurrence among the major point of the activity is lost; perfectionism Axis II disorders, extreme heterogeneity among that interferes with task completion; excessive patients with the same Axis II disorder, arbitrary devotion to work to the exclusion of leisure activi- diagnostic thresholds for the boundary between ties; is overconscientious, scrupulous, or infl exible “normal” and “pathological” personality func- about morality, ethics, or values; inability to discard tioning, and inadequate coverage of personality worn-out or worthless objects that have no real or pathology such that the diagnosis of PD not oth- sentimental value; reluctance to delegate tasks; a erwise specifi ed (NOS) is the most common PD miserly spending style toward self and others; diagnosis (Widiger & Trull). In addition, moder- and/or rigidity and stubbornness. Prevalence in ate reliability for cluster C PDs has been identi fi ed. outpatient settings is estimated between 8 and 9% McGlashan et al. (2000 ) reported reliabilities for (Zimmerman et al., 2005 ) and in the general AVPD and OCPD of 0.68 and 0.71, respectively. population between 2 and 8% (Grant et al., Blais and Norman (1997 ) reported a reliability of 2004 ; Torgersen et al., 2001) . The need for inter- 0.67 for DPD. However, concerns about reliabil- personal control in OCPD can lead to hostility and ity continue to be a focus across DSM-IV Axis II occasional explosive outbursts of anger at home disorders (Clark, 2007 ) . and work (Villemarette-Pittman, Stanford, Greve, Houston, & Mathias, 2004 ) . DPD (APA, 2000 ) is described as an excessive Nature of the Problem need to be taken care of and fears of autonomy expressed through submissive and clinging Anxiety disorders are highly prevalent diagnoses behaviors and fears of separation as indicated by and are associated with substantial life impair- fi ve or more of the following criteria: dif fi culty ments (Boden, Fergusson, & Horwood, 2007 ; making everyday decisions without an excessive Bruce et al., 2005 ; Grant et al., 2005 ; Roy-Byrne amount of advice or reassurance from others; & Cowley, 1994 ; Weisberg, 2009 ; Yates, 2009 ) . needing others to assume responsibility for major These signi fi cant impairments are often com- areas of his or her life; diffi culty expressing plicated by the presence of a comorbid PD disagreement with others due to fears that support diagnosis which, as we will discuss below, has or approval will be withdrawn; diffi culty initiat- been found to increase clinical severity, decrease ing projects or carrying out tasks autonomously; psychosocial functioning, reduce the proba- going to excessive lengths to obtain nurturance bility of remission, and increase the likelihood and support from others, including volunteering for relapse. 22 Cluster C and Anxiety Disorders 351

Prevalence of co-occurrence. Investigators have Liebowitz, 1993 ; Hofmann, Newman, Becker, documented the signi fi cant prevalence of co-occur- Taylor, & Roth, 1995 ; Hope, Herbert, & White, ring AVPD, OCPD, and DPD in individuals with 1995; Van Velzen, Emmelkamp, & Scholing, anxiety disorders. Brown and Barlow ( 1992 ) 2000 ) . In OCD, both Coles, Pinto, Mancebo, and reported high rates of comorbidity among anxiety Rasmussen (2008 ) and Garyfallos et al. ( 2010 ) disorders and PDs, especially for cluster C PDs. found that individuals with OCD plus OCPD, Oldham et al. ( 1995 ) , in a study of 200 inpatients when compared to individuals without OCPD, had and outpatients, found that the odds of an anxiety a signi fi cantly younger age at onset of fi rst obses- disorder co-occurring with AVPD, OCPD, or DPD siveÐcompulsive symptoms, as well as poorer psy- was more than fi ve times greater than chance. chosocial functioning, even though the groups did Within speci fi c anxiety disorders, 40Ð70% of not differ in overall severity of OCD symptoms. In patients with panic disorder also met criteria for a addition, they reported higher rates of hoarding comorbid PD (Otto & Gould, 1996 ) with the and incompleteness-related symptoms (including majority receiving diagnoses of AVPD, OCPD, or symmetry obsessions and cleaning, ordering, DPD (Mennin & Heimberg, 2000 ) . In a review of repeating compulsions), as compared to OCD sub- AVPD, Alden, Laposa, Taylor, and Ryder (2002 ) jects without OCPD. It appears that the presence reported that the frequency of comorbid general- of a co-occurring PD increases the severity of the ized social phobia and AVPD ranges from 25 to psychopathology across anxiety disorders. 89%. Reich ( 2000 ) noted that when examining the co-occurrence of social phobia and PDs other than Detrimental impact on course of anxiety disor- AVPD, DPD is the most frequent comorbid PD. ders. There are relatively few empirical investi- Finally, recent studies on OCD have consistently gations of the prospective course of anxiety found elevated rates of OCPD, with estimates disorders. In a 5-year prospective study examining ranging from 23 to 34% (Garyfallos et al., 2010 ; the natural course of anxiety disorders in 514 par- Lochner et al., 2011 ; Pinto, Mancebo, Eisen, ticipants as part of the Harvard/Brown Anxiety Pagano, & Rasmussen, 2006 ; Samuels et al., 2000 ) . Research Program (HARP), comorbid DSM- This increased prevalence of cluster C PDs with III-R PDs were associated with reduced remission anxiety disorders has signifi cant impacts on sever- rates for generalized anxiety disorder (GAD) and ity, functioning, and course of anxiety disorders. social phobia, but not panic disorder (Massion et al., 2002 ) . Speci fi cally, DPD and AVPD decreased Increased symptom severity and decreased func- remission rates for GAD and AVPD decreased tioning . Prior research in individuals with anxiety remission rates for social phobia. However, this disorders and co-occurring cluster C PDs indicate study had several limitations. Notably, only three a clinical presentation associated with increased anxiety disorders were assessed, and the rates of severity of psychopathology. For example, patients specifi c PDs in the overall sample was too low with panic disorder and a comorbid PD diagnosis to allow the analysis of some PDs as course were more likely than panic patients without a predictors (e.g., only 5Ð9% OCPD). In addition, comorbid PD to have a history of depression, have their analyses examined remissions but did not a history of childhood anxiety, and exhibit more look at relapse, chronicity, or new episodes of symptom severity prior to beginning treatment anxiety disorders. In a large study of the natural- (Pollack, Otto, Rosenbaum, & Sachs, 1992 ) . istic course of OCD, those with comorbid OCPD Individuals with social phobia and comorbid were signifi cantly less likely to partially remit AVPD have consistently demonstrated more severe from OCD after 2 years as compared to those symptoms and poorer global functioning than without comorbid OCPD, controlling for the those without AVPD suggesting that comorbid presence of other cluster C personality disorders AVPD may be an indicator of greater severity (Pinto, 2009 ) . (Brown, Heimberg, & Juster, 1995 ; Heimberg, Shea et al. ( 2004) investigated longitudinal 1996 ; Heimberg, Holt, Schneier, Spitzer, & associations between PDs and Axis I disorders 352 N.M. Cain et al. over a 2-year follow-up period using a prospective signifi cantly associated with poorer clinical design and continuous measures of course within outcome at 1-year post-CBT treatment for panic the Collaborative Longitudinal Personality disorder. Feske, Perry, Chambless, Renneberg, Disorders Study (CLPS), a prospective, naturalis- and Goldstein ( 1996 ) found that individuals with tic study designed to assess the course and out- comorbid social phobia and AVPD improve at a come of patients with PDs. Speci fi cally, they were slower rate than those with social phobia alone. interested in examining improvement in Axis I In a 6-year follow-up of 284 Norwegian outpa- disorders as a predictor of remission from PDs as tients using DSM-III-R diagnoses, OCPD pre- well as improvement in PDs as a predictor of dicted panic disorder at follow-up and AVPD remission from anxiety disorders. They found that predicted social phobia at follow-up (Alnæs & AVPD demonstrated signifi cant associations with Torgersen, 1999) . In studies of OCD, the pres- social phobia and OCD in both directions such that ence of OCPD predicted poorer response to decreased AVPD symptoms were associated with serotonin reuptake inhibitor treatment (Cavedini, improvements in social phobia and OCD and that Erzegovesi, Ronchi, & Bellodi, 1997) and expo- improvements in social phobia and OCD were sure and ritual prevention (Pinto, Liebowitz, Foa, associated with improvements in AVPD symptoms & Simpson, 2011 ) . over 2 years. OCPD was not associated with It is important to note that research has not changes in anxiety disorders over a 2-year course. consistently identi fi ed negative outcomes in the Ansell et al. (2010 ) extended the fi ndings of treatment of anxiety disorders with comorbid Shea et al. ( 2004 ) in the CLPS sample by examin- cluster C PDs. For example, Dreessen, Arntz, ing rates of remission, relapse, and new onset of Luttels, and Sallaerts (1994 ) examined the role of anxiety disorders in the CLPS study groups over a comorbid PDs in a sample of patients with panic 7-year follow-up period. Ansell and colleagues disorder with or without agoraphobia. Thirty-one found that OCPD was associated with increased patients received CBT over a 12- to 15-week risk for new onset of OCD, GAD, and agorapho- period and they found no differences on change bic episodes; increased risk of GAD relapse; and from pre- to posttreatment for panic disorder decreased risk for PTSD relapse over and above patients with and without comorbid PDs. other predictors. In addition, they found that Similarly, a recent study found greater improve- AVPD was associated with decreased likelihood ments in psychodynamic treatment of patients of social phobia remission, increased likelihood with panic disorder and cluster C PD comorbidity of social phobia and OCD onset, and greater chro- (Milrod, Leon, Barber, Markowitz, & Graf, nicity in social phobia episodes. AVPD was also 2007 ) . In social phobia, Brown et al. (1995 ) found associated with decreased risk for relapse of panic similar rates of response to group CBT among disorder with agoraphobia (Ansell et al., 2010 ) . individuals with generalized social phobia with The research suggests that, in general, individuals and without AVPD. Huppert, Strunk, Roth with cluster C PDs have a more negative natural Ledley, Davidson, and Foa (2008 ) found that course of anxiety disorder symptoms. comorbid AVPD did not predict differential treatment response for social phobia. In fact, they Detrimental impact on treatment of anxiety dis- found that individuals with AVPD improved more orders . Consistent with the research on natural than those without AVPD early in treatment. In course, the majority of treatment outcome stud- addition, as noted above, Ansell et al. (2010 ) ies suggest that comorbid PDs are associated found that AVPD was associated with decreased with negative outcomes in the treatment of risk for relapse of panic disorder with agorapho- anxiety disorders. For example, Chambless, bia and OCPD was associated with decreased Renneberg, Goldstein, and Gracely ( 1992 ) found risk for relapse of PTSD over and above other that avoidant, dependent, histrionic, and paranoid psychological predictors. Further research is PDs were associated with negative treatment needed to clarify how and for whom the treat- outcome following CBT for panic disorder. ment outcome of anxiety disorders is better with Hoffart (1994 ) found that avoidant traits were comorbid cluster C PDs. These fi ndings may 22 Cluster C and Anxiety Disorders 353 re fl ect personality trait tendencies (e.g., avoid- The most common example of the spectrum ance and rigidity) that decrease experiences that model is the signifi cant overlap between AVPD and may be associated with relapse. generalized social phobia (Siever & Davis, 1991 ) . Researchers have often noted a high degree of overlap between the generalized subtype of social pho- Theoretical Models for How bia and AVPD (e.g., Heimberg, 1996 ; Hofmann, Personality Disorders Contribute Heinrichs, & Moscovitch, 2004 ; Schneier, Spitzer, to Treatment Complexity Gibbon, Fyer, & Liebowitz, 1991 ) . This fi nding is not surprising given that six of seven diagnostic cri- Given the results investigating the impact of teria for AVPD include the social/interaction com- AVPD, OCPD, and DPD on the clinical course ponent that is essential to the diagnosis of social and treatment outcome of anxiety disorders, it is phobia. However, this high degree of comorbidity necessary to examine the features of personality has led researchers to question the utility of main- that contribute to this treatment complexity. taining two diagnostic categories on two separate Several models have been proposed to address DSM axes. It has been suggested that it may be the mechanisms by which personality and psy- more clinically useful to consider these diagnoses chopathology may infl uence the presentation or as different points on a social phobia continuum of appearance of one another; may share a common, increasing severity: from non-generalized social underlying etiology; and may contribute to the phobia to generalized social phobia without AVPD development or etiology of one another, thus to generalized social phobia with AVPD. This leading to increased comorbidity and treatment would allow for treatment interventions to be complexity (Klein, Wonderlich, & Shea, 1993 ; designed to target each point on the social phobia Widiger & Smith, 2008; Widiger, Verheul, & van continuum thus improving clinical course and out- den Brink, 1999 ) . In this chapter, we review two come for social phobia (Hummelen, Wilberg, models, the spectrum model and the pathoplastic Pederen, & Karterud, 2007 ; McNeil, 2001 ) . model, which help to clarify how cluster C personality features may impact the clinical presen- The pathoplastic model. Pathoplasticity is char- tation, clinical course, and treatment of speci fi c acterized by a mutually in fl uencing non-etiologi- anxiety disorders. cal relationship between psychopathology and another psychological system, such as person- The spectrum model . The spectrum model argues ality (Klein et al., 1993 ; Widiger & Smith, 2008 ; that PDs and personality traits may represent Widiger et al., 1999 ) . In this way, psychopathol- characterological variants of Axis I mental disor- ogy and personality in fl uence the expression of ders (Widiger & Smith, 2008 ) thus leading to each other, but neither exclusively causes the high rates of comorbidity between the anxiety other, as is hypothesized to be the case in a spectrum disorders and PDs. Brown and Barlow (1992 ) relationship (Widiger et al.). Pathoplasticity noted that the high co-occurrence of cluster C recognizes that the expression of certain mal- PDs among anxiety disorders may speak to the adaptive behaviors, symptoms, and mental limitations inherent in the diagnostic criteria for disorders all occur in the larger context of an these disorders and may point to the fact that individual’s personality (Millon, 1996, 2005 ) . Axis I anxiety disorders and Axis II cluster C dis- One example of a pathoplastic model uses orders occur along a common dimension with interpersonal circumplex theory (IPC; Leary, differences primarily existing on chronicity and 1957) to examine meaningful heterogeneity in severity. For example, some argue that OCPD social processes and traits within Axis I disorders. should be considered part of an OCD spectrum of Interpersonal theory posits that adaptive and mal- disorders (Bartz, Kaplan, & Hollander, 2007 ) , adaptive interpersonal styles can be described but underlying etiological similarities and differ- using the two dimensions of the IPC: communion ences have not been adequately studied to date and agency. This model depicts an individual’s (Pinto, Eisen, Mancebo, & Rasmussen, 2008 ) . interpersonal style by placing him or her in the 354 N.M. Cain et al.

Fig. 22.1 Interpersonal circumplex. Note. An example of the eight octants found in the Interpersonal circumplex (IPC) adapted from Leary (1957 ) . Octants are labeled with the alphabetical notation originally provided by Leary (1957 ) two dimensional space created by the orthogonal expression of psychopathology (e.g., Barrett & dimensions of communion and agency (see Barber, 2007 ) , predict variability in response to Fig. 22.1 for an example of an IPC adapted from psychotherapy within a disorder (e.g., Alden & Leary, 1957 ) . Circumplex octants offer useful Capreol, 1993 ; Borkovec, Newman, Pincus, & summary descriptors of interpersonal behavior, Lytle, 2002; Maling, Gurtman, & Howard, 1995 ) , marking the poles of the main dimensions but and account for a lack of uniformity in regulatory also representing blends of the underlying dimen- strategies displayed by those who otherwise are sions (i.e., hostile-dominance or friendly-submis- struggling with similar symptoms (e.g., Wright, siveness) (Pincus & Gurtman, 2006 ) . Figure 22.1 Pincus, Conroy, & Elliot, 2009 ) . Differences in illustrates a two-letter octant labeling scheme interpersonal diagnosis will affect the manner in which has been used by convention to refer to the which patients express their distress and will specifi c octants across measures with ease (e.g., in fl uence the type of strategy needed to regulate PA, BC, DE). The IPC allows for the location of their self, affect, and relationships (Pincus, individual or group data within the circumplex. Lukowitsky, & Wright, 2010 ) . By computing scores on each axis, a set of Cartesian coordinates can be generated to defi ne IPC and cluster C. Several studies have exam- the location of the predominant interpersonal ined cluster C PDs using the IPC. For example, style reported by individuals or groups. Pincus and Wiggins ( 1990 ) reported that AVPD Interpersonal pathoplasticity can describe is associated with low agency and low commu- the observed heterogeneity in the phenotypic nion on the IPC, which was replicated by Soldz, 22 Cluster C and Anxiety Disorders 355

Budman, Demby, and Merry ( 1993 ) in a sample treatment response. In particular, Przeworski et al. of psychotherapy patients. More recently, Leising, ( 2011) reported that nonassertive and exploitable Rehbein, and Eckhardt (2009 ) examined predic- GAD patients exhibited higher end-state function- tors of AVPD using octants of the IPC and found ing immediately following CBT treatment and at that problems with social inhibition were the best 6-month follow-up than cold and intrusive GAD interpersonal predictor of AVPD diagnosis. A patients. Thus, the contrasting styles of interper- series of studies relating dependency to the IPC sonal presentation within a diagnostic category suggested that dependency is associated with the have important implications for case formulation entire range of friendly, friendly-submissive, and and treatment planning. Adding to the strength of submissive interpersonal functioning (Pincus, these fi ndings, these GAD interpersonal subtypes 2002 ; Pincus & Gurtman, 1995 ; Pincus & Wilson, have also been replicated in a German clinical 2001 ) . Speci fi cally, Pincus and Wilson ( 2001 ) sample (Salzer et al., 2008 ) . noted that dependency might be expressed via Interpersonal pathoplasticity has also been passivity, helplessness, ingratiating deference, or examined in nonclinical (Kachin, Newman, & a warm-loving approach. Pincus, 2001 ) and clinical (Cain et al., 2010 ) Finally, in a recent investigation relating a samples of socially phobic individuals. In their measure of OCPD to the IPC, Cain ( 2011 ) found clinical sample, Cain et al. found two interper- that the overall construct of OCPD was associ- sonal subtypes of socially phobic patients: a ated with hostile-dominant interpersonal func- friendly-submissive subtype and a cold-submissive tioning. However, the trait dimensions underlying subtype. The two subtypes did not differ on pre- OCPD were associated with a wide range of treatment symptom severity or diagnostic comor- interpersonal functioning. In particular, diffi culty bidity, but did exhibit differential responses to with change was associated with submissive, outpatient psychotherapy. Overall, friendly- nonassertive interpersonal problems; maladap- submissive social phobics had signifi cantly lower tive perfectionism and reluctance to delegate scores on measures of social anxiety and were associated with exploitable and unassuming signifi cantly higher scores on measures of well- interpersonal problems; emotional restraint was being and satisfaction at posttreatment than cold- associated with social inhibition; and rigidity was submissive social phobics. associated with hostile-dominant interpersonal Taken together, the results of these studies problems (Cain, 2011 ) . investigating interpersonal pathoplasticity in anxiety disorders suggest that examining interpersonal IPC pathoplasticity with anxiety disorders . traits may be key to understanding the in fl uence of Numerous investigations have found that individual cluster C PDs on anxiety disorder course and differences in interpersonal style exhibit pathop- treatment outcome. It may also be useful to begin lastic relationships with anxiety disorders (e.g., Cain, developing and testing guidelines to more effec- Pincus, & Grosse Holtforth, 2010 ; Kachin, Newman, tively treat patients who have a similar Axis I & Pincus, 2001 ; Kasoff & Pincus, 2002 ; Pincus & diagnosis but different interpersonal problems. Borkovec, 1994 ; Salzer et al., 2008) . For example, patients diagnosed with GAD can be discriminated based on distinct clusters of interpersonal prob- Treatment Approaches lems (Kasoff & Pincus, 2002 ; Pincus & Borkovec, 1994 ; Przeworski et al., 2011 ) . In these studies, Despite high rates of co-occurrence and poorer Pincus and colleagues found four interpersonal clinical course and treatment outcome, there is subtypes of GAD patients refl ecting predominantly limited research examining speci fi c treatment cold, intrusive, exploitable, and nonassertive strategies and interventions that may be effective problems, respectively. These groups did not differ for treating anxiety disorders with comorbid cluster in symptom severity, comorbid psychopathology, C PDs. Treatment of AVPD with comorbid social or attachment style, but did exhibit differences in phobia has been the most widely investigated of 356 N.M. Cain et al. the cluster C PDs. For example, Huppert et al. anxiety disorders. For example, Alden and (2008 ) examined treatment outcome in social Capreol (1993 ) examined the extent to which the phobia with comorbid AVPD in one of fi ve treat- interpersonal problems of AVPD individuals pre- ment conditions: fl uoxetine pharmacotherapy, dicted treatment response to behavioral treatments. comprehensive cognitive-behavior group therapy Results showed that AVPD patients reported two (CCBT), CCBT + fl uoxetine pharmacotherapy, distinct types of interpersonal problems on the CCBT + pill placebo (PBO), and PBO only. All IPC: exploitable problems and cold problems. participants received 14 weeks of active treat- Patients who reported problems related to being ment. Results suggested that all treatments were exploited by others (exploitable avoidants) superior to PBO, but no signi fi cant differences bene fi ted from both graduated exposure and skills among the active treatments emerged. As noted training procedures, while AVPD patients with earlier, they found that comorbid AVPD did not problems related to cold, distrustful, and angry predict differential treatment response for social behavior (cold avoidants) only bene fi ted from phobia. However, Huppert et al. ( 2008 ) noted graduated exposure. Alden and Capreol ( 1993 ) several qualitative differences between individu- suggested that patients with AVPD differ in terms als with AVPD compared to those without AVPD. of their interpersonal problems and that these In particular, clinical impressions made during differences may in fl uence response to behavior treatment suggested that patients with AVPD therapy for anxiety and avoidance. often avoid a range of situations that make them Riley, Lee, Cooper, Fairburn, and Shafran feel uncomfortable—not just anxiety-provoking ( 2007 ) examined CBT for clinical perfectionism. social situations. In addition, those with AVPD As described earlier, perfectionism is a core often seem unable or unwilling to tolerate the feature of OCPD. Riley et al. noted that perfec- anxiety associated with confronting any novel tionism often complicates and impedes the prog- situation. Huppert et al. ( 2008 ) argued that per- ress of treatment of Axis I disorders particularly haps those individuals with AVPD may need anxiety disorders. They conducted a randomized exposure to situations beyond those that are social controlled trial of CBT for clinical perfectionism to learn that novel experiences in general should in twenty individuals. They de fi ned clinical per- not be avoided. fectionism as a dysfunctional type of self-focused Borge et al. ( 2010 ) examined changes in AVPD perfectionism in which the individual pursues and DPD dimensions in 77 socially phobic self-imposed, personally demanding standards patients using a medication-free residential cog- despite adverse consequences (Riley et al.). nitive therapy (CT) or residential interpersonal Treatment consisted of ten sessions of CBT over therapy (IPT). They found that both treatments 8 weeks. The treatment was manualized and con- were associated with a decrease in avoidant and sisted of four elements originally developed by dependent personality dimensions; however, Fairburn, Cooper, and Shafran (2003 ) : (1) identi- DPD dimensions decreased signifi cantly more in fying perfectionism as a problem and the ways CT than in IPT. Also, they found that changes in perfectionism is maintained (e.g., repeated per- social phobia symptoms during treatment did not formance checking or over training); (2) conduct- predict changes in AVPD or DPD dimensions. ing behavioral experiments to learn more about Their results suggest that socially phobic patients the nature of their perfectionism and alternative with comorbid DPD may benefi t from CT rather ways of coping (e.g., the impact of checking than IPT. Borge et al. ( 2010 ) noted that it is repeatedly vs. checking only occasionally); (3) important that AVPD and DPD be considered psychoeducation and cognitive restructuring (in when assigning socially phobic individuals to combination with behavioral experiments) to speci fi c treatments. modify personal standards, self-criticism, and There is also limited research examining cognitive biases such as selective attention to treatments for the personality features of cluster perceived failure; and (4) broadening the indi- C PDs that impede progress in the treatment of vidual’s capacity for self-evaluation, by identify- 22 Cluster C and Anxiety Disorders 357 ing and adopting alternative cognitions and twice-weekly 90-min sessions) as part of a behaviors. Riley et al. (2007 ) found that 75% of research study. Exposure sessions consisted of individuals (15/20) demonstrated clinically reviewing progress with between-session EX/RP signi fi cant improvement and treatment gains procedures, confronting fears in session for pro- were maintained at 8- and 16-week follow-ups. longed periods of time without ritualizing, and They recommended that this treatment could be assigning speci fi c exposures to practice before used as an adjunct to CBT when clinical perfec- the next session. George was instructed to stop tionism is a treatment barrier. rituals after the fi rst exposure session and to record any rituals that occurred. According to his therapist, George’s personality Case Example: EX/RP for Patient style (e.g., precision about wording of therapist’s with Comorbid OCD and OCPD instructions, rigidity with regard to how he completes his rituals, anger outbursts) signi fi cantly “George” is a highly intelligent, single male in his interfered in treatment progress. George was not late 20s with severe OCD and comorbid OCPD. compliant with treatment procedures, particularly His major obsessions center on a need for exact- assigned practice exposures and response pre- ness/certainty and a need for the “just right” feel- vention, and was frequently argumentative. He ing before completing an action. His major objected to the concept of response prevention, compulsions include checking, rereading, repeat- describing it as “unrealistic,” and believed that it ing, and handwashing. Beyond his OCD symp- would be “wrong” not to do his rituals at all. One toms, George admits that he is rigid, stubborn, of his exposure assignments was to watch part of highly rule bound, and guided by a strict sense of a TV program, rather than watching it from right and wrong. He is precise and even exacting beginning to end (which was George’s rule for in his words and actions. He experiences extreme TV viewing). George noted that after he com- interference in functioning. He has been unem- pleted the exposure assignment, he went back to ployed for the last 2 years, unable to return to his watching TV “my way.” For another exposure job in sales after taking a medical leave of absence assignment, George was to spend 30 min using due to OCD. He lives on his own in an apartment his computer imperfectly. He recalls getting and currently supports himself with savings. so frustrated during this particular assignment George spends most of his time sleeping or watch- that he punched his wall. George also adopted ing television to avoid triggering symptoms. With a narrow view of his assignments and had the exception of buying fast food and infrequent dif fi culty generalizing to related situations. After social contacts, he is mostly homebound. He takes he skipped a session (which would not be made excessive amounts of time to complete even sim- up) and arrived late for others, he deemed the ple tasks (showering, laundry, preparing a meal, treatment “imperfect.” At the posttreatment making phone calls, reading, handling money, assessment, he showed a mild reduction in symp- and typing or using a computer) and will avoid toms. However, he was unable to maintain gains these activities whenever possible since they are by the 6-month posttreatment assessment and usually physically and mentally exhausting for OCD severity returned to baseline level. him to complete. Because of his need for perfection and completeness, he is unable to manage or set limits with his time and will strongly object to Conclusions and Future Directions any attempts by others to limit time spent on activities. For example, George took more than This clinical case illustrates the detrimental 8 h to complete clinic intake questionnaires that impact that cognitions, behavior, and interper- others can complete in less than 1 h. sonal problems associated with OCPD can have George received exposure and response on the treatment course of OCD. As reviewed prevention (EX/RP) treatment for OCD (8 weeks; above, there is an extensive literature showing 358 N.M. Cain et al. that the presence of a comorbid cluster C PD treatment response to behavioral interventions diagnosis increases clinical severity, decreases depending on the types of interpersonal problems psychosocial functioning, reduces the probability reported by AVPD individuals. In particular, they of remission, and/or increases the likelihood for noted that patients who reported problems related relapse for anxiety disorders. However, despite to being exploited by others bene fi ted from the negative outcomes associated with having a graduated exposure and skills training proce- comorbid cluster C PD, there is relatively little dures, while AVPD patients with problems related research examining treatment approaches to to cold, distrustful, and angry behavior only address this complexity. Future research is needed bene fi ted from graduated exposure. to begin developing and testing treatment inter- Given the substantial impairments and nega- ventions that will more effectively treat cluster C tive outcomes associated with anxiety disorders comorbidity for anxiety disorders. First, and co-occurring cluster C pathology, it is neces- modifi cations to traditional CBT approaches may sary to continue to explore the mechanisms by be necessary to target this complexity. For exam- which personality and psychopathology may ple, in their clinical impressions, Huppert et al. in fl uence the presentation or appearance of one (2008 ) noted that patients with social phobia and another; may share a common, underlying AVPD avoid a wide range of situations and they etiology; and may contribute to the develop- are often unwilling to tolerate anxiety associated ment or etiology of one another, thus leading to with novel stimuli. Huppert et al. suggested that increased comorbidity and treatment complexity. modifi cations to CBT might be needed to expose In addition, signifi cant advances in treatment are those patients with AVPD to situations beyond necessary to adequately address this complexity those that are just social. Similarly, other research- and improve treatment outcome. ers have suggested that lengthening brief CBT treatments and/or paying greater attention to mal- Acknowledgments Supported by NIMH grant K23 adaptive interpersonal patterns in CBT treatments MH080221 (Pinto). may be necessary when treating patients with comorbid cluster C PDs (see Crits-Christoph & Barber, 2007 ) . References Second, more research is needed to investigate possible adjunctive treatments for anxiety disor- Alden, L. E., & Capreol, M. J. (1993). Avoidant personal- ders that may be used to target comorbid cluster ity disorder: Interpersonal problems as predictors of treatment response. Behavior Therapy, 24 , 357Ð376. C PDs and their underlying facets. Riley et al. Alden, L. E., Laposa, J. M., Taylor, C. T., & Ryder, A. G. (2007 ) demonstrated clinically signi fi cant (2002). Avoidant personality disorder: Current status improvement in a study investigating CBT for and future directions. 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Brett J. Deacon and Nicholas R. Farrell

With hundreds of clinical trials and dozens of To illustrate, in a sample of over 800 licensed meta-analytic reviews attesting to its effective- doctoral-level psychologists, Becker, Zayfert, ness (Deacon & Abramowitz, 2004 ; Olatunji, and Anderson ( 2004 ) found that fewer than 20 % Cisler, & Deacon, 2010 ) , exposure-based cog- of respondents reported using exposure therapy nitive-behavioral therapy (CBT) is the most to treat clients with posttraumatic stress disorder empirically supported psychological treatment (PTSD). Indeed, exposure was not widely uti- for the anxiety disorders. Clinical practice lized even among trauma experts with specialized guidelines published by the American Psychiatric training in this approach. These fi ndings were Association (2011 ) and the National Institute replicated in a more recent survey of more than for Clinical Excellence (2011 ) recommend expo- 250 trauma experts by van Minnen, Hendriks, sure-based CBT approaches as fi rst-line anxiety and Olff ( 2010) . Imaginal exposure was the least treatments. Relative to pharmacotherapy, expo- used treatment for PTSD, and respondents pre- sure-based therapy typically produces similar ferred both eye movement reprocessing and short-term bene fi t and superior long-term main- desensitization and supportive counseling to tenance of treatment gains (e.g., Barlow, Gorman, exposure therapy despite the weaker scientifi c Shear, & Woods, 2000 ) . Exposure therapy is also evidence for the ef fi cacy of these approaches. more cost-effective (Heuzenroeder et al., 2004 ) The underutilization of exposure therapy is and more acceptable and preferable to clients and not specifi c to PTSD. A German study found that their caregivers (Brown, Deacon, Abramowitz, & although almost all therapists requested coverage Whiteside, 2007 ; Deacon & Abramowitz, 2005 ) . for exposure therapy from obsessiveÐcompulsive Taken together, these observations support a disorder (OCD) clients’ health insurers, over strong case for exposure-based CBT as the treat- 80 % of their clients reported that no exposure ment of choice for anxiety disorders. Indeed, this component was used in their treatment (Böhm, treatment may have more scientifi c support than Förstner, Külz, & Voderholzer, 2008 ) . In addi- any other psychotherapy of any kind, for any tion, Becker et al. ( 2004 ) reported that fewer than mental disorder. 15 % of clinicians with expertise in PTSD Despite its demonstrated effectiveness, expo- reported using exposure therapy when treating sure therapy is rarely used by practicing clinicians. other anxiety disorders due to a lack of training. Poor dissemination of CBT to mental health practitioners has resulted in a lack of client access B. J. Deacon , Ph.D. (*) ¥ N. R. Farrell , M.A. to this treatment ( Gunter & Whittal, 2010 ) . The Department of Psychology , University of Wyoming , majority of adults with an anxiety disorder do not 3415, 1000 East University Avenue , Laramie , WY 82071 , USA receive effi cacious treatment (e.g., Stein et al., e-mail: [email protected] 2004 ; Young, Klap, Sherbourne, & Wells, 2001 ;

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 363 DOI 10.1007/978-1-4614-6458-7_23, © Springer Science+Business Media New York 2013 364 B.J. Deacon and N.R. Farrell

Young, Klap, Shoai, & Wells, 2008) , and when follows: (a) Community therapists emphasize clients are able to access psychotherapy, it is client self-directed exposure rather than rarely evidence-based (Goisman, Warshaw, & therapist-assisted exposure, and (b) community Keller, 1999 ; Taylor et al., 1989 ) . therapists typically combine exposure therapy Dissemination failure alone cannot fully with arousal-reduction strategies such as progres- account for the underutilization of exposure sive muscle relaxation and breathing retraining, therapy. A startling fi nding revealed by Becker whereas treatment manuals typically omit such et al. (2004 ) is that the majority of therapists procedures and focus on the delivery of repeated, who had received training in exposure therapy prolonged exposure tasks. The modal delivery of did not use this treatment. Why would therapists exposure by community therapists is concerning, trained in this approach, and presumably aware as exposure appears less effective when imple- of its well-established scientifi c effi cacy, shun mented in a self-directed manner (e.g., exposure for less substantiated therapies? We Abramowitz, 1996 ) , and arousal-reduction strate- propose that negative beliefs about exposure gies are not evidence-based adjuncts and may therapy (e .g ., that it is unethical , intolerable , even interfere with long-term improvement (e.g., and unsafe ) impede the utilization of this treat- Schmidt et al., 2000 ) . Why do practitioners tend ment , even among therapists trained to admin- to implement exposure therapy in this manner? ister it . We hypothesize that clinicians who use exposure Findings from therapist surveys reveal that therapy minimize the intensity of its delivery due even when exposure therapy is utilized, it is often to concerns about the adverse consequences of implemented in a suboptimal manner. Freiheit, subjecting clients to high anxiety during exposure Vye, Swan, and Cady (2004 ) found that psychol- tasks . This notion begs the question: How might ogists, nearly all of whom reported using “CBT” minimizing the intensity of exposure therapy with their anxious clients, utilized techniques affect client outcomes? such as relaxation and breathing retraining more Research has yet to directly address how ther- frequently than exposure in the treatment of anx- apist beliefs about exposure might in fl uence the ious clients. Comparable fi ndings were reported manner and effectiveness of its delivery. However, by Hipol and Deacon ( in press ) in a survey of indirect evidence may be found in the Pediatric Wyoming mental health practitioners. Therapist- OCD Treatment Study (POTS Team, 2004 ) , a assisted exposure was used by less than 30 % of large-scale, placebo-controlled clinical trial com- clinicians in the treatment of clients with OCD, paring exposure therapy, sertraline, and their social phobia, panic disorder, and PTSD. Of combination in the treatment of children and ado- interest, the majority of therapists who did utilize lescents with OCD. The study’s primary fi nding exposure with their clients also reported using was that combined treatment was superior to breathing retraining, progressive muscle relax- exposure therapy and sertraline alone, which did ation, meditation, and nondirective supportive not differ from each other. However, this outcome therapy. Similar to the psychologists surveyed by was qualifi ed by an extraordinarily large differ- Freiheit et al. (2004 ) , Wyoming therapists uti- ence in the ef fi cacy of exposure at two different lized client self-directed exposure more than study sites. Despite using procedures designed to twice as often as therapist-assisted exposure standardize adherence with the exposure therapy (Hipol & Deacon, in press ) . treatment manual (e.g., direct supervision, case Surveys of practicing clinicians (Freiheit et al., conferences, training meetings, review of video- 2004 ; Hipol & Deacon, in press ) indicate that the taped sessions), exposure was more than four implementation of exposure therapy in the com- times as effective in reducing OCD symptoms at munity, when it occurs, is very different from its the University of Pennsylvania than at Duke typical manner of delivery in treatment manuals University. At the Pennsylvania site, exposure studied in clinical trials (e.g., Kozak & Foa, 1997 ) . alone was as effective as combination treatment; The primary differences can be summarized as at Duke, augmentation with sertraline more than 23 Therapist Barriers to Exposure 365 doubled the ef fi cacy of exposure therapy. How can clinical psychology is not evidence-based such fi ndings be explained? Franklin et al. (2004 ) (Weissman et al., 2006 ) . reported signi fi cant variation between therapists In the absence of scienti fi cally grounded train- in client outcomes and suggested that site differing, many mental health professionals are deeply ences were driven by “super-therapists” who may ambivalent about the relevance of research to have set a more ambitious agenda with regard to their clinical practice. In contrast to medicine in exposure tasks and pushed their clients harder to which there is near-unanimous agreement that pursue it (M. E. Franklin, September 10, 2010, practice should be guided by treatment guidelines personal communication). One (admittedly spec- derived from research evidence (Wolfe, Sharp, & ulative) possibility raised by the POTS study is Wang, 2004 ) , mental health professionals often that therapists who attain the best client outcomes reject evidence-based treatments on the grounds deliver exposure therapy in a particularly inten- that fi ndings from clinical trials are invalid and sive manner owing to their con fi dence in the irrelevant to real-world practice (e.g., Silberschatz, safety , tolerability , and effi cacy of this in Persons & Silberschatz, 1998 ) . Indeed, the treatment . typical mental health practitioner is more likely In summary, despite its status as the most to prize his or her intuition and experience over effective psychological treatment for the anxiety scienti fi c evidence (Garb & Boyle, 2003 ) . The disorders, exposure-based CBT is rarely utilized, notion that all psychotherapies are equivalent even by clinicians trained in its delivery. (aka, the “Dodo Bird” verdict), which remains Moreover, the minority of therapists who provide popular despite clear evidence to the contrary exposure therapy often do so in a less-than-ideal (Hunsley & Di Giulio, 2002 ) , provides little moti- manner. A number of empirical fi ndings suggest vation for practitioners to seek additional training that therapists hold negative beliefs about in evidence-based practices. The current tension exposure that may hinder its utilization and affect between skeptical mental health practitioners and the manner in which it is delivered to anxious exasperated clinical scientists (Tavris, 2003 ) is clients. These therapist-level barriers are reviewed reminiscent of the confl ict that raged among phy- below. sicians a century ago about whether the practice of medicine was an art or a science (Baker, McFall, & Shoham, 2009 ) . Barriers to the Dissemination In 2006 , the American Psychological of Evidence-Based Psychological Association published the organization’s posi- Treatments tion statement on evidence-based practice in psychology. This report was the product of the Undoubtedly, exposure therapy is affected by the Task Force on Evidence-Based Practice, a group same set of therapist barriers that obstruct the uti- composed of both ardent supporters and vehe- lization of evidence-based psychotherapies more ment opponents of the movement to identify and generally. These include a lack of training oppor- disseminate empirically supported treatments tunities in CBT and an emphasis on training men- like exposure therapy. The Task Force de fi ned tal health professionals in practices not supported evidence-based practice as “the integration of by scientifi c evidence. To illustrate, the majority the best available research with clinical exper- of social work and professional clinical psychol- tise in the context of client characteristics, cul- ogy (Psy.D.) graduate programs do not require a ture, and preferences” (p. 273). This defi nition didactic and clinical supervision in any evidence- of fi cially sanctions the notion that research evi- based treatment. Even when such training is pro- dence and clinical judgment are equally valid vided (e.g., in psychiatry residency programs), it methods for selecting appropriate interventions. is often cursory and insuf fi cient to instill adequate The report provides little guidance for resolving competency. At present, most required psycho- con fl icts between the clinician’s intuition and therapy training in psychiatry, social work, and fi ndings from empirical research, and therapists 366 B.J. Deacon and N.R. Farrell thus appear free to consider their own practice Taken together, a large number of practical and “evidence-based” without regard to whether the ideological barriers contribute to the failure to ade- treatments they use have passed muster in clinical quately disseminate empirically supported treat- trials. Indeed, a recent survey of clinical psy- ments to mental health professionals. Principal chologists found that respondents, on average, among these include a lack of training in evidence- characterized 73.1 % of their services as evi- based interventions and the perception that science dence-based according to the APA’s defi nition is only tangentially relevant to the practice of psy- (Berke, Rozell, Hogan, Norcross, & Karpiak, chotherapy. In addition to these more general reser- 2011 ) . The modal response, provided by approx- vations about evidence-based treatments, exposure imately one-third of psychologists, was 100 %. therapy is subject to a potent set of intervention- Thus, a striking incongruity exists between the speci fi c negative beliefs which we discuss below. low utilization of empirically supported treatments like exposure therapy and the high rate at which clinicians believe their practice is “evi- Therapist Barriers to the dence-based.” Dissemination of Exposure Therapy Negative therapist beliefs about the use of manualized treatments constitute another barrier Exposure therapy has a public relations problem to the dissemination of empirically supported with many in the fi eld of psychotherapy (Olatunji, treatments. Addis, Wade, and Hatgis ( 1999 ) Deacon, & Abramowitz, 2009 ; Richard & Gloster, identi fi ed several such beliefs about manuals, 2007 ) . Prejudice against exposure often stems including the following: (a) The therapeutic rela- from the fact that this intervention evokes distress tionship will be compromised, (b) treatment pro- (albeit temporary), rather than soothes it, as one ceeds according to a one-size-fi ts all approach and might intuitively expect a treatment for anxiety to cannot be adequately individualized to specifi c do. More specifi c negative beliefs about exposure clients, and (c) therapist input and creativity will include the following: (a) It is unethical, (b) it be stifl ed, thereby leading to job dissatisfaction. poses an unacceptably high risk of harm to cli- Although the accuracy of these perceptions is ents, and (c) it is stressful and potentially harmful highly debatable (Addis et al.; Barlow, Levitt, & to the therapist. In this section, we present a criti- Bufka, 1999 ) , they are commonly held by practic- cal analysis of these concerns. Using case exam- ing clinicians and serve to dampen enthusiasm for ples from our own clinical practice, we illustrate the use of empirically supported treatments, the manner in which endorsement of these beliefs including exposure therapy, that are often deliv- might affect the manner in which clinicians ered using treatment manuals. implement exposure therapy. Dissemination efforts are also hampered by a host of economic and practical concerns. Exposure therapy is unethical . The fi rst principle Learning a new psychotherapy is expensive, in the American Psychological Association’s time-consuming, and requires a great deal of Ethical Principles of Psychologists and Code of effort. Gray, Elhai, and Schmidt (2007 ) found Conduct (2002 ) admonishes psychologists to that among a sample of trauma experts, the most “take care to do no harm” and “safeguard the endorsed barriers to use of empirically supported welfare and rights” of their clients. Because treatments included insuffi cient time to learn the exposure therapy entails deliberate provocation treatment and attend training seminars, as well of anxiety and distress, some therapists believe as the prohibitive expense associated with such its very nature violates accepted ethical stan- training. Because experts in exposure-based dards. One therapist, quoted in a New York Times CBT tend to be clustered in urban areas associ- article (Slater, 2003 ) , described exposure as “tor- ated with major medical centers, many practitio- ture, plain and simple.” Our experience suggests ners in rural settings lack convenient access to that this sentiment is commonplace among training opportunities. therapists across the mental health professions, 23 Therapist Barriers to Exposure 367 particularly those with psychodynamic and stimuli are not accompanied by catastrophic out- humanistic theoretical orientations, and is a pri- comes and that he possesses the ability to tolerate mary reason why some practitioners do not the distress they evoke. provide exposure therapy—and would not do so, Practitioners who believe exposure therapy to even if they were trained in this approach. be unethical, either intrinsically or according to Some practicing exposure therapists likely har- its manner of delivery, might bene fi t from consid- bor concerns about the ethicalness of this treat- ering the work of a physical therapist or physi- ment. They may not consider exposure to be cian. Often, their treatments involve exposing inherently unethical, but may tie its acceptability clients to temporary, manageable amounts of pain to the manner in which it is delivered. Exposure and distress for the sake of long-term recovery. tasks that evoke very high levels of client anxiety, Indeed, the experience of temporary discomfort or that place the client in “extreme” situations is sometimes necessary to ensure the desired lon- beyond those encountered by most people on a ger-term outcome. The process of exposure ther- daily basis (e.g., immersing one’s hands in gar- apy requires that clients “invest anxiety now for a bage), may be considered both unnecessary and calmer future” (Abramowitz, Deacon, & ethically indefensible by well-meaning clinicians. Whiteside, 2010 ) . Well-meaning therapists who Therapists who adopt this perspective may deliver minimize the anxiety invested by their clients for exposure in an overly cautious and sympathetic ethical and humanistic reasons are paradoxically manner in an attempt to safeguard their clients’ depriving their clients of the optimally effective rights and dignity. Consider the following case: treatment they deserve. Mr . A is a 27 - year -old Marine Corps veteran Clinicians often assume that clients perceive who served in operation Iraqi Freedom and cur- exposure therapy as aversive and unethical and rently suffers from combat - related PTSD . During will instead prefer to undergo treatment that does his tour of duty he witnessed the deaths of numer- not entail the distress associated with directly ous Iraqi civilians and members of his unit from facing one’s fears. Fortunately, exposure therapy gunfi re and improvised explosive devices . He is appears to be held in generally high esteem by bothered by intrusive recollections of these events anxious clients and their caregivers. Compared to and experiences distressing images of people pharmacotherapy, exposure-based CBT is rated around him being maimed and killed by explo- as more credible, acceptable, and likely to be sions when he is in crowded public places . effective in the long-term (Brown et al., 2007 ; A therapist overly concerned with upholding Deacon & Abramowitz, 2005 ; Norton, Allen, & the ethical principles of benefi cence and non- Hilton, 1983) . Moreover, exposure therapy is male fi cence (APA, 2002 ) might forego prolonged rated as at least as acceptable, ethical, and effec- imaginal exposure with Mr. A, reasoning that tive as cognitive therapy and relationship-oriented asking him to revisit his painful memories would psychotherapy by undergraduate students and be inhumane. Alternatively, the therapist might agoraphobic clients (Norton et al.). The fi nding implement imaginal exposure but allow the client that therapist reservations about exposure therapy to withhold the specifi c details of his traumatic are not shared by clients who receive this treat- experiences to minimize his distress. Rothbaum ment provides an important counterpoint to the and Schwartz (2002 ) noted that overly sympa- notion that exposure therapy is inherently inhu- thetic or cautious exposure therapists run the risk mane and unethical. of unintentionally reinforcing their clients’ fears. In the case of Mr. A, such an approach might also Exposure therapy is harmful to the client . deprive him of the opportunity to emotionally Exposure is believed by some practitioners to process his traumatic memories, thereby prevent- place clients at an unacceptably high risk of harm ing habituation to the full range of fear cues asso- in various ways. Most commonly, therapists ciated with his PTSD. The client might also fail worry that clients will be harmed by their own to learn that particularly anxiety-provoking anxiety during exposure tasks. This concern 368 B.J. Deacon and N.R. Farrell refl ects a number of myths about the nature of unwilling to become pregnant due to a severe anxiety itself. One such misconception is that the phobia of vomiting . She believes that vomiting experience of prolonged, intense anxiety-related might cause her to choke and die and avoids somatic symptoms may lead to a medical emer- stimuli that might cause her to become nauseous gency, such as loss of consciousness or heart and / or ill . attack. A similar belief is that anxiety is literally Mr. P’s exposure therapy would be expected intolerable in high doses. Some therapists believe to emphasize interoceptive tasks such as hyper- their clients to be suf fi ciently fragile that the ventilation and breathing through a straw. A experience of high anxiety will cause them to therapist who believes that the anxiety-related decompensate, perhaps in the form of a psychotic body sensations evoked by these exercises are episode or loss of control over their own behav- potentially dangerous might employ concurrent ior. A related belief is that trauma sufferers may arousal-reduction strategies such as relaxation be “revictimized” by the recollection of a painful and breathing retraining. Similarly, the therapist memory. Other concerns associated with high might encourage the client to perform the exer- anxiety during exposure tasks include the possi- cises using a small number of brief trials, each bility of symptom exacerbation and/or treatment separated by a long rest period to allow his refusal and attrition. Common to these beliefs is symptoms to subside. In this manner, the client the assumption that clients with anxiety disorders would be spared from experiencing anxiety lack the resilience necessary to safely experience symptoms that the therapist fears could escalate their own anxiety symptoms. to potentially dangerous levels. Unfortunately, Exposure therapy is also sometimes assumed the client would not be able to learn that the to pose a threat to clients in the form of danger- experience of prolonged and intense anxiety- ous stimuli used during exposure tasks. Examples related physical sensations, such as those experi- include animals (e.g., dogs), potential contami- enced during his panic attacks, do not lead to nants (e.g., toilet seats), and external situations catastrophic outcomes. (e.g., driving). Some therapists believe that Mrs. G is extremely distressed by her obses- “extreme” exposure tasks, the likes of which sions and is ashamed of their content. A therapist appear at the top of many client fear hierarchies, concerned about the harmful effects of high anxi- are especially likely to be harmful. ety is likely to be especially cautious in the use of How might such beliefs affect the delivery of exposure with this client. Concerned that Mrs. G exposure therapy? Consider the following three would be unable to tolerate the distress associ- cases: ated with imaginal exposure to obsessions involv- Mr . P , age 45 , experiences daily , unexpected ing the violent death of her beloved daughter at panic attacks . During his attacks , he has promi- her own hands, the therapist may forego this nent symptoms of dizziness , shortness of breath , technique altogether. Alternatively, the therapist and heart palpitations which he fears will lead to might allow the client to conduct imaginal expo- a loss of consciousness . He avoids physical exer- sure in a self-directed manner in order to avoid cise and participation in any activities that evoke the heightened anxiety associated with sharing these sensations . the details of her obsessional fears with the thera- Mrs . G , age 28 , gave birth to her fi rst child pist. Concerned that the client might decompen- two months ago . Since that time she has experi- sate due to intolerably high anxiety during enced intrusive , unwanted obsessions about stab- situational exposures (e.g., giving her daughter a bing her daughter with knives and drowning her bath) and act on her harming obsessions, the in the bathtub . She has turned parenting duties therapist might refrain from implementing in vivo over to her husband and avoids being alone in exposure, or require the husband to be present as the house with her daughter . a safety measure. Exposure therapy conducted in Mrs . R is a 26 - year - old married woman who this manner runs the risk of reinforcing the is interested in having children . However , she is client’s catastrophic beliefs about being crazy for 23 Therapist Barriers to Exposure 369 having such obsessions and posing a threat to her requirements of exposure therapy sometimes daughter’s safety. place clients at greater emotional and/or physical Mrs. R’s emetophobia is driven primarily by risks than many traditional forms of verbal psy- the belief that she may choke and die during the chotherapy. For example, exposure can involve act of vomiting. Despite the obvious therapeutic the remote but real potential for harm when cli- value of having the client vomit during exposure, ents handle snakes or touch “contaminated” the cautious therapist might elect to forego such objects such as garbage cans. Although when an “extreme” task in order to avoid subjecting the conducted properly these exercises involve client to intolerably high anxiety and the possibil- acceptably low levels of risk, exposure therapists ity, however remote, that vomiting may actually must carefully consider the client’s safety when prove harmful. An exposure therapist concerned designing and implementing exposure practices. about the client’s safety may proceed with tasks Strategies for minimizing risk such as negotiating such as viewing video clips of individuals vomit- informed consent, determining acceptable levels ing and asking the client to engage in activities of safety during exposure tasks, and dealing with with the potential to induce mild stomach dis- negative outcomes are reviewed by Olatunji comfort (e.g., moderate exercise immediately fol- et al. ( 2009 ) . lowing consumption of a large meal). Although such exposure tasks may be useful, they would Exposure therapy is harmful to the therapist . This not provide suffi cient corrective information treatment is often viewed as posing a number of regarding the client’s principal feared outcome. risks to the therapist. Concerns about one’s abil- Accordingly, the client would fail to learn that the ity to tolerate the client’s negative affect repre- act of vomiting itself is acceptably safe and toler- sent a signifi cant therapist barrier to the able (albeit unpleasant) and might continue to dissemination of exposure therapy (Litz, 2002 ) . postpone her plans for starting a family. This concern may be especially likely to arise in Exposure therapists can take heart in the real- the context of imaginal exposure for PTSD, dur- ization that, by de fi nition, individuals with anxi- ing which the therapist listens to detailed accounts ety disorders are already experiencing signi fi cant of often horrifying trauma narratives. Some ther- anxiety symptoms in their daily lives. As such, apists believe that such experiences can be the experience of high anxiety during exposure “vicariously traumatizing” and produce persis- tasks is not novel and in most cases is likely to be tent, negative psychological effects. Other practi- no more intolerable or dangerous than the anxi- tioners may question their ability to tolerate their ety symptoms clients are used to dealing with own negative affect during particularly intense from time to time. It is also useful for therapists exposure sessions. to remember that despite its distressing and some- Clinicians who believe exposure to be inhu- times dramatic nature, anxiety is an adaptive mane, intolerably aversive, or potentially danger- response that is designed to protect us from harm. ous may also worry about the legal risks associated It is rather absurd to suppose that evolution with the use of this treatment. Boundary cross- equipped humans with an alarm system for deal- ings associated with exposure sessions conducted ing with threats to our survival that is, itself, outside the of fi ce might be viewed as paving the dangerous. way for an inappropriate dual relationship. A very large body of research attests to the tol- Therapists may believe that especially anxiety- erability, safety, and ef fi cacy of exposure therapy. provoking exposure tasks increase the risk of This treatment is not reliably associated with malpractice lawsuits from clients who may dec- increased risk of client attrition relative to other ompensate and/or experience harm in other ways psychotherapies, and symptom exacerbation is from the treatment. rare, temporary if it occurs at all, and unrelated to The following case examples help to illustrate prognosis (Olatunji et al., 2009 ) . These observa- the manner in which negative therapist beliefs tions aside, it is undeniable that the unique about exposure may affect its delivery: 370 B.J. Deacon and N.R. Farrell

Mr . L , age 50 , was repeatedly sexually abused accompanying the client. Given that the client is in his early teens by a 16 - year -old boy . He is currently unable to perform this task on her own, ashamed of his failure to fi ght off the perpetrator the failure to conduct this exposure in a therapist- and frequently bursts into tears when discussing assisted manner increases the risk that the expo- his sexual abuse history . He attempts to suppress sure would result in a negative outcome, such as memories of the abuse and avoids external cues the client prematurely terminating the task due to associated with the trauma . high anxiety. Such an outcome might decrease Ms . W , age 23 , experiences frequent , unex- the client’s self-effi cacy and foster the perception pected panic attacks during which she fears that that she will not be able to fully bene fi t from she will suffocate and die . She requires the pres- exposure therapy. ence of a trusted friend or family member when Practitioners who lack the ability to tolerate leaving home and avoids traveling more than a their own distress during exposure therapy ses- few miles from a local hospital next to her home sions are ill equipped to provide this treatment in where she frequents the emergency room . a competent fashion. We agree with Gunter and The use of imaginal exposure would doubtless Whittal’s (2010 ) contention that “trust in the evoke substantial distress for Mr. L., and a thera- intervention, comfort in administering it, and pist concerned about his or her own ability to tol- confi dence in one’s ability to address client reac- erate the client’s anxiety might elect not to use tions to exposure treatment are all vital prerequi- this procedure. Alternatively, the therapist might sites to the use of exposure in clinical practice” attempt to minimize the client’s anxiety by imple- (p. 196). Exposure therapists must strike a bal- menting imaginal exposure in a client self- ance between empathy for their client’s distress directed manner or by allowing the client to and maintaining a professional distance that refrain from elaborating on the most distressing allows for therapeutic, professional responses elements of the trauma narratives during therapy (Foa & Rothbaum, 1998 ) . This balance is dif fi cult sessions. Therapists who attempt to protect them- to maintain in some instances, as when trauma selves from emotional distress during exposure victims recount particularly terrible experiences run the risk of depriving clients from fully over- during imaginal exposure. However, even the coming their pathological anxiety. In the case of most compassionate therapist must remember Mr. L., failure to conduct prolonged imaginal that it is his or her job to assist the client in recov- exposure might prevent him from emotionally ery from clinical anxiety, and losing emotional processing the full range of memories associated control or withholding exposure therapy is with his history of sexual abuse. The client’s fail- incompatible with this goal. Indeed, clients draw ure to habituate to particularly distressing trau- strength from the therapist’s outward expressions matic memories would likely maintain his of confi dence in their ability to tolerate the dis- avoidance and belief that he is unable to tolerate tress associated with particularly diffi cult expo- the distress associated with recalling memories sures. An important aspect of one’s development of his trauma history. as an exposure therapist involves learning to cope In vivo exposure for Ms. W. might involve with and accept the emotional distress clients traveling increasingly further outside her “safe exhibit during particularly challenging therapeu- zone” around the hospital. An obvious exposure tic tasks. From time to time, unburdening oneself task would be for her to drive outside of town to by talking to colleagues, or seeking distraction in a rural area where immediate help would be the form of other professional or personal activi- unavailable in the event of a panic attack. A ther- ties, is useful to cope with the unique demands of apist who is overly concerned with the ethical exposure therapy. “slippery slope” of conducting an out-of-the- Therapists who believe that exposure therapy offi ce exposure with a client of the opposite sex poses a risk management problem would bene fi t might assign this task as homework rather than from the knowledge that the anxiety evoked dur- risking the appearance of impropriety by ing exposure sessions is generally tolerable, 23 Therapist Barriers to Exposure 371 harmless, and no different from what clients are therapists alike. Because of such beliefs, efforts already experiencing. Reassuringly, there is no to disseminate exposure therapy to practitioners evidence to suggest that exposure is associated likely require more than simple instruction in the with an increased risk of litigation. Richard and nuts and bolts of the application of exposure Gloster (2007 ) searched the legal record for court techniques. cases involving exposure therapy. Their exhaus- Clinical scientists continue to strive to improve tive search criteria did not reveal a single instance the ef fi cacy (e.g., Rapee, Gaston, & Abbott, of litigation related to this treatment. Similarly, 2009 ) and acceptability (e.g., Rachman, none of the 84 members of the Anxiety Disorders Radomsky, & Shafran, 2008 ) of exposure therapy Association of America surveyed by Richard and and will doubtless do so for the foreseeable Gloster reported knowledge of any legal action or future. However, the evidence base for existing ethics complaints regarding exposure. This sur- exposure-based cognitive-behavioral therapies is vey approach, however, cannot rule out the pos- now suf fi ciently well developed that efforts at sibility that relevant complaints have been fi led dissemination are proceeding in earnest (McHugh but dismissed or settled out of court. Lastly, we & Barlow, 2010 ) . In the United States, the most note that malpractice insurance carriers appear prominent example is the widespread effort unconcerned with the use of exposure. Malpractice within the Veteran’s Health Administration to rates are much lower for psychotherapy than for train therapists in evidence-based psychothera- many other healthcare providers, and we are not pies for PTSD, including prolonged exposure aware of any insurance companies that charge therapy (Foa, Hembree, & Rothbaum, 2007 ) . The higher premiums for therapists who provide Improving Access to Psychological Therapies exposure therapy. In summary, the available evi- (IAPT) program in the United Kingdom is the dence suggests that exposure is acceptably safe most extensive dissemination effort in the world. and tolerable and that it carries little risk of In 2010, the Department of Health invested actively harming clients (or their therapists). approximately £300 million (approximately $435 million U.S. dollars) to train healthcare professionals in evidence-based treatments for depres- Conclusions and Future Directions sion and anxiety, and early clinical outcomes are impressive (Clark et al., 2009 ) . Exposure-based CBT is the most evidence-based Empirical research on the nature and psychological treatment for pathological anxiety. modifi cation of therapist barriers to exposure has Unfortunately, clients suffering from anxiety dis- the potential to improve efforts to disseminate orders are often unable to access this intervention this treatment to mental health professionals. owing to the widespread failure to disseminate it Future studies might address the following ques- to practitioners. This chapter reviews the numer- tions: (a) What are the negative beliefs about ous and formidable barriers that prevent mental exposure therapy held by therapists? (b) How do health practitioners from utilizing exposure ther- such beliefs affect whether or not, and how, thera- apy. However, the poor utilization of exposure is pists utilize exposure techniques in their practice? only part of the story, as a host of additional bar- (c) How do negative therapist beliefs about expo- riers may serve to reduce the ef fi cacy of exposure sure affect client outcomes? (d) What training therapy even when it is delivered by trained strategies are most effective in modifying nega- therapists. tive beliefs about exposure? (e) To what extent is Exposure therapy is a uniquely dif fi cult treat- the success of efforts to train practitioners in the ment to disseminate. Strong, negative beliefs competent delivery of exposure therapy contin- about this intervention are pervasive among men- gent upon modi fi cation of negative beliefs about tal health professionals. Despite its well-established this treatment? Efforts to develop measurement effi cacy, exposure is widely considered to be tools for assessing therapist beliefs about expo- unethical, harmful, and intolerable for clients and sure are under way, and researchers are beginning 372 B.J. Deacon and N.R. Farrell to tackle these questions in a systematic manner know about evidence-based practice: Familiarity with (e.g., Harned, Dimeff, Woodcock, & Skutch, online resources and research methods. Journal of Clinical Psychology, 67 , 329Ð339. 2011) . Despite a host of practical and ideological Böhm, K., Förstner, U., Külz, A., & Voderholzer, U. barriers, substantial progress is being made in the (2008). Versorgungsrealität der zwangsstörungen: dissemination of exposure-based treatments for Werden expositionsverfahren eingesetzt? anxiety disorders. We hope that the information Verhaltenstherapie, 18 , 18Ð24. Brown, A., Deacon, B. J., Abramowitz, J. S., & Whiteside, presented in this chapter will encourage addi- S. P. (2007). 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Retrieved January 31, 2011, from http:// Taylor, C. B., King, R., Margraf, J., Ehlers, A., Telch, M., guidance.nice.org.uk/CG . Roth, W. T., et al. (1989). Use of medication and Norton, G. R., Allen, G. E., & Hilton, J. (1983). The social in vivo exposure in volunteers for panic disorder validity of treatments for agoraphobia. Behaviour research. The American Journal of Psychiatry, 146 , Research and Therapy, 21 , 393Ð399. 1423Ð1426. Olatunji, B. O., Cisler, J., & Deacon, B. J. (2010). Effi cacy van Minnen, A., Hendriks, L., & Olff, M. (2010). When of cognitive behavioral therapy for anxiety disorders: do trauma experts choose exposure therapy for PTSD A review of meta-analytic fi ndings. Psychiatric Clinics patients? A controlled study of therapist and patient of North America, 33 , 557Ð577. factors. Behaviour Research and Therapy, 48 , Olatunji, B. O., Deacon, B. J., & Abramowitz, J. S. (2009). 312Ð320. The cruelest cure? Ethical issues in the implementa- Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, tion of exposure-based treatments. Cognitive and S. E., Betts, K., Mufson, L., et al. (2006). National sur- Behavioral Practice, 16 , 172Ð180. vey of psychotherapy training in psychiatry, psychol- Pediatric OCD Treatment Study (POTS) Team. (2004). ogy, and social work. Archives of General Psychiatry, Cognitive-behavior therapy, sertraline, and their com- 63 , 925Ð934. bination for children and adolescents with obsessive- Wolfe, R. M., Sharp, L. K., & Wang, R. M. (2004). Family compulsive disorder: The Pediatric OCD Treatment physicians’ opinions and attitudes to three clinical Study (POTS) randomized controlled trial. Journal of practice guidelines. The Journal of the American the American Medical Association, 292 , 1969Ð1976. Board of Family Practice, 17 , 150Ð157. Persons, J. B., & Silberschatz, G. (1998). Are results of Young, A. S., Klap, R., Sherbourne, C. D., & Wells, K. B. randomized controlled trials useful to psychothera- (2001). The quality of care for depressive and anxiety pists? Journal of Consulting and Clinical Psychology, disorders in the United States. Archives of General 66 , 126Ð135. Psychiatry, 58 , 55Ð61. Rachman, S., Radomsky, A., & Shafran, R. (2008). Safety Young, A. S., Klap, R., Shoai, R., & Wells, K. B. (2008). behaviors: A reconsideration. Behaviour Research Persistent depression and anxiety in the United States. and Therapy, 46 , 163Ð173. Psychiatric Services, 59 , 1391Ð1398. Harnessing the Web: Internet and Self-Help Therapy for People 2 4 with Obsessive–Compulsive Disorder and Posttraumatic Stress Disorder

Steffen Moritz , Kiara R. Timpano , Charlotte E. Wittekind , and Christine Knaevelsrud

People with an acute eye infection, a broken leg, tem and then consider speci fi c illness-related or abdominal pain will seek help from a physi- reasons for treatment abstinence. Many of the cian usually without much hesitation. In contrast, treatment barriers discussed have been identi fi ed the threshold to consult a treatment provider for across different cultures and nations, and as we disorders labeled as psychiatric or psychological hope to demonstrate, Internet and self-help ther- is much higher. Often, many years pass until apy may provide an effective and timely solution professional help is sought and for some patients to some of the current challenges faced by the traditional mental health care specialists (i.e., psychiatric-psychological help system. a psychologist and/or psychiatrist) are not even the fi rst choice. Before turning to the primary focus of this chapter—self-help and Internet ther- Reasons for Not Seeking apy for obsessive-compulsive disorder (OCD) Psychological or Psychiatric Help and posttraumatic stress disorder (PTSD)—we will brie fl y summarize why and to what extent Most individuals with psychiatric disorders do people with mental disorders refrain from or are not receive psychological or psychiatric treat- deprived of ef fi cacious therapy. This section is ment because treatment is either not available, meant to highlight the necessity for alternative denied, or not competently delivered. Moreover, approaches to help to “treat the untreated.” We as we will discuss in greater detail below, a large will begin with a review of more general reserva- subgroup of patients choose not to pursue treat- tions of many patients against the health care sys- ment options. Further, the conventional healthcare system is increasingly challenged by alternative medicine (AM). A recent German study reported that 37% of psychiatric patients had visited a healing or alternative practitioner S. Moritz (*) ¥ C. E. Wittekind Department of Psychiatry and Psychotherapy , (“Heilpraktiker”) before their hospital stay University Medical Center in Hamburg-Eppendorf , (Demling, Neubauer, Luderer, & Worthmuller, Martinistrasse 52 , Hamburg 20246 , Germany 2002 ) . In the United States, 21% of the people e-mail: [email protected] with mental disorders had sought alternative or K. R. Timpano complementary medicine during the last 12 Department of Psychology , University of Miami , months (Unützer et al., 2000) , and up to 50% of Coral Gables , P.O. Box 248185 , FL 33124-0751 , USA the general population in English-speaking coun- C. Knaevelsrud tries consult therapists specialized in AM Clinical Psychology and Psychotherapy , Free University Berlin , Habelschwerdter Allee 45, Room JK 26/208 , (Silenzio, 2002 ) . Many patients do this in Berlin 14195 , Germany secrecy, fearing to be judged as “traitors” by

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 375 DOI 10.1007/978-1-4614-6458-7_24, © Springer Science+Business Media New York 2013 376 S. Moritz et al. their physicians (White, 2000 ) . Importantly, large Hottenrott, & Moritz, 2010 ) disclosed that they proportions of patients with mental illness as fear becoming “mad” or “dangerous,” and two- well as the general public are very critical of thirds were ashamed of their mental illness. pharmacotherapy, which is often (mis-)perceived Accordingly, a number of patients are afraid to as the standard, fi rst-line intervention of the be questioned by the police or may lose their psychiatric/psychological health care system children if they disclose aggressive obsessions. (Angermeyer & Matschinger, 1996; Lauber, A related study in the United States (Marques Nordt, & Rossler, 2005; Moritz, Peters, Karow, et al., 2010 ) examined the extent of treatment Deljkovic, & Naber, 2009) . Approximately 60% utilization and barriers to treatment in a sample of the psychiatric population shares the opinion of 175 individuals recruited over the Internet that conventional (chemical) medication should with (self-reported) OCD. While the rates of only be taken when herbal remedies are not treatment utilization were a bit higher than those effective (Demling et al., 2002 ) . reported by the WHO, only 60% of the participants were currently receiving treatment for their OCD symptoms. The following barriers to treat- Mind the (Treatment) Gap! ment were identi fi ed: cost of treatment, lack of insurance coverage, shame, and doubt that treat- Perhaps the most common reason why psychiat- ment would be effective. Importantly, many par- ric disorders are not treated is lack of money and/ ticipants received treatments other than the or poor availability of appropriate interventions. gold-standard interventions. This was particu- In fact, a large proportion of people are deprived larly true for psychotherapy; the majority of par- of any medical help, regardless if it is conven- ticipants received mere “talk therapy” rather tional or alternative in nature. Around 70% of the than the empirically validated cognitive behav- world population has access to less than 1 psy- ioral therapy. chiatrist per 100,000 inhabitants. In some African regions, the ratio drops to 1 per 5,000,000 in contrast to 0.5Ð1 per 10,000 in European countries The Use of the Internet and Self-Help (Klecha, Barke, & Gureje, 2004 ) . In many devel- Books for (Self-)Treatment oping countries and those struck by war, no psychiatric system exists at all. Many of these There is growing evidence that many people not countries lack the most basic medical care. Even actively engaged in face-to-face treatment look in countries that have established a working for health/treatment information on the Internet, health care system, individuals living in remote engage in Internet networks devoted to their areas may not have access to treatment providers problems, or turn to self-help books. A Norwegian (Wootton & Titov, 2010 ) . study estimates that in 2010, 84% of the The World Health Organization (WHO) has Norwegian population has been using the Internet estimated that only 40% of individuals with for health purposes (Wangberg, Andreassen, OCD actually receive professional care (Kohn, Kummervold, Wynn, & S¿rensen, 2009 ) , which Saxena, Levav, & Saraceno, 2004) . The corre- is roughly equivalent with data obtained in sponding rates for PTSD are varying across dif- Germany (Otto & Eichenberg, 2010 ) . Of 2,411 ferent populations (combat veterans, victims of German people from the general population, sexual violence, crime victims) and range approximately 90% appraised the Internet as between 25 and 40% (e.g., Elhai, North, & potentially useful for seeking health information Frueh, 2005; Hoge, Auchterlonie, & Milliken, and around 40% would consider communicating 2006 ) . For these populations, shame and stigma with people with similar problems in an Internet are predominant motives for treatment absti- forum (Eichenberg, Blokus, & Brähler, 2010 ) . nence. In a recent survey, a substantial subgroup According to the German survey by Otto and of OCD patients (Hauschildt, Jelinek, Randjbar, Eichenberg ( 2010) , almost every fourth patient 24 Harnessing the Web: Internet and Self-Help Therapy for People... 377 informs her- or himself on the Internet before included overall usefulness, grounding in psy- seeing a clinician (22.95%), and 89% of the phy- chological science, the extent to which it offers sicians have experience with patients who refer- reasonable expectations, and whether it offers ence Internet-based health information during specifi c guidance for implementing the self-help treatment (Masters, 2008 ) . As the sections below techniques or offers potentially harmful advice. will demonstrate, the Internet is a vital tool not Results demonstrated that fi ve OCD books were only for the assessment but also the delivery of identifi ed as “high quality” and were among the treatment via email or online tools. “top ten,” whereas books on PTSD received In addition to the Internet, a more conven- mostly lower marks and one was even identifi ed tional way to obtain health/treatment information as potentially harmful. is by the means of books. A total of 75% of the Some therapists have actively responded to participants with OCD af fi rmed that they had this new trend of patients using self-help biblio- read at least one self-help book on OCD (Moritz, therapy materials and searching the Internet to Wess, Treszl & Jelinek, 2011 ) . Bibliotherapy is acquire knowledge. As cited above, more than not only popular with patients but is also endorsed four out of fi ve clinicians recommend bibliother- by 85% of clinicians as an adjunct to face-to-face apy or the participation in self-help groups for treatment. A similar number of clinicians (82%) their patients (cited after Harwood & L’Abate, recommends self-help groups (Harwood & 2009 ) . According to a German survey (Eichenberg L’Abate, 2009 ) . The development and use of self- et al., 2010 ) , most therapists offer email commu- help bibliotherapy is not without problems. nication to their patients (92.3%), for example, Unlike new clinical interventions, which neces- for the purpose of crisis intervention or informa- sitate approval by ethical review boards and are tion exchange. Given the ubiquitous nature of in many cases only employed following large- email, it may be surprising that in reality a factual scale empirical support and their inclusion into exchange takes place only in every 15th patient. national guidelines, self-help books can be pub- It should also be noted that most survey respon- lished by anyone. A conventional publisher is not dents regarded email usage merely as an adjunct even necessary as self- or electronic publishing to direct intervention (i.e., not as a stand-alone facilities are widely available. The advertisement intervention). There also remains a substantial of these books is also not rigorously regulated. minority of psychotherapists who entirely reject Most online bookstores have established a para- online communication in a counseling (22%) or academic peer-review system where readers or therapeutic (45%) context, largely due to prob- lay people provide reviews. These endorsements lems associated with data privacy and safety. are often prone to biases and may perhaps even blatantly mislead the reader. Harwood and L’Abate (2009 ) write “a problem with commer- Studies Conducted over the Internet: cially available self-help materials is that system- Pros and Cons atic evaluation of their effectiveness is not easy to obtain” (p. 63). A recent evaluation raised grave Internet surveys are an innovative mechanism that concerns even against self-help “best sellers.” allows the research community to examine the The assessment by Shaked ( 2005 ) on ten contem- effectiveness of self-help books and Internet treat- porary and popular personal self-help books ments and also provide a means by which a cur- published between 1997 and 2002 arrived at the rently underserved population can be reached. conclusion that most of these books lack empiri- Numerous sophisticated online tools exist that cal support to a moderate extent. Another study enable researchers to administer questionnaires asked expert psychologists to assess 50 top-sell- and collect data over the Internet (e.g., http:// ing self-help books for anxiety, depressive, and www.unipark.info/ or http://www.limesurvey. trauma-related disorders (Redding, Herbert, org/ ). The section below on “Bibliotherapy in Forman, & Gaudiano, 2008 ) . Criteria for evaluation OCD ” provides several examples for this kind of 378 S. Moritz et al.

Table 24.1 Arguments for and against online studies to evaluate Internet therapy and self-help books Pro Con Provides help at a low threshold: especially valuable for individuals currently Diagnostic status is hard to verify: on a waitlist for treatment or who are at present unwilling or unable to obtain expert ratings are generally favored treatment (no therapies offered because of war, third world country, political/ over self-help instruments cultural paradigm [e.g., psychological disorder erroneously considered as religious sin], no health insurance) Economic: far less costly than standard studies Psychotherapy by a psychothera- pist is likely more helpful than an Internet therapy (for exceptions see Carlbring et al., 2005 ; Kiropoulos et al., 2008 ) Effective option to assess the ef ﬁ cacy of self-help manuals Crisis intervention is hard to implement Reliability and completion rates are satisfactory when certain precautions are Completion rates can be very low; taken (e.g., incentives, reminders) psychometric properties of many paper-and-pencil tests are largely unknown for Internet administration Multiple log-ons cannot entirely be prevented in the event that cookies are deleted

research. Table 24.1 contrasts a number of pros methodological issues. Internet studies assessing and cons for conducting this type of research. A the ef ﬁ cacy of psychological interventions strong argument in favor of Internet studies is that (e.g., email, Internet-based therapy, self-help bib- they are economic, from both a monetary and a liotherapy, guided self-help) often have low com- time perspective. Internet studies are particularly pletion rates (e.g., Meyer et al., 2009 ) . There are useful when assessing the validity of alternative also concerns about the validity of diagnoses and medical approaches that would unlikely receive the appropriate measures that should be adopted external funding by prominent research organiza- in case of emergencies/crisis. Another concern tions such as the National Institute of Mental about the online evaluation of symptoms and Health, the German Research Foundation, or the treatment responses relates to the psychometric Wellcome Institute. Internet studies can also pro- properties of self-report instruments used in vide an informative basis for which book or self- Internet studies. Traditionally, clinician ratings help technique should be recommended to patients are regarded as the gold standard; such direct after discharge or patients on a waitlist. It often interviews are often not feasible in Internet stud- takes 10 years until OCD patients seek profes- ies. A growing number of studies, however, assert sional help for their problems, and there can be an satisfactory to very good psychometric properties additional lag of 6 or more years until the diagno- of scales administered over the Internet (e.g., sis is correctly determined and appropriate treat- Moritz, Jelinek, Hauschildt, & Naber, 2010 ) . For ment is initiated (Blanco et al., 2006 ; Hollander example, in one of our Internet studies, which will et al., 1996 ; Pinto, Mancebo, Eisen, Pagano, & be reviewed in greater detail below, a self-report Rasmussen, 2006 ) . From this perspective, self- version of the Yale-Brown Obsessive-Compulsive help literature represents a useful mechanism to Scale (Y-BOCS) (Goodman et al., 1989) , the potentially bridge the treatment gap and may even major outcome instrument in OCD research, enhance motivation for face-to-face treatment. yielded a 4-week retest reliability of r = 0.8 The most poignant problems and challenges to and was highly correlated (r = 0.6) with the conducting Internet studies lie in inherent Obsessive-Compulsive Inventory-Revised (OCI-R) 24 Harnessing the Web: Internet and Self-Help Therapy for People... 379

(Foa et al., 2002 ) , another OCD scale (Moritz, Harwood and L’Abate ( 2009 ) provided a more Jelinek, et al., 2010 ) . A study by Coles, Cook, and critical appraisal: “In general, across a variety of Blake ( 2007 ) directly compared paper vs. Internet self-help approaches for the treatment of OCD, administration of the Obsessive-Compulsive good outcomes appear to occur in less than 50% Inventory (OCI) (Foa, Kozak, Salkovskis, Coles, of patients” (p. 65). However, it should be stressed & Amir, 1998 ) . Results assert that the two for- that clinical studies often struggle with similarly mats were virtually equivalent. low response rates when dropout is included. Moreover, as Harwood and L’Abate ( 2009 ) recognized, low outcome may not relate to self- Empirical Studies on Internet and help per se but rather to the speci fi c technique or Self-Help Therapy for OCD and PTSD intervention employed. Most studies summarized below reported As mentioned above, a large proportion of symptom relief under self-help or Internet ther- patients in need of treatment never sees the inside apy, although the magnitude of symptom reduc- of a psychiatric hospital or specialist’s offi ce. In tion tended to be lower than that expected by OCD, this population has been estimated at standard face-to-face therapy. However, Mataix- roughly 60% (Kohn et al., 2004 ) . In other words, Cols and Marks (2006 ) noted that “making effec- only 40% of those with clinically impairing OCD tive self-treatment guidance available may symptoms actually seek treatment, and of the increase the number of patients being helped” minority who do, most wait an average of 10 (p. 75)—even if no optimal level of symptom years or more to ultimately seek a treatment pro- reduction is achieved. At the same time, a meth- vider (Marques et al., 2010 ) . In PTSD the extent odological caveat lies in the fact that virtually all of the problem is comparable (Hoge et al., 2006 ) self-help studies conducted so far included an and so are the reasons, particularly perceived element of therapeutic guidance. Pre-post assess- stigma and poor treatment availability (Pietrzak, ments in many studies summarized below were Johnson, Goldstein, Malley, & Southwick, 2009 ) . made in a clinical environment which likely In the subsequent subsections, the available scared off some potential participants reluctant to research on self-help and Internet therapy for seek treatment because of anxiety (fear to be OCD and PTSD is summarized. The closing sec- treated against one’s will because of severe psy- tion will provide a summary and some recom- chopathology and “public danger”), shame (e.g., mendations for future research. to be judged as “pervert” due to aggressive and sexual obsessions), and avoidance (e.g., fear of an in-depth confrontation with traumatic memo- Obsessive-Compulsive Disorder ries). Since the review by Mataix-Cols and Marks ( 2006) , new studies have been conducted. A The literature on Internet therapy and self-help growing number did not include direct therapeu- interventions for OCD prior to 2006 was fi rst tic support and thus represent a more uncon- summarized by Mataix-Cols and Marks ( 2006 ) . founded assessment for the effectiveness of In their review considering case studies, open and self-help. randomized controlled trials (RCTs) of bibliotherapy, self-help groups, telecare, and computer- aided self-help for OCD, they expressed guarded Computer- and Phone-Assisted optimism for this novel (nondirective) approach Therapy in OCD and recommended a stepped care model. Whereas for less complex cases self-help or bibliotherapy The implementation of computer-aided therapy with brief help-line live advice may suffi ce, for for OCD dates back to the 1980s, when Baer and more severely disturbed patients, intensive face- colleagues developed a computer program to-face guidance was deemed indispensable. (OC-CHECK) to enhance patients’ compliance 380 S. Moritz et al. with behavioral therapy (Baer, Minichiello, & the Padua Inventory (PI) (Sanavio, 1988 ) and the Jenike, 1987 ) . Each of the two patients who par- Beck Depression Inventory (BDI), but improve- ticipated in the study was provided with two por- ment on the Y-BOCS was nonsigni fi cant. table computers: a laptop that was used at home A recent study tested the effectiveness of an familiarizing the patients with the procedure and existing online-group treatment for compulsive a smaller, calculator-size computer to carry with hoarding 1 (Muroff, Steketee, Himle, & Frost, them outside of the home. The program was 2010 ) . The program requires members to take designed to help patients refrain from ritualizing, active steps to reduce compulsive hoarding and to by asking them to resist the urge for 3 min. post their activities on a regular basis. The web Furthermore, OC-CHECK stored information training is based on CBT methods. Members about the date, time, intensity, and frequency of have electronic access to mental health informa- urges and checking rituals per day. Both patients tion, educational resources on hoarding, and to a reduced their checking rituals signi fi cantly when chat group. The sample consisted of forum mem- the computers were used in conjunction with bers and a natural wait-list group. Data were col- standard behavioral therapy, and in turn, rituals lected via the Internet at fi ve time points over the increased when participants stopped using the course of 1 year (every 3 months). Results indi- computers. Still, two additional study patients cated that recent- as well as long-term members declined to use this approach. One clear limita- improved signi fi cantly over 6 months. Long-term tion consists in the very small sample size ques- members reported fewer hoarding symptoms tioning the validity of the results. These promising than recent members possibly suggesting benefi ts fi ndings should be therefore interpreted with from membership over time. In contrast, wait-list caution. members improved somewhat but not signifi cantly Kirkby et al. (2000 ) tested the ef fi cacy of a on most measures. Differences between recent- humanÐcomputer interaction (HCI; see also and wait-list groups did not reach signi fi cance. Clark, Kirkby, Daniels, & Marks, 1998 ) . Thirteen Less posting activity was associated with greater subjects with OCD (seven mainly washers and hoarding severity. six mainly checkers) completed three weekly Most studies to date have been conducted with 45-min computer-administered treatment ses- BT Steps (now named OCFighter), whereby BT sions consisting of an exposure treatment pro- stands for behavior therapy. The BT Steps system gram, whereby the principles of exposure therapy is a fully interactive computer program accessed and ritual prevention were conveyed by tracking remotely via touch-tone telephone using (phone-) an interactive person with contamination obses- interactive-voice-response (IVR) technology. sions and washing rituals. The participants’ task Patients obtain a manual, an ID number, a per- was to direct the fi gure through a dirt exposure sonal password, and an IVR access at home. It with ritual prevention (ERP) to reduce the fi gure’s guides the patient though an individually tailored anxiety level and its urge to wash. Participants self-help for OCD. BT Steps contained nine were instructed to imagine they were the person steps, whereby the fi rst four steps are devoted to on the computer screen doing the ERPs. During self-assessment. the execution of the program, HCIs were recorded An Anglo-American research group (Marks to describe the participants’ behavior. None of et al., 1998 ) was the fi rst to test BT Steps. In total, the subjects had attended behavioral treatment 63 subjects participated: 40 from the UK and the for OCD prior to the study. Across the three ses- USA in study 1 and 23 from the UK in study 2. sions, participants increased their vicarious expo- At baseline, Y-BOCS, the Hamilton Depression sure behavior and decreased their washing behavior. The clinical improvement was greater 1 for subjects who performed more enactments of Hoarding will not be classi fi ed as an obsessive-compulsive disorder in the DSM-V suggesting that hoarding hand washing in the fi rst session. Scores from the might differ substantially in form, aetiology, and treat- OCD subjects fell modestly but signi fi cantly on ment from other presentations of OCD. 24 Harnessing the Web: Internet and Self-Help Therapy for People... 381

Rating Scale (HDRS) as well as the Work/Social nician could include either nine scheduled, Adjustment Scale (WSAS) were assessed. therapist-initiated phone calls (n = 22) or took Additionally, in study 2, patients rated under- place only on request from the patients (n = 22). standing of exposure therapy and their motivation The latter group was instructed to call the clinic if to use BT Steps. After completion of BT Steps, they had problems working through BT Steps. At all participants were asked to complete the same baseline, patients reported chronic OCD symp- questionnaires as before. Symptom change was toms (mean duration = 16 years; mean rated using a single-item version of the Patient Y-BOCS = 26) and moderate depressive symp- Global Improvement (PGI). The two studies toms. After the intervention, both groups revealed similar outcomes: 84% of the 63 sub- improved signifi cantly in OCD symptoms and jects completed the self-assessment component disability (WSAS). However, signifi cantly fewer and 43% (study 1) to 48% (study 2) of the partici- scheduled-support patients dropped out (2 vs. 9) pants proceeded to the self-treatment part. and for this group improvement was signifi cantly Improvement only occurred when participants greater on the Y-BOCS and the WSAS total went on to perform self-exposure. If participants score. Furthermore, scheduled-support patients completed more than one ERP task, they improved completed more homework sessions of self- signifi cantly on Y-BOCS and WSAS scores. 71% exposure and ritual prevention (95% vs. 57%). of the participants rated themselves as responders Total support time was 76 min per patient for the (PGI). Performing more ERPs was associated scheduled patients and 16 min for the on-demand with greater gains. In study 2, high motivation at group. In summary, patients’ compliance and baseline and rapid completion of the self-assess- improvement in BT Steps was enhanced by pro- ment signi fi cantly predicted lower symptoms at viding proactive phone calls from a clinician. posttreatment. In another study, Greist et al. (2002 ) assessed In a second study on BT Steps (Bachofen the effi cacy of BT Steps. The participants con- et al., 1999 ) , 21 patients initially participated, sisted of 218 OCD patients meeting DSM-IV-TR whereby 16 completed self-assessment over a criteria who were randomly assigned to one of mean of 21 days and rated themselves at baseline the following treatment options: (1) BT Steps, (2) and at the end of BT Steps on the Y-BOCS, clinician-guided behavior therapy, and (3) sys- HDRS, and on the WSAS. At the end of BT tematic progressive muscle relaxation (PMR; Steps, the 1-item PGI scale was completed along manual-guided). All subjects went through an with scales about motivation. Patients who rated assessment on which different measurements themselves as more motivated at baseline were administered. Data was collected on the improved signi fi cantly more in the course of the Y-BOCS, Patient and Clinical Global Impressions intervention on the Y-BOCS total, Y-BOCS scales (PGI & CGI), WSAS, and the HDRS. The obsessions, and WSAS social leisure item scores. treatment duration for all groups took 10 weeks. Baseline motivation was also higher in patients Treatment outcome revealed that systematic who went on to do two or more ERP sessions relaxation therapy was ineffective to help patients than in those who did not. The outcomes across with OCD (see also Moritz et al., 2010 ). OCD the two open studies are similar, but the patients subjects obtaining a computer-guided therapy in the present study progressed more rapidly. showed signifi cant improvement on the Y-BOCS, Kenwright, Marks, Graham, Franses, and the CGI, and PGI scales, although clinician- Mataix-Cols (2005 ) studied the impact of phone guided treatment was more effective. The ef fi cacy support from a clinician (scheduled support vs. of the computer-guided treatment increased with requested support) for the compliance and out- greater use of the computer and higher frequency come of BT Steps. A total of 44 therapy resistant of instructed self-exposure. OCD patients from around the UK used the pro- Marks et al. ( 2003 ) investigated the ef fi cacy of gram over 17 weeks. All participants received the four different self-help programs for depression rationale of BT Steps. Phone support from a cli- (Cope), phobia/panic (FearFighter), general 382 S. Moritz et al. anxiety (Balance), and OCD (BT Steps). Different posttreatment and at 3-month follow-up. The self-ratings were collected at pre- and posttreat- wait-list control group (n = 15) was reassessed ment. Dependent on the patient’s diagnosis, they after 4 weeks (no follow-up). Outcome was either received the Fear Questionnaire (for pho- assessed with the Clinical Global Impression bia/panic), the BDI (for depression), the Beck Scales (CGI-Severity/CGI-Improvement), the Anxiety Inventory (for generalized anxiety disor- CY-BOCS, the ADIS-IV-C/P, the Child der), or the Y-BOCS (OCD). Out of 355 referrals, Obsessive-Compulsive Impact Scale Child and 210 were screened and identi fi ed as eligible, and Parent (COIS-C/P), the Multidimensional 108 eligibles completed the computer-aided CBT. Anxiety Scale for Children (MASC), the The fi ndings showed a statistically signifi cant Children’s Depression Inventory (CDI), Family improvement in three of four systems (Fear Accommodation, and a Satisfaction with Services Fighter, Cope, and BT Steps). The completers Scale. When controlling for baseline group dif- needed a per-patient overall mean support of only ferences, W-CBT was superior on all primary about 1 h over 12 weeks by a clinician (CBT: at outcome measures (CY-BOCS, CGI, remission least 8 h per clinician). In addition, the patients status) with very large effect sizes ( d ³ 1.36). were satis fi ed with their computer-aided CBT. Average CY-BOCS reduction was 56.1% for The authors conclude that computer-aided self- W-CBT (waitlist—12.9%). Eighty-one percent help could be a “clinician extender” shortening of the W-CBT participants were considered treat- the patient time per clinician and thus reducing ment responders (waitlist—13%) and 56% met the costs for CBT. remission criteria (waitlist—13%). Despite a With the exception of the fi nal study, the lit- slight increase of symptom severity over time, erature on BT Steps has been reviewed by Tumur, gains were generally maintained in the follow- Kaltenthaler, Ferriter, Beverley, and Parry (2007 ) . up. Participants improved signi fi cantly in the They conclude that BT Steps may broaden the COIS-C and family accommodation. access to CBT and potentially save therapist’s Improvements in the MASC and the CDI did not time which in turn may shorten waiting periods reach signi fi cance. for OCD patients. However, they note potential problems with the current empirical basis in that a publication bias cannot be ruled out and only Bibliotherapy in OCD two investigations were planned as RCTs with adequate quality. The pilot studies are also This section is devoted to the evaluation of bib- plagued by high dropout rates. Overall, we agree liotherapy for OCD, whereby most studies have with the evaluation of Tumur et al. “that BT Steps been conducted over the Internet. The fi rst study is an important treatment strategy that could have of this kind was by Fritzler, Hecker, and Losee an important role in the future of psychological ( 1997 ) who explored the ef fi cacy of self-directed treatment” (p. 201). treatment in OCD. Of 12 patients who had ini- A yet unpublished wait-list controlled ran- tially participated, 6 males and 3 females with domized trial (Storch et al., 2011 ) tested the primary checking, cleaning, cleaning/checking, ef fi cacy of a webcam-delivered CBT program and hoarding problems eventually completed the (W-CBT) for children and adolescents with OCD. treatment and met with therapists for fi ve therapy Following pre-assessment, the 31 children and sessions over a 12-week period. Participants were adolescents (7Ð16 years, 12 female) met with provided a self-help book ( When once is not their therapist once in order to build rapport. enough; Steketee & White, 1990 ) on which the Participants assigned to the W-CBT group (n = 16) treatment was founded. Among other topics, it received fourteen 60Ð90-min sessions of family- explained how to implement self-directed expo- based CBT over 12 weeks. Treatment was indi- sure with response prevention. The self-report vidualized to symptom profi le and developmental version of the Y-BOCS was chosen as the primary level. Reassessment took place within 1 week outcome measure. Results demonstrated statistically 24 Harnessing the Web: Internet and Self-Help Therapy for People... 383 signi fi cant improvement for nine patients—three either be neutral or positive and in no overt seman- met criteria for clinical signi fi cance of improve- tic relationship with OCD-related concerns. The ment. The authors concluded that bibliotherapy concept draws upon a cognitive phenomenon with brief therapist intervention may be the fi rst termed the fan effect: The more associations exist choice of intervention for people with OCD but for a given cognition, the less the weight of each also hypothesized that therapists’ professional single association. For example, a patient who is experience may be related to outcome. preoccupied with the number “13”—which for Furthermore, they speculated that this interven- him or her solely means or predicts disaster— tion may be less successful for severely impaired should learn that “13” has alternative neutral patients and presumably also for hoarders. meanings. For example, that the 13th element of A study conducted by Tolin et al. ( 2007 ) the periodic system is aluminum, the USA was directly compared self-administered (guided by initially formed with 13 states and that some the manual Stop Obsessing!) and therapist- prominent sports players have the number 13 on administered ERP (guided by an experienced their jerseys. Novel associations may not extin- doctoral-level psychologist) in a RCT with 41 guish the linkage between a certain cognition with OCD patients. Patients had a history of at least OCD symptoms (i.e., worries, obsessive thoughts, one current or previous adequate psychopharma- compulsions) but may reduce the strength of the cological trial. Overall, the groups were compa- connection and thereby empower the subject to rable according to baseline characteristics, withstand or ignore obsessive urges. A core although the ERP group showed somewhat assumption of the model predicting that individu- more comorbid diagnoses and was a little als with OCD process ambiguous words (e.g., older (40 vs. 34 years). Clinical assessments homographs such as cancer) preferably in the con- were made at pretreatment and posttreatment, text of the OC meaning (i.e., illness) and connect and three additional follow-up assessments were them to a lesser degree to other (neutral or posi- conducted 1, 3, and 6 months later. Whereas ther- tive) cognitions (e.g., animal) has been recently apist-administered ERP was superior to self-help confi rmed (Jelinek, Hottenrott, & Moritz, 2009 ) . (35% vs. 17% improvement from pre- to post- For the evaluation study, a total of 38 people treatment according to ITT), self-help also with a likely diagnosis of OCD were recruited exerted signi fi cant gains over time. From pre- over the Internet via online OCD self-help treatment to the 6-month follow-up, the therapist- forums. Four weeks after the email dispatch of administered ERP group showed an improvement the association splitting manual, a reassessment of 8.19 points on the Y-BOCS total score. In the was conducted. Pre- and post-assessments self-administered group the score fell 3.3 points included the Maudsley Obsessive-Compulsive during this time. The authors conclude that Inventory (MOCI; Hodgson & Rachman, 1977 ) , although improvement seen under self-adminis- the Y-BOCS, and the BDI. A retrospective rating tered ERP was lower than that of conventionally showed that at least one-third of the subjects felt guided ERP, self-administered ERP represents a that the technique had decreased their symptoms. (cost-)effective intervention for a subgroup of A more rigorous pre-post comparison asserted patients. this for the Y-BOCS score. Depending whether a A study published by one of the authors per protocol or intention to treat analysis was (Moritz, Jelinek, Klinge, & Naber, 2007 ) investi- adopted, 33Ð42% of the participants fulfi lled gated the ef fi cacy of association splitting, a tech- response criteria. As no follow-up was conducted nique aimed at the reduction of obsessive thoughts and no comparison group was recruited, this result (Moritz & Jelinek, 2007 ) . The technique, which is should be interpreted with caution. However, an available in different languages at no cost at www. experimental study, also conducted over the uke.de/assoziationsspaltung, teaches patients to Internet, confi rmed that patients familiar with the generate and associate novel cognitions to fear- association splitting generated the least related OCD cognitions. New associations should OC-related and negative associations to core 384 S. Moritz et al.

OCD words (Jelinek et al., 2009 ) . A recent later. Groups performed similar at both time (Moritz & Jelinek, 2011 ) study in 46 participants points on the self-report version of the Y-BOCS with a likely diagnosis of OCD who were ran- and the OCI-R. The lack of effect was mirrored domly allocated to either association splitting or by patients’ retrospective ratings. The results a wait-list control also showed that our technique speak against the ef fi cacy of ATT as a stand-alone reduces OCD symptoms, especially obsessions, bibliotherapy approach for OCD, even for those as well as depression in the range of a medium to who performed the technique regularly according large effect size. to self-report. The present study demonstrates We have learned several lessons from this pilot another potential advantage of Internet research study. Our subsequent Internet studies now all over clinical studies. Clinical trials usually apply a employ either wait-list or active control partici- “cocktail” of different approaches (ranging from pants. In another study (Moritz et al., 2011 ) the psychopharmacological treatment to occupa- attention training technique (ATT; Wells, White, tional therapy) making treatment effects “messy” & Carter, 1997 ) was administered and tested and hard to attribute to single factors. Internet against a wait-list condition. The ATT is aimed at investigations can keep such confounds low. intrusive thoughts and usually conveyed by a Meridian tapping (MT) is a body-oriented therapist. However, as it is simple to learn and alternative medical technique which among patients can easily perform the technique on their other psychological problems claims to cure own, we reformulated the original instructions as anxiety disorders. It is aggressively promoted a self-help technique. Preferably, two sessions, as an alternative treatment for all kinds of each lasting 15 min, had to be performed each day problems and disturbances. Some of its advo- (see also Fisher & Wells, 2009 , pp. 97Ð100; Wells cates report that at least 70 or even 97% of the & Papageorgiou, 2004 , pp. 266Ð267). In the patients are cured (Craig, 2003 ) . Solid empiri- fi rst step, participants had to detect several dis- cal evidence for its ef fi cacy is scarce, and some tinct noises inside and outside a room. In step 2, studies that were seen as proof for its success attention should be focused for approximately by its propagators can in fact be interpreted 1 min on one of these noises only, before attention differently (see Moritz, Aravena, et al., 2010 ) . is switched to another noise while ignoring all As the theoretical foundations of MT are others. In step 3, once a sound has captured full refuted by many scientists (e.g., Gaudiano & attention, an attention switch to another noise Herbert, 2000 ) , chances for public funding for should be undertaken, whereby attention should a large-scale trial are limited. For the present switch from noises inside to noises outside the study (Moritz, Aravena, et al., 2010 ) , we there- room back and forth. In the fourth and fi nal step, fore tested the ef fi cacy of a published MT self- the patient should contemplate all noises at the help approach for OCD (Raubart & Seebeck, same time and count these. The ATT is an intui- 2008 ) against PMR via the Internet. After a tive method for the treatment of OCD in view of baseline assessment using standard outcome neuropsychological fi ndings (Greisberg & scales (Y-BOCS, OCI-R, BDI short form), 70 McKay, 2003; Külz, Hohagen, & Voderholzer, participants likely suffering from OCD were 2004 ) linking OCD to enhanced rigidity, per- randomly allocated to either MT or to PMR. severation, and poor executive functioning Four weeks after the dispatch of the self-help (however see Basso, Bornstein, Carona, & manuals (including video demonstrations of Morton, 2001; Moritz et al., 2001 ). For the study, the technique), participants were asked to take an invitation was posted on OCD help forums part in a post assessment involving the same and communicated via the web site of the German instruments as before and a retrospective ques- and Swiss OCD Societies. A total of 80 partici- tionnaire. In retrospect, MT was deemed more pants with OCD were recruited and either helpful than PMR (39% vs. 19%). However, assigned to the ATT or a wait-list condition. the more rigorous pre-post assessment yielded Assessments were made at baseline and 4 weeks no evidence for a stronger decline of OCD 24 Harnessing the Web: Internet and Self-Help Therapy for People... 385 symptoms under MT on any of the psychomet- Finally, we evaluated competitive memory ric measures. Importantly, the Y-BOCS scores training (COMET) which has shown some did not even change substantially across time effectiveness in people with low self-esteem for both interventions. The present study thus (e.g., Korrelboom, de Jong, Huijbrechts, & stands in strong opposition to bold claims Daansen, 2009 ) but also severe psychiatric dis- about the ef fi cacy of MT. orders, for example, OCD (Korrelboom, van Recently, our research group has developed der Gaag, Hendriks, Huijbrechts, & Berretty, an eclectic self-help manual entitled “My 2008 ) . In brief, the subject is instructed to blend Metacognitive Training for OCD (myMCT)” obsessive thoughts with competing memories (Moritz, Jelinek, et al., 2010 ) . The myMCT aims of a different modality. For example, if a sub- at raising patients’ awareness about cognitive ject is afraid that he could harm his own child, biases that are broadly regarded as risk and he learns to defuse the obsessive thoughts with maintenance factors of OCD. Among these are real memories that stand in strong opposition the six cognitive biases and beliefs proposed by (e.g., being gentle to one’s child, reading a the OCD working group (Obsessive Compulsive birthday card to the “best dad in the world”). Cognitions Working Group, 1997 ; e.g., infl ated The thoughts should also be attenuated by tak- responsibility, over-estimation of threat, perfec- ing an incompatible (e.g., proud) posture. A tionism; 2001 ; 2003; 2005) . In addition, the total of 65 people with a likely diagnosis of myMCT comprises self-developed techniques OCD were recruited and randomly allocated to like association splitting (see above) or attention either the COMET group (39-page manual) or splitting. The myMCT also touches latent wait-list control. For the primary outcome, the aggression which is frequently found in OCD Y-BOCS, no effects emerged neither for group patients in combination with over-moral atti- nor time nor the interaction. For the BDI and tudes (Moritz, Wahl, et al. 2009) . The training the OCI-R, unspeci fi c improvements occurred was primarily intended for patients currently in both groups. While most subjects (80%) unable or unwilling to attend standard therapy. found the technique comprehensible, our study Via the recruitment channels sought for the prior might not have been a fair test of the technique studies, 86 individuals with a likely diagnosis of as the manual was rather long so that it cannot OCD were recruited over the Internet. Half of be excluded that subjects did not adopt the the participants were immediately sent the approach as intended. We are thus reluctant to myMCT manual; the other half was allocated to draw fi rm conclusions as the method is quite a wait-list group. After 4 weeks, a reassessment complicated and originally conveyed by a was scheduled. The myMCT group showed therapist. signifi cantly greater improvement for OCD symptoms according to the Y-BOCS total score compared with the wait-list group ( d = 0.63), Posttraumatic Stress Disorder particularly for obsessions (d = 0.69). Medium to strong differences emerged for the OCI-R Internet resources and interventions for PTSD (d = 0.70). A signi fi cant but smaller effect was have dramatically increased in the last decade. observed for the short form of the BDI (d = 0.50). Web sites dedicated to information for trauma Since this pilot study, the manual has been survivors are particularly prevalent and address expanded and contains novel exercises on a broad range of traumatic experiences, includ- response prevention and self-esteem and is thus ing sexual violence, fatal diseases, and natural hoped to yield even stronger effects on compul- disasters. Some of these informational web sites sions and depression than the fi rst version. The can be a valuable resource for trauma survivors. manual has been translated into English and is However, there are also examples that present also available in Russian, Portuguese and biased and inaccurate information. One of the German (Moritz, 2010 ) . problems is that web sites lack consensually 386 S. Moritz et al. de fi ned criteria or universal certi fi cates of exclusively cognitive behavioral oriented and approval, making it diffi cult for consumers to translate traditional, empirically supported identify if a web site is run by a professional or approaches into a Web-based interface a trustworthy organization vs. a lay person/orga- (Amstadter, Broman-Fulks, Zinzow, Ruggiero, nization conveying false information. In an & Cercone, 2009 ) . However they vary distinc- analysis of 80 sites targeting trauma survivors, tively according to degree of human support, Bremner, Quinn, Quinn, and Veledar ( 2006 ) ranging along a continuum extending from found that 42% of the web sites provided inac- completely self-help or stand-alone programs curate or even harmful information. Only 18% to primarily therapist-administered treatment cited scientifi c references for the information using a Web-based program to augment the they provided, and 50% of the web sites were intervention. not authorized by mental health professionals. Still, the Internet offers several characteristics that might be bene fi cial for trauma patients. One Internet-Based Self-Help for PTSD such characteristic is the anonymity with which individuals can participate in chat rooms, support Ruggiero et al. (2006) investigated the feasibility groups, or even online interventions. Traumatic of a stand-alone, online-based intervention to events are often associated with degrading and provide mental health resources to trauma vic- shameful experiences (Budden, 2009 ) , which can tims of disaster and terrorist attacks (survivors of give rise to guilt and self-blame (Kubany et al., the 9/11 terrorist attacks). The aim of the pro- 1996 ) . These feelings may in turn be associated gram was to provide information and educational with a reduced readiness to seek therapeutic help resources covering a broad range of relevant clin- in a conventional face-to-face setting. The ical issues (in total seven modules—PTSD/panic, Internet and its (visual) anonymity therefore may depression, worry, alcohol, marijuana, other provide a comparably safe environment where drugs) and to promote effective coping strategies. patients can regulate and control the degree of Based on the user’s clinical symptom pro fi le and intimacy they want to share, without the fear of predefi ned clinical thresholds for relevant symp- real-life judgment, rejection, or devaluation. This tom levels, the relevant self-help modules were mode of communication may reduce (feared) automatically identifi ed and administered. social risks and promotes the disclosure of pain- Module screeners asked about past-year symp- ful and shameful thoughts. toms and were designed to be brief, highly sensi- A second helpful characteristic of the tive, and moderately speci fi c. Internet is the ease of portability of informa- The PTSD/panic module screener asked, for tion. From a public health perspective, techno- example: “In the past year, have you (a) had panic logical interventions via the Internet facilitate or anxiety attacks?, (b) avoided people, places, mental health recovery. This aspect is particu- situations, or conversations that remind you about larly relevant following natural disasters or something very bad that happened to you?. mass catastrophes (e.g., after the Tsunami, (c) felt anxious or very upset when in the pres- 2006), when immediate care for a large number ence of people, places, or things that remind you of individuals is critically needed, yet incredi- about something very bad that happened to you?” bly diffi cult to deliver via traditional interven- Upon completion of each module, the level of tions. Internet-based interventions represent a distress was assessed and subsequent modules mode of care that is inexpensive, highly trans- were adapted accordingly. To prevent early drop- portable, easily standardized, administered, and out and improve compliance, the authors updated, as well as easily tailored to the needs employed a stage-of-change approach (i.e., pre- of specifi c individuals. contemplative, contemplative, preparation, All currently available evidence-based action, and maintenance stages) through individ- Internet-treatment programs for PTSD are ualized feedback and a motivational language. 24 Harnessing the Web: Internet and Self-Help Therapy for People... 387

Two years after the 9/11 terrorist attacks, 1,035 assigned to the intervention group compared to New Yorker inhabitants who initially took part in the wait-list controls showed signi fi cant reduc- an epidemiological study received an invitation tions in depressive symptoms and anxiety as to take part in the treatment investigation. In total, well as less avoidance behaviors and intrusions 28% (n = 285) of the original sample were with effect sizes ranging from d = 0.59 to included. The intervention was rated as feasible d = 2.08. However, treatment adherence, log-in by the participants; however, completion rates for time, or completion rates were not reported. the individual modules were modest (63.5%, Furthermore, the generalizability of these prom- depression; 63.4%, tobacco use; 57.7%, mari- ising results is somewhat restricted by the small juana; 56.1%, PTSD; 42.6%, alcohol; 36.4%, sample size and the homogenous sample (pri- anxiety; and 36.4%, drugs). The time spent per marily female students). module varied considerably from 4.4 min for the Interestingly, previous well-designed and alcohol module to 20.3 min for the depression methodologically sound studies on the effi cacy module. Participants acknowledged an increase of conventional (i.e., non-Internet-based) self-help of knowledge. One caveat for this investigation for PTSD failed to produce signifi cant reductions was that standard ef fi cacy assessment measures in symptomatology (Ehlers et al., 2003 ; Turpin, (changes in symptoms/clinically relevant behav- Downs, & Mason, 2005 ) or to prevent the devel- iors) were not included. Therefore, although the opment of PTSD (Bugg, Turpin, Mason, & program seemed generally acceptable to partici- Scholes, 2009 ) . One reason for the effects found pants, the impact of this approach is diffi cult to by Hirai and Clum ( 2005 ) might be due to the ascertain. adaptability of computer-supported self-help pro- Hirai and Clum ( 2005 ) tested the feasibility grams to the speci fi c patient and their needs. and effi cacy of an 8-week Internet-based self- Based on the symptom pro fi le, the patient’s input help program with interactive behavioral tech- and progress through the modules, computerized niques for traumatic event-related consequences self-help programs select treatment modules, (SHTC) with undergraduate students and adults generate feedback, and adapt didactic presenta- from a community-based setting. Participants tions, reinforcement, and future assignments were recruited from ads in the print media, which might promote the ef fi cacy of these online, and a student subject pool. Diagnostic approaches. screening was completed via the telephone. To Despite the initially promising support for be included in the study, applicants had to report Internet-based self-help programs for PTSD, the a signi fi cant traumatic event and meet the reex- limited empirical data and methodological limi- periencing and avoidance criteria from the tations of this research indicate that fi ndings PTSD diagnosis. The treatment consisted of should be regarded with caution. Two recent psychoeducation, relaxation training, cognitive meta-analyses revealed that low rates of treat- restructuring, and written exposure modules. ment initiation and high rates of dropout are two The program also included skills practice in problems that emerge in programs that do not combination with mastery tests and automatic involve human contact (Barak, Hen, Boniel- feedback. Therapist involvement during the Nissim, & Shapira, 2008 ; Spek et al., 2007 ) . program was made only to prompt participants The missing therapist contact might have con- to undergo assessments or mastery tests or to tributed to a higher probability of treatment dis- provide information about the timeline toward engagement. Also, despite sophisticated completion of the program and in case of need programming, fully automated programs are of technical assistance. In total, 27 applicants always based on a limited number of scenarios were found to be eligible for participation and and response options. This implies that speci fi c were randomly assigned to the active treatment concerns of the patient may not be addressed group or a wait-list control group. The majority and could also lessen adherence or limit the use of participants were female students. Participants of the program. 388 S. Moritz et al.

ment assessment, participants in the treatment Web-Enhanced Therapist-Driven condition showed a strong reduction of PTSD Interventions for PTSD symptoms (IES) with large effect sizes (d = 1.50 on avoidance and d = 1.99 on intrusions). General One of the fi rst research groups to explore the psychopathology also decreased signi fi cantly and potential of Internet-based interventions for PTSD yielded large effect sizes for anxiety, depression, was Alfred Lange et al. (2000 ) at the University and somatization (SCL-90) (d = 1.23, d = 1.28, and of Amsterdam. In the 1990s, they developed a d = 1.25, respectively). The second randomized therapist-supported, Internet-based cognitive control trial included a clinical sample of 101 behavioral treatment for posttraumatic stress sub- patients which replicated prior results of the pre- sequent to a traumatic event (Interapy). The theo- ceding studies (Lange et al., 2003 ). Signifi cant retical base of Interapy emerged from experimental improvement on all health-related measures such research regarding the ef fi cacy of structured writ- as depression, anxiety, and physical health was ing therapies on mental and physical health. The detected. In addition, trauma-related symptoms, treatment consists of structured writing assign- such as intrusions and avoidance, were signi fi cantly ments facilitated through a database implemented reduced. Effect sizes ranged from d = 1.28 for on the Internet. Communication between thera- intrusions to d = 1.39 for avoidance. The dropout pist and patient is exclusively text-based and rate was fairly high (41%). In a separate investiga- asynchronous. The writing protocol comprises tion, Lange et al. ( 2000 ) found that prior experi- three treatment phases: (a) self-confrontation, (b) ence with computers was not a prerequisite for a cognitive reappraisal, and (c) social sharing. successful treatment response. The improvement Potential patients log in and complete the screen- levels of participants with little or no experience ing questionnaires (Impact of Event Scale (IES) with the Internet were comparable to the improve- Horowitz, Wilner, & Alvarez, 1979 ; Symptom ment of participants who had extensive experi- Checklist-90 (SCL-90), anxiety, depression, som- ence with the Internet. The Interapy treatment atization, and sleeping problems subscales; approach was cross-culturally examined in a RCT Somatoform Dissociation Questionnaire (SDQ-5); with 96 patients from a German-speaking sample Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & with posttraumatic stress reactions (Knaevelsrud Vanderlinden, 1997 ; online). Patients are assigned & Maercker, 2007, 2010) . Intention to treat analy- to two weekly 45-min writing assignments over a ses produced similar effect sizes as in the Dutch 5-week period (10 essays in total). After every study (Impact of Event Scale revised, IES-R) with second essay, patients receive feedback and fur- d = 1.40 for intrusions, d = 0.98 for avoidance, and ther instructions from the therapist (within 24 h). d = 1.41 for hyperarousal. However, a lower drop- At the beginning of each phase of treatment, out rate (16%) was reported. patients receive psychoeducation on the principles The Interapy program was tested (using a cul- of the treatment module. turally adapted version called “Ilajnafsy” meaning Uncontrolled (Lange et al., 2000 ) and as well “psychological help” in Arabic) in Iraq with a as RCT trials (Lange, van de Ven, Schrieken, & sample of Arabic-speaking, war-traumatized civil- Emmelkamp, 2001 ) have been conducted to eval- ians with PTSD reactions (Knaevelsrud & uate Interapy for the treatment of PTSD in the Maercker, 2007 ; Wagner, Schulz, & Knaevelsrud, Netherlands. The fi rst study included 20 under- in press) . Ilajnafsy is provided by native Arabic- graduate students who had experienced traumatic speaking psychotherapists or psychiatrists living life events and showed symptoms of PTSD. At in relatively safe areas in Iraq or neighboring coun- posttreatment, participants showed signi fi cant tries (e.g., Palestine, Syria, the Emirates) or in improvements on posttraumatic stress symptoms Europe. The therapists were trained in the Interapy and psychological functioning (IES, SCL-90). approach in 7-day workshops. Just as Interapy, the The fi rst randomized control trial included 30 Ilajnafsy treatment is highly standardized. Text traumatized undergraduate students. At posttreat- blocks are used for psychoeducation and instruc- 24 Harnessing the Web: Internet and Self-Help Therapy for People... 389 tions, but feedback is tailored to the individual initial face-to-face contact with a therapist in the case. All therapists participate in weekly supervi- context of a clinical interview/assessment session sion sessions and contribute to an online supervi- (PTSD Symptom Scale—interview version, sion forum implemented on the web site. PCL; BDI) and are provided with additional Participants were mainly recruited by means email and/or telephone contact as necessary. In of radio, TV, and print media. Further informa- addition to the face-to-face evaluation, partici- tion was posted on Arabic health-related web pants receive an introduction and orientation on sites and made available on a Facebook informa- how to use the program and how to apply simple tion page and in a YouTube fi lm clip. An initial relaxation techniques. Patients are encouraged to pilot study examined the feasibility and applica- contact their therapist when needed and are bility of this treatment program in the Iraqi con- assured that their therapist will monitor their text. Of 212 persons who completed the online progress. In a RCT, DE-STRESS was compared screening questionnaires, 40 patients were found to Internet-based supportive counseling for PTSD to be eligible for participation. Of those, only 15 in a sample of survivors of the 2001 Pentagon completed the course of treatment. The majority attacks and Iraq/Afghanistan combat veterans of patients were female (n = 13; 86.7%) and had (Litz, Engel, Bryant, & Papa, 2007 ) . A total of 45 experienced an average of fi ve different traumas, patients were included, 33 patients completed including the kidnapping or killing of a family treatment (30% dropout rate). Both groups member/close relative, torture, sexual violence (DE-STRESS and Internet-based supportive related to war, and threat to their own life. The counseling) showed a signifi cant reduction for effect sizes of symptom reduction ranged from total PTSD severity (PCL), avoidance behaviors, d = 1.23Ð1.44 for PTSD. The effect size for and hyperarousal levels. However, no treatment depression was d = 1.51 and d = 1.50 for anxiety. effects could be detected with regard to reexperi- Considering the fact that no psychological inter- encing symptoms. Although depression (BDI) vention for PTSD has previously been evaluated scores did not differ between groups at posttreat- in the Arab context, a key fi nding is that partici- ment, differences between groups emerged at the pants seem to benefi t from the Internet-based 6-month follow-up assessment. Speci fi cally, the cognitive behavioral intervention to the same CBT group showed lower depression, anxiety, extent as patients in a non-confl ict Western con- and total PTSD symptoms (effect sizes comparing text. However, the attrition rate in this pilot study the two groups ranged from d = 0.95Ð1.03). was relatively high (62%), which may partly Most recently, Klein and colleagues pub- refl ect the ongoing instable and insecure living lished results from an open trial of a therapist- conditions in Iraq. assisted cognitive behavior therapy Internet Litz, Williams, Wang, Bryant, and Engel intervention for patients with PTSD (PTSD- (2004 ) designed a therapist-assisted Internet self- Online; Klein et al., 2010 ) . This was the fi rst help program for traumatic stress (DE-STRESS). trial where the diagnosis was based on a tele- They included a modifi ed version of stress inocu- phone-based structured clinical interview lation training (8 weeks in total). The program according to DSM-IV criteria. A total of 134 focuses more on improving coping skills than on adults were recruited through mental health web trauma processing. The fi rst 6 weeks are dedi- sites, as well as local and national media; how- cated to the improvement of coping skills and ever, only 22 individuals were included in the management of dysfunctional thinking. Week 7 study. The treatment consisted of a 10-week, and 8 comprise trauma processing and relapse interactive, cognitive behavioral program that prevention receptively. The intervention involves included the following elements: psychoeduca- teaching individuals strategies to help cope and tion on anxiety, stress, and trauma (module 1); manage reactions to trauma cues and comorbid anxiety management including instructions, problems. These strategies are reinforced through video/audio instructions on breathing exercises, daily homework assignments. Participants make and PMR (modules 2 and 3); management of 390 S. Moritz et al. dysfunctional thinking (modules 4Ð6); individu- First Phase: Self-Confrontation ally tailored instruction (audio fi les and written) on how to expose oneself to the images of the First, patients are instructed to write two essays on trauma (writing about the trauma) and/or in vivo the circumstances of the traumatic event. They are (modules 7Ð9); and relapse prevention includ- asked to express all their fears and thoughts about ing information on other anxiety disorders, the event and to focus on sensory perceptions in as mood, substance abuse/use, stress, and sleep much detail as possible. Participants are asked to management (module 10). Each participant was write their essays in the present tense, in the fi rst allocated a username and log-in password and person, and without worrying about grammar, had to work through one module per week. The style, or the logical chronology of events. participant and the therapist communicated via encrypted email and therapists answered within Therapist instruction : “ In the following texts , I 48 h to participants’ email. The dropout rate was would like to ask you to choose one moment from 27%. At postassessment, 69% of the sample your traumatic event . One moment that you can showed clinically signi fi cant improvement of hardly bear to think about , but that keeps intruding PTSD symptoms and 77% of the sample at fol- on your thoughts . Write down the most painful low-up assessment. However no signi fi cant memories and emotions you have when you think improvement on general psychological mea- about it and describe everything that you experience sures was found. The average total therapist every feeling , every thought and physical reaction.” time required was 194.5 min. The results of Web-enhanced therapist-driven Before Ms. I started with her text she commented: interventions for PTSD suggest that online interven- “ This is the fi rst message I write to you Dr. X. As a tions are feasible and that therapist-assisted Internet matter of fact my head bursts from all the bad program for trauma survivors can effectively reduce memories. In the last days since I decided to do this PTSD symptom severity. However, sample selec- therapy I was almost fl ooded with pictures from the tions (e.g., gender, education, and racial/ethnicity); past Ð it is almost impossible to choose one single uptake rates (how many of those targeted actually use incident. Our daily life is still so violent and the this approach), just as user pro fi les (e.g., age, social feeling of being vitally threatened has become economic status); and indication ranges (e.g., symp- natural not just to me Ð but for every Iraqi .” tom severity, comorbidity, speci fi c symptom pattern) are yet to be critically investigated. Example of the patient ’ s text : “ The men in the car are still tracking me Ð every time I switch lanes Ð they do too , I try to speed up now Ð but Humanitarian Aid Online: Interapy in they do the same . I force myself to focus ; I keep Iraq (Ilajnafsy) on looking in the rear mirror , trying to memorize their face . I have never seen these men before ; Subsequently, a case illustration of Ilajnafsy, as they are not Iraqis ( I can tell it from the way they introduced above, is provided. Each treatment wear their Eqal ( headband )). What do they want phase includes an example of the therapist’s from me ? What do they want from my family ? writing instruction and an excerpt of the They must have followed us from the hospital . I patient’s text. The patient Ms. I. is a 41-year- feel hot . I don ’ t know where to go . If I go home old female Iraqi who survived two kidnapping they know where I live and I will put my whole attempts and a severe physical assault. At her family at risk ? Where can I go ? Where should I initial assessment, she reported severe PTSD go ????? My mind is almost blacking out . My head symptoms and a very restricted level of func- is aching , I cannot think Ð it feels like a stone . tioning (inability to work, social withdrawal). What can I do ? Pictures of dead bodies on a The text below is taken from the actual tran- pickup truck from last week are coming in my scripts of the treatment. head again . I need help , please !!! I am sweating 24 Harnessing the Web: Internet and Self-Help Therapy for People... 391 and my heart is racing . My head is about to your pain… We both know that I can’ t do much explode . My eyes are tearing . I am scared and more than to remind you of some facts in life angry , my brain is of no use . Why is no one help- that you may have forgotten or lost faith in ing me ? I feel so lost , so weak . Why is this done to after what you have been through … me ? What have I done wrong to deserve this ? First of all , you have managed to escape the God , tell me what to do ! The car is pulling over attempted kidnappings and did not get kidnapped and cuts off my way Ð I have to stop ! Three men and this is an achievement by itself , you managed are stepping out of the car.” to run and save your family . You are safe now Thank god Ð writing time is up … I am still and that is very important . shaking !! You are a strong person who fought to save her Ms. I got robbed and assaulted but survived as family from serious dangers . You have done what the perpetrators got disturbed by a local police you could at the moment and you were brave . I force, which was alarmed by witnesses. The sub- know it is dif fi cult but we may need to learn to jectively worst moment was the situation accept experiences that we can ’t change and to described above when she was afraid to be raped be smart enough to learn the wisdom in each hard and/or killed. She felt ashamed of having been lesson we take . Maybe you can think of a way to unable to defend herself and of having been redirect those negative feelings into something unable to prevent this assault from happening. positive . Express your anger when you feel angry ; Especially in the fi rst phase, she needed repeated if you feel like talking talk to someone that you encouragement to continue the exposure. trust or feel comfortable with . Don ’t be ashamed . And don ’t waste your energy on feelings like hate and revenge . These feelings hurt you more than Second Phase: Cognitive Reappraisal they hurt the people who harmed you . You are a good person who is loved and In this cognitive restructuring phase, patients cherished by all the people who know you , by are instructed to write a supportive and encour- your family , your friends this is the greatest aging letter to a hypothetical friend. They are strength any human can have , this is the real asked to imagine that this friend had also expe- treasure in life.” rienced the same kind of traumatic experience and was now facing the same dif fi culties. The letter should re fl ect on guilt feelings, challenge Third Phase: Social Sharing dysfunctional automatic thinking and behavior and Farewell Ritual patterns, and correct unrealistic assumptions. The aim is to foster the development of new During the third phase, patients receive psychoe- perspectives on the traumatic event and its cir- ducation about the positive effects of social shar- cumstances. An example instruction of the ing. In a fi nal letter, they then take symbolic leave therapist for the fi rst two essays in this phase is of the traumatic event. Patients can address the as follows: letter either to themselves, to a close friend, or another signi fi cant person involved in the trau- Therapist instruction: “ Imagine you are writ- matic event. The letter does not ultimately have ing a supportive letter to your friend, who to be sent. experienced the same situation as you . Could she have foreseen what happened? Do you Therapist instruction: “ You wrote that you would think she was responsible for this?” like to write the letter to your friend. First, I would like to ask you to describe the circumstances that Example of the patient’ s text: happened. Which moments were so important that you would like to tell yourself about them? It is “ My friend, I am writing you, hoping my words important to give the past, the present and the will make a difference , that they help to ease future the same weight in this letter .” 392 S. Moritz et al.

Example of the patient ’ s text : shame or stigma; patients living in countries with no proper psychological-medical help sys- “ Dear X , tem; people in remote areas). As the current review demonstrates, Internet therapy and self- I write this letter to you , to tell you about some help is an umbrella term comprising very differ- experiences you don ’ t know about . Things I was ent approaches (e.g., bibliotherapy evaluated via not courageous enough to share with you . But I Internet studies, computer-assisted therapy). want you to know now as I believe it may help A common denominator is that no face-to-face you to understand me more and at the same time therapy is conducted: the therapist is either help me to get over some of the diffi cult events I absent (bibliotherapy), available only upon have experienced … request (some forms of computer-assisted ther- For a very long time I thought that all the apy), or is involved in an asynchronous (email nightmares and the fl ashbacks and my panic therapy) or synchronous non-face-to-face fash- reactions were a “normal ” thing Ð I just got so ion. As the reviewed investigations employed used to it . I did not realize that these were “ symp- very different programs in different settings, it is toms ” and that they were expanding . Like the not surprising that no consistent picture emerges exaggerated reactions when someone tried to with regard to the effi cacy of (guided) self-help. wake me up when I was asleep , or when hearing Clearly, no bold claims can be made about self- fi reworks or other simple everyday events . I did help per se. The success of self-help largely not even notice my increased solitude and depends on the methods adopted. increased loneliness and introverted behavior While interventions delivered or supported by that all my friends and beloved ones had a health care specialist is probably superior to the noticed …. same intervention practiced via self-help (e.g., The two kidnapping attempts , the awful scenes Tolin et al., 2007 ) according to the few studies of the dead people and threats I have been comparing both approaches directly (see however through , radically changed my view of the world . Carlbring et al., 2005 ; Kiropoulos et al., 2008 ) , I could not trust anyone or more precisely any self-help is not only an important alternative men . I could not trust life anymore …. where proper therapy cannot be delivered but Now I look back on these horrible events . I may act as a complement to raise the quality of have more trust in myself as I see myself as a bet- regular therapy. Self-help manuals and Internet ter person . I believe now that my reactions were devices could complement the arsenal of psycho- the best I could do at that time and that given the therapists and shorten treatment times (Marks circumstances I could not have reacted differ- et al., 2003 ) . For example, patients undergoing ently or in a better way . I have managed to save short-term intervention may be encouraged to myself and the people with me . And I should be read special chapters and exercise techniques for proud of that . And I am !…” which there is no suf fi cient time during therapy (Mataix-Cols & Marks, 2006 ) . Studies indicate that the effect sizes and success rates of interven- Discussion tions conducted in RCTs with well-trained, experienced, and ardent psychotherapeutic staff do The use of the Internet and self-help therapy not fully translate into clinical practice even if the is gaining momentum. While it is, and will same label is used (e.g., CBT). Approximately presumably remain a less potent alternative to 50% of the therapists trained in CBT do not prac- face-to-face psychotherapy, it comes with many tice exposure and response prevention, and some advantages and for some settings it may repre- newer evidence-based techniques (e.g., mindful- sent the only option for providing some form of ness) may not be known to some therapists, dis- empirically validated treatment to sufferers (e.g., missed or forgotten/neglected (Böhm, Förstner, currently treatment-reluctant patients due to Külz, & Voderholzer, 2008 ; Külz et al., 2009 ) . 24 Harnessing the Web: Internet and Self-Help Therapy for People... 393

Table 24.2 Recommendations for online studies evaluating Internet and self-help approaches Basic requirements Cookies should be enabled (in order to prevent multiple log-ons) Large sample (N > 50) Recruitment over specialized self-help forums or a contact list of previously treated and adequately diagnosed in- or outpatients to ensure that the target population is reached Lie scales (e.g., openness); minimum performance duration of 15 min to ﬁ ll out the entire survey in order to recruit individuals with high treatment motivation Availability of a specialist in case of technical or psychological problems Approval by the local ethic committee Advanced features Randomized controlled trial (experimental vs. waitlist or active control) Completion >70% (multiple reminders are recommended to raise completion rates) Retest reliability of primary outcome measure (r > 0.7) as assessed by Internet administration of the measure Veri ﬁ cation of diagnoses via email exchange and preferably telephone, Skype, or doctor-in-charge (downside: may scare off some potential participants) Follow-up study (may decrease completion rate)

Currently, many Internet and self-help review, these alternative approaches could be approaches are evaluated in a clinical setting. instrumental in providing treatment to individuals A problem with this approach—apart from fund- who would otherwise not have access to treatment ing—is that it only reaches the subgroup (and providers. Furthermore, both self-help and Internet perhaps minority) of patients who are willing to interventions may foster treatment motivation in see a health care professional. Shame, stigma, patients who, for example, are skeptical about the and unfounded fears especially in OCD patients bene fi ts of face-to-face therapy and who would be to be incarcerated against one’s will, e.g., because more amenable to starting with such an alternative of aggressive obsessions may scare off many treatment format. The overarching hope in con- patients to participate in such studies which are tinuing to develop this type of intervention is to thus not representative. Indeed, it has been found better disseminate ef fi cacious treatments to the that help-seeking and non-help-seeking patients many millions of individuals worldwide who are differ on many aspects, most importantly quality not receiving the treatments they need. of life and illness insight (Besiroglu, Cilli, & Askin, 2004 ) . In our view, Internet studies come Acknowledgement The authors would like to thank with many advantages and are especially valu- Jeannette Jörkell, Andrea Keretic, Katharina Struck, able for feasibility (i.e., proof-of-concept) stud- Miriam Voigt, and Ricarda Weil for help with the literature review. ies. Table 24.2 lists a number of criteria and precautions that should be taken into account when planning such a study. Importantly, Internet studies like clinical trials need approval by an References ethics committee. In view of only peripheral contact (mainly email) researchers are advised to Amstadter, A. B., Broman-Fulks, J., Zinzow, H., Ruggiero, provide participants with telephone numbers and K. J., & Cercone, J. (2009). Internet-based interventions for traumatic stress-related mental health prob- (email) addresses in case of adverse events. lems: A review and suggestion for future research. To conclude, we hope that self-help and Internet Clinical Psychology Review, 29 , 410Ð420. approaches gain more attention within the Angermeyer, M. C., & Matschinger, H. (1996). Public scientifi c community and are no longer judged as attitude towards psychiatric treatment. Acta Psychiatrica Scandinavica, 94 , 326Ð336. ineffective or perhaps even harmful substitutes to Bachofen, M., Nakagawa, A., Marks, I. M., Park, J.-M., more traditional treatments. As discussed in our Greist, J. H., & Baer, L. (1999). Self-treatment of 394 S. Moritz et al.

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Eric A. Storch and Dean McKay

The past several decades have been characterized The movement to determine best practices for by signifi cant advancements in the understanding common complexities associated with psychopa- and treatment of psychiatric diagnoses. Well- thology has been with us for some time. As Gordon conceptualized and empirically supported inter- Paul famously intoned, the goal of psychotherapy ventions/approaches are in place for virtually all research is to identify the conditions, clients, and of the disorders covered in the book, and new circumstances for which any treatment is ideally studies are rapidly coming out that provide fur- suited (Paul, 1969 ) . This implies that clinicians ther insight into mental health treatments that have at their disposal a menu of therapies from work. Although encouraging and a marked step which to select when treating clients with various forward, straightforward, uncomplicated presen- complex presentations. Interestingly, many signs tations are often the exception rather than the rule and symptoms that imply different psychopatho- in terms of the individuals included in these tri- logical states have been observed and go by names als. Yet, in applied practice, clinical presentations that would be considered antiquated in the current characterized by varied complexities are com- nosology. Many problems considered complica- mon and can markedly impact treatment course tions in the treatment of psychopathology have and outcome without appropriately consider- been described, and at the same time, practitioners ation. The purpose of this book is to advance the traditionally fail to adequately understand or literature beyond the understanding that a partic- account for these problems (Meehl, 1973 ) . These ular treatment, on average, works for the average accounts, however, predate the movement to pro- person with the corresponding disorder. Rather, it mote scienti fi cally informed principles of treatment is our hope that this two-series volume increases delivery. It therefore seems that the time has arrived the application of personalized care in the mental to fully address the complexities associated with health treatment of adults and children who pres- core diagnostic problems. In this vein, the anxiety ent as clinically complex. disorders have been subject to extensive study, many commonly observed complexities have been systematically examined, and modi fi cations to the protocols developed for “uncomplicated” cases have been described and in some cases tested. The empirically supported treatment movement * E. A. Storch ( ) has shown that numerous therapies could, indeed, University of South Florida , Tampa , FL , USA e-mail: [email protected] become established as well-validated approaches for treating psychopathology (reviewed in D. McKay Department of Psychology, Fordham University , Chambless & Ollendick, 2001 ) . Concurrent with Bronx , NY , USA the movement to identify core principles and

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 399 DOI 10.1007/978-1-4614-6458-7_25, © Springer Science+Business Media New York 2013 400 E.A. Storch and D. McKay practices that would reliably alleviate symptoms, Given this, it is critical to move beyond ef fi cacy it was considered best to also examine potential studies that demonstrate that treatment X works comorbid conditions as complicating factors (i.e., for Y condition, by examining moderators of Rachman, 1991 ) . However, comorbidity implies treatment response with an eye for developing two conditions that are prohibitive in understand- interventions that account for these issues. Stated ing complexities. First, comorbidity implies that differently, we need to know who is not bene fi ting speci fi c diagnostic thresholds are passed resulting from extant interventions, as well as why this may in more than one diagnosis being assigned to a be the case (i.e., outcome mediators). With that case. While this does in fact occur with some reg- information, the intervention in question can then ularity, it also poses a problem for the many more be tailored to account for these variables. Along cases that are subthreshold for the diagnosis, and these lines, we highlight the role of empirically yet the comorbid associated problem nonetheless supported practice (Treat, Bootzin, & Baker, interferes with treatment delivery. And, second, 2007 ) that involves the application of established comorbidity implies that the potential diagnostic treatment approaches within the context of speci fi c problem is alongside the condition for which a symptom presentations that fosters the use of target treatment is applied. While this too is fre- treatment plans that are formulated for speci fi c quently the case (i.e., the common complication diagnoses, not necessarily speci fi c individuals in obsessiveÐcompulsive disorder (OCD) of who happen to suffer from the diagnosis. comorbid depression; see Keeley, Storch, Merlo, Beyond the issue of how to effectively intervene & Geffken, 2008 ) , it does not account for the with individuals who present with varied complexi- many times when a condition is instead secondary ties are issues with treatment dissemination. We per- to the target problem (such as depression that ceive the fi eld to be at a critical juncture in this regard results from OCD). These observed limitations in as there are numerous providers in the community, considering comorbidity as a pure model for yet many do not provide evidence-based interven- understanding complexities have led instead to tions, and, arguably, others provide forms of inter- consideration given to dimensional features of vention that do not bene fi t the affected person and ancillary psychopathology that interferes with weaken confi dence in the fi eld of psychology as a therapy. This is the primary thrust of this volume. health profession. While this has been recognized As noted in each chapter, there are fairly robust and served as a motivating force in federally funded empirical data supporting cognitive behaviorally research and the development of alternative service oriented interventions for a range of disorders and delivery platforms (e.g., telemedicine), progress has problem behaviors. However, also as shown been slow at best, and problematically, there are across the varied chapters, multiple confounding increasing numbers of programs that train well- factors can impact treatment delivery and out- intentioned providers to provide nonempirically come, which require adjustments to established established or evaluated services. Inconsistency approaches. Given this, treatments must be tai- among psychological providers in the community— lored to the clinical presentation of each individ- who trusts that the provider has their best interest at ual to maximize ef fi cacy, as well as intervention heart—in the type of psychotherapy provided con- acceptability. For example, a topic that has veys the inaccurate notion that psychotherapy is received attention among anxious youth is the ineffective. And, valuable resources are drained presence of disruptive behavior (Storch et al., 2008 ) . (e.g., insurance, family savings) at the risk of contin- Application of existing therapies without account- ued impairment and encouraging a sense of hope- ing for the manner in which disruptiveness might lessness in those who have had limited response to impact treatment course would likely yield atten- non-evidence-based treatments. Indeed, while inef- uated outcome. Similarly, comorbid psychopa- fective treatment may be potentially benign in the thology must be considered in the individual’s eyes of some providers, it has been cited recently as clinical presentation and may require adaptations a speci fi c harmful effect of therapy (Dimidjian & in how the case is conceptualized and treated. Hollon, 2010 ) . For these reasons, dissemination 25 Conclusion 401 efforts that encourage the use of evidence-based there is more to be done to disseminate information interventions in clinical settings are critically high- about best practices for handling such factors with lighted as an area for additional attention. Although consistency and replicability. With this in mind, it is clear that dissemination efforts are required to we hope that the present volume provides a start- move the path forward, barriers exist that need to ing point in this regard to (1) improve clinical out- be considered. Efforts to bring training of effective come and (2) guide researchers for evaluating the interventions into training programs that provide effi cacy of varied approaches to dealing with personnel who work on the “front lines” are required. diverse patient factors. At a grassroots level, this means reaching out to colleagues across disciplines to provide interdisciplin- ary training in therapies that work. A recent task References force has developed guidelines to inform training programs in best practices in ensuring practitioners Chambless, D. L., & Ollendick, T. H. (2001). Empirically have the necessary skills to evaluate and implement supported psychological interventions. Annual Review of Psychology, 52 , 685Ð716. empirically supported practices, particularly cogni- Dimidjian, S., & Hollon, S. (2010). How would we know tive behavior therapy (Klepac et al., in press ) . This if psychotherapy were harmful? American mirrors a growing international movement to Psychologist, 65 , 21Ð33. increase the delivery of empirically supported treat- Keeley, M. L., Storch, E. A., Merlo, L. J., & Geffken, G. R. (2008). Clinical predictors of response to cognitive- ments (i.e., the National Institute of Clinical behavior therapy for obsessive-compulsive disorder. Excellence; Silk, 2010 ) . With these efforts, and Clinical Psychology Review, 28 , 118Ð130. working with funding sources to prioritize how Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., resources are allocated for the provision of treat- Belar, C. D., Berry, S. L., et al. (in press). Guidelines for cognitive-behavioral training within doctoral psy- ments that have demonstrated effi cacy, the likeli- chology programs in the United States: Report of the hood that clients will receive the proper care will inter-organizational task force on cognitive and behav- increase. However, it is not simply enough to dis- ioral psychology doctoral education. Behavior seminate effective interventions. Rather, consider- Therapy . Meehl, P. E. (1973). Why I do not attend case conferences. ation for how these interventions must be tailored to In P. E. Meehl (Ed.), Psychodiagnosis: Selected papers address clinical factors—many of which were (pp. 225Ð302). Minneapolis, MN: University of detailed in this book—is a necessity and will direct Minnesota Press. the next way of clinical dissemination efforts. Indeed, Paul, G. L. (1969). Behavior modi fi cation research: Design and tactics. In C. M. Franks (Ed.), Behavior we are seeing some of this with the focus on modu- therapy: Appraisal and status (pp. 29Ð62). New York, larized interventions in their application to childhood NY: McGraw-Hill. problems (Weisz et al., 2012 ) . Rachman, S. (1991). A psychological approach to the study of comorbidity. Clinical Psychology Review, 11 , 461Ð464. Silk, K. R. (2010). Introduction to the special issue on Conclusion National Institute for Health and Clinical Excellence. Personality and Mental Health, 4 , 1Ð2. When we crafted the book, our goal was to convey Storch, E. A., Merlo, L. J., Larson, M., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., et al. (2008). The the multiple intricacies and complexities for work- impact of comorbidity on cognitive-behavioral therapy ing with individuals with anxiety. It is our hope response in pediatric obsessive compulsive disorder. that the book helps the reader conceptualize fac- Journal of the American Academy of Child and tors that may contribute to clinical complexity and Adolescent Psychiatry, 47 , 583Ð592. Treat, T. A., Bootzin, R. R., & Baker, T. B. (2007). treatment challenges, with the goal of formulating Psychological clinical science: Papers in honor of interventions that are tailored to individual patient Richard M. McFall . New York, NY: Taylor & Francis. characteristics and yield improved outcomes. Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, Although mental health providers are improving at S. K., Miranda, J., Bearman, S. K., et al. (2012). Testing standard and modular designs for psychother- recognizing and integrating varied clinical factors apy treating depression, anxiety, and conduct prob- into their case conceptualization and intervention, lems in youth: A randomized effectiveness trial. Archives of General Psychiatry, 69 , 274Ð282. About the Editors

Eric A. Storch , Ph.D., is Professor and All Children’s Hospital Guild Endowed Chair in the Departments of Pediatrics and Psychiatry & Behavioral Neurosciences, University of South Florida. He holds a joint appointment in the Department of Psychology. He is Associate Editor for three journals: Child Psychiatry and Human Development , Journal of Cognitive Psychotherapy, and Journal of Obsessive - Compulsive and Related Disorders , and serves on the editorial boards of Journal of Clinical Child and Adolescent Psychology , Journal of Child Health Care , Psicologia Conductual , and Journal of Anxiety Disorders . He has published more than 300 peer-reviewed journal articles and book chapters and has given more than 250 conference presentations. In addition to his peer-reviewed articles, Dr. Storch has edited or coedited three books dealing with treatment of complex cases in children, obsessive-compulsive disorder, and childhood anxiety. He has received grant funding for his work in OCD, related disorders (e.g., tics), and anxiety from the National Institutes of Health, Agency for Health Care Research and Quality, CDC, International OCD Foundation, Florida Department of Health, pharmaceutical companies, Tourette Syndrome Association, and National Alliance for Research on Schizophrenia and Affective Disorders (NARSAD). In addition to treatment outcome, Dr. Storch has speciﬁ c research interests in treatment augmentation and dissemination. He directs the University of South Florida Obsessive-Compulsive Disorder Program and is highly regarded for his treatment of pediatric and adult OCD patients.

Dean McKay , Ph.D. , ABPP , is Professor, Department of Psychology, Fordham University. He currently serves on the editorial boards of Behaviour Research and Therapy, Behavior Modiﬁ cation, Behavior Therapy, and Journal of Anxiety Disorders and is Editor-in-Chief of Journal of Cognitive Psychotherapy. Dr. McKay is President-elect of the Association for Behavioral and Cognitive Therapies (Presidential term 2013-2014). He has published more than 130 journal articles and book chapters and has more than 150 conference presentations. He is Board Certiﬁ ed in Behavioral and Clinical Psychology of the American Board of Professional Psychology (ABPP), and is a Fellow of the American Board of Behavioral Psychology and the Academy of Clinical Psychology. He is also a Fellow the American Psychological Society. Dr. McKay has edited or co-edited eight books dealing with treatment of complex cases in children and adults, obsessive-compulsive disorder,

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 403 DOI 10.1007/978-1-4614-6458-7, © Springer Science+Business Media New York 2013 404 About the Editors disgust in psychopathology, and research methodology. His research has focused primarily on Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Disorder, and Hypochondriasis and their link to OCD as well as the role of disgust in psychopathology. His research has also focused on mechanisms of information processing bias for anxiety states. Dr. McKay is also director and founder of Institute for Cognitive Behavior Therapy and Research, a private treatment and research center in Westchester County, New York. Index

A trauma memory characteristics , 207–208 Actor–partner interdependence mode , 278 treatment noncompliance , 208 Acute stress disorder , 12–13 cluster A personality disorders (see Cluster A Adolescents personality disorders) clinical case study , 171–173 depression (see Depression) cognitive behavioral therapy motivation (see Motivation for behavior change) cognitive techniques , 170 patient–therapist mismatch (see Patient-therapist contextual factors and comorbidity , 168–169 mismatch) detailed psychoeducational information , 168 personality disorders developmental factors , 165–166 cluster C disorders , 25–26 exposure exercises , 170 interpreting fi ndings , 27–28 fl ow chart of , 166, 167 linear models , 25 interpersonal skills training , 164 prognosis of , 26–27 medication role , 170–171 therapeutic alliance (see Therapeutic alliance) motivational interviewing questions , 167 therapeutic variables relaxation strategy , 169 client motivation , 28–29 school refusal , 164 therapeutic alliance , 28 social factors , 166 treatment approaches social phobia , 164 comorbid Axis II , 30 therapist language , 167 integrative treatment , 30 social anxiety disorder (see Social anxiety disorder) motivational interviewing , 30–31 speci fi c phobia transdiagnostic and uni fi ed treatments , 29–30 cognitive self-control vs. contingency Agoraphobia , 14 management , 42–43 Anorexia nervosa one-session treatment , 43–44 clinical features , 338 predictors of , 44–45 mortality rate , 338 Adult anxiety disorders treatments axis I comorbidity health stabilization , 342 depression , 24 pharmacological interventions , 341 drug use disorders , 24 psychosocial interventions , 341 GAD and PTSD , 23–24 Anxiety, Depression, and Mood Scale (ADAMS) , 152 panic disorder , 24 Anxiety disorders self-medication hypothesis , 24–25 de fi nition , 3 BPD and PTSD etiology of abuse and trauma , 206 biological preparedness , 6 axis I dissociative disorders , 205–206 classical conditioning , 4–5 dialectical behavior therapy (see Dialectical cognitive theory , 7 behavior therapy (DBT)) contemporary learning theory , 9 emotion dysregulation , 206–207 genetic heritability , 7 exposure-based treatments , 204 negative information transfer , 5–6 intentional self-injury , 204–205 non-associative theory , 6–7 sequential treatments , 209 observational learning , 5 single-diagnosis treatments , 209 temperament , 7–8 substance use , 205 triple vulnerability theory , 8–9 therapist factors , 208 fear , 3

E.A. Storch and D. McKay (eds.), Handbook of Treating Variants and Complications in Anxiety Disorders, 405 DOI 10.1007/978-1-4614-6458-7, © Springer Science+Business Media New York 2013 406 Index

Anxiety disorders (cont.) social phobia nature and description CBT , 352 acute stress disorder , 12–13 clinical course , 351–352 agoraphobia , 14 cognitive therapy , 356 GAD , 10 interpersonal therapy , 356 OCD , 10–11 prevalence of co-occurrence , 351 panic disorder , 13–14 spectrum model , 353 PTSD , 11–12 treatment conditions , 356 separation anxiety disorder , 16 social phobia , 15 speci fi c phobias , 14–15 B substance use disorders Bibliotherapy, OCD common variable theory , 287 association splitting , 383 data supporting models , 288–289 attention training technique , 384 high-risk model , 287 competitive memory training , 385 self-medication hypothesis , 287 meridian tapping , 384 worry , 3 metacognitive Training for OCD , 385 in young children (see Young children) pre-and post-assessments , 383–384 Attention de fi cit hyperactivity disorder (ADHD) self-administered ERP , 383 comorbid externalizing disorders , 65 Y-BOCS , 382–383 DBD , 98 Borderline personality disorder (BPD). See Posttraumatic Attention training technique (ATT) , 384 stress disorder (PTSD) Autism spectrum disorders (ASD) Brief Intervention for Socially Anxious Drinkers adaptive functioning impairments , 85 (BISAD) , 294 child motivation and active treatment participation , 90 cognitive behavioral therapy adapted model , 87–88 C child-based intervention , 88 Children. See also Young children child motivation and active treatment ASD (see Autism spectrum disorders (ASD)) participation , 90 CBT combined child and parent intervention , 88 parent-implemented bibliotherapy , 39 components of , 85 parent involvement , 38–39 comprehensive skill application , 89, 92 pharmacotherapy agents , 39–40 coping and independence skills , 91–92 young vs. older children , 39 ef fi cacy of , 86–87 intellectual disability empirical and logical question-asking and ADAMS , 152 evaluation , 85–86 behavioral treatment components , 153–155 exposure to core element , 86 clinical case study , 156–158 follow-up , 92 cognitive treatment components , 155 hierarchy and treatment plan , 92 diagnostic interviews and behavioral observation parent training , 88 tasks , 152–153 schemas development , 86 FSAMR , 151–152 self-help skills , 90 GAS-ID , 151 social awareness , 89 OCD , 150–151 social skills , 89 pharmacotherapy , 155–156 special interest , 89 risk factors , 150 termination , 92 self-report measures , 151 treatment and ef fi cacy , 90–91 speci fi c phobias , 150 treatment outcome , 93 treatment strategy , 153, 154 waitlist condition , 88 obsessive–compulsive disorder prevalence of , 83 CBT vs. SRI medication , 46 psychiatric comorbidity , 84 CY-BOCS ratings , 46–47 psychosocial stressors , 85 predictors of social-communicative limitations , 85 child alliance , 41–42 symptomology and diagnostic issues , 83–84 comorbidity role , 41 Avoidant personality disorder (AVPD) , family dysfunction and frustration , 40 350–351 maternal anxiety , 41 diagnostic criteria , 340, 349 parental anxiety and depression , 40–41 interpersonal pathoplasticity , 354–355 parental psychopathology , 40 interpersonal problems , 356 role of fathers , 42 Index 407

speci fi c phobia detailed psychoeducational information , 168 cognitive self-control vs. contingency developmental factors , 165–166 management , 42–43 exposure exercises , 170 one-session treatment , 43–44 fl ow chart of , 166, 167 predictors of , 44–45 interpersonal skills training , 164 Children’s Yale-Brown Obsessive Compulsive Scale medication role , 170–171 (CY-BOCS) score , 315 motivational interviewing questions , 167 Clinical complexities relaxation strategy , 169 comorbidity , 400 school refusal , 164 empirically supported treatment movement , 399 social factors , 166 psychopathological states , 399 social phobia , 164 psychotherapy , 399 therapist language , 167 treatment dissemination , 400–401 anxiety disorders Cluster A personality disorders clinical presentation , 314–315 anxiety disorders cluster C personality disorder , 356–357 clinical presentations , 235–237 depression , 246–247 cognitive-behavioral treatments , 232 ASD (see Autism spectrum disorders (ASD)) cognitive rigidity , 234 AVPD and social phobia , 352 dif fi culty establishing rapport , 229 children empirical hypothesis testing , 234–235 parent-implemented bibliotherapy , 39 exposure-based treatment work , 234 parent involvement , 38–39 extremely poor social functioning , 231–232 pharmacotherapy agents , 39–40 fear hierarchy design , 234 young vs. older children , 39 increase illogical thinking & perception , 230–231 depression and anxiety level of ambiguity , 234 antidepressant medications , 247–248 lower motivation for treatment , 228–229 exposure-based CBT , 246–247 motivational interviewing , 232–233 disruptive behavior disorders odd and eccentric PDs , 228 behavioral parent training , 101 phenomenological linkage , 224–225 parent contingency management , 102 social skills training , 235 pharmacological approaches , 103 therapeutic relationship enhancement , 233 treatment strategies , 102 visual aids , 234 exposure-based therapy dissemination worsen information processing de fi cits , 230 (see Exposure-based CBT dissemination) written review sheets , 234 motivational interviewing , 268–269 DSM-IV-TR , 223–224 OCD paranoid PD , 224 dependence of children, caregivers , 129 schizoid PD , 224 developmental differences , 129 schizotypal PD , 224 ERP , 129 Cluster C personality disorder family functioning , 129–130 anxiety disorders parent behavioral training , 129 CBT, clinical perfectionism , 356–357 therapist-parent alliance , 263 clinical course , 351–352 therapist-patient mismatch , 259–262, 271–272 EX/RP treatment , 357 webcam-delivered CBT program , 382 interpersonal circumplex theory , 353–354 Collaborative Longitudinal Personality Disorders Study pathoplastic model , 353 (CLPS) , 352 prevalence of co-occurrence , 351 Comorbid anxiety disorders spectrum model , 353 clinical presentation symptom severity and decreased functioning , 351 anxiety symptom assessment , 314 treatment outcome studies , 352–353 CBT , 314–315 AVPD ( see Avoidant personality disorder (AVPD)) CY-BOCS score , 315 dependent personality disorder (see Dependent interoceptive exposures , 315 personality disorder (DPD)) relapse prevention and preparation , 315 OCPD ( see Obsessive-compulsive personality epidemiological and community based research , disorder (OCPD)) 309–310 psychometric limitations , 350 generalized anxiety disorder , 310 Cognitive-behavioral group therapy , 294 multichannel exposure therapy , 313 Cognitive behavioral therapy (CBT) , 38, 255–256 panic disorder , 310 adolescents posttraumatic stress disorder , 310 cognitive techniques , 170 psychoeducation , 313–314 contextual factors and comorbidity , 168–169 severity , 310 408 Index

Comorbid anxiety disorders (cont.) standard DBT , 211–212 social anxiety disorder , 310 suicidal and self-injury , 210 transdiagnostic treatments Disruptive behavior disorders (DBD) cognitive-behavioral therapies , 313 CBT generalized anxiety disorder , 312 behavioral parent training , 101 panic disorder , 312–313 parent contingency management , 102 social phobia , 311–312 pharmacological approaches , 103 speci ﬁ c phobias , 312 treatment strategies , 102 treatment impacts cooccurring impairments , 99 empirically supported treatments , 310–311 dysphoric emotions , 99 fture aspects , 316–317 generalized anxiety disorder and separation anxiety OCD with comorbid PTSD , 311 disorder primary GAD , 311 behavioral treatment , 104–105 Competitive memory training (COMET) , 385 pharmacological treatment , 104 Coping Cat program , 58–59 reactive aggression , 98 treatment complexity behavioral parent training , 99 D behavioral treatment , 100–101 Dependent personality disorder (DPD) CBT , 99–100 fears of autonomy , 350 exposure tasks , 100 social phobia functional assessment , 99 interpersonal therapy , 356 hyperactivity and impulsivity , 100 medication-free residential CT , 356, 357 poor emotion regulation skills , 101 Depression Dysthymia , 243–244 and anxiety antidepressant medications , 247–248 clinical issues , 251 E cognitive differences , 244 Emotion dysregulation, BPD and PTSD cognitive therapy , 247, 248 intense non-fear emotions , 207 comorbidity rates , 244 over-engagement , 206–207 conceptualization and treatment , 249–251 under-engagement , 207 exposure-based CBT , 246–247 Empirically supported treatments (EST) future aspects , 251–252 comorbidity neurological and psychophysiological difference , in adults , 64 244 in children , 62, 64 patient background and assessment , 248–249 multiple disorders , 65–66 predictors of , 245 treatment implementation , 66 prevalence rates , 246 in youth , 64–65 social phobia , 245 Coping Cat program , 58–59 temporal examination , 244–245 cultural factors , 67–68 signs and symptoms , 243 family factors Diagnostic and Statistical Manual-IV-TR (DSM-IV-R) CBT , 67 criteria parental anxiety , 66–67 cluster A personality disorders , 223–224 spousal relationships , 66 cluster C personality disorders , 349, 350 GCBT vs. ICBT , 59, 60 OCD, BT Steps , 381 generalized anxiety disorder (GAD) , 58 substance use disorders , 285 obsessive-compulsive disorder Dialectical behavior therapy (DBT) ERP , 59, 61 with DBT PE protocol remission rate , 62, 63 clinical presentation , 216–218 panic disorder , 59, 61 exposure sessions , 213–215 post-traumatic stress disorder , 62 higher-priority behaviors , 215–216 social phobia , 58 pre-exposure sessions , 212–213 therapeutic process variables vs. standard DBT , 210 alliance , 68–69 termination and consolidation , 215 collaboration , 70 treatment complexities , 210–211 involvement , 69–70 dropout rate , 210 Exposure and response prevention (ERP) , 59, 61, 225, 357 empirically supported treatment , 210 Exposure-based CBT dissemination moderate effect sizes , 210 community therapists , 364 Index 409

evidence-based psychological treatments Internet-based therapy economic and practical concerns , 366 advantages , 378 empirically supported treatments , 365–366 disadvantages , 378–379 negative therapist beliefs , 366 email communication , 377 practical and ideological barriers , 366 health information , 376–377 future aspects , 371–372 OCD obsessive–compulsive disorder , 363 BT Steps system , 380–382 posttraumatic stress disorder , 363, 371 compulsive hoarding , 380 therapist barriers human–computer interaction , 380 harmful therapy to client , 367–369 OC-CHECK program , 379–380 negative therapist beliefs , 369–371 webcam-delivered CBT program , 382 unethical treatment , 366–367 online tools , 377 Exposure with ritual prevention (ERP) , 380 posttraumatic stress disorder evidence-based programs , 386 portability of information , 386 F self-help program , 386–387 Family con fl ict traumatic events , 385–386 adolescence , 329 web-enhanced therapist-driven interventions , interparental con fl ict (see Interparental con fl ict (IPC)) 388–390 parent–child con fl ict (see Parent–child con fl ict) web sites , 386 pediatric anxiety , 329 recommendations , 393 sibling con fl ict , 328–329 Interparental con fl ict (IPC) , 330 Fear Survey for Adults with Mental Retardation child anxiety , 323–324 (FSAMR) , 151–152 cognitive-contextual framework , 324–325 compensatory hypothesis , 326–327 depression , 322–323 G emotional security hypothesis , 323 Generalized anxiety disorder (GAD) , 10 family processes and parenting , 325–326 behavioral treatment , 104–105 parenti fi cation and triangulation , 327 empirically supported treatment , 58 parenting and spillover effects , 326 pharmacological treatment , 104 physiological reactions , 323 Glasgow Anxiety Scale for those with Intellectual social learning , 326 Disability (GAS-ID) , 151 clinical presentation , 330–332 domestic violence , 322 family discord , 322 H internalizing symptoms , 322 Harvard/Brown Anxiety Research Program meta-analyses , 322, 323 (HARP) , 351 Interpersonal circumplex theory anxiety disorders , 355 cluster C , 354–355 I Improving Access to Psychological Therapies (IAPT) program , 371 L Intellectual disability (ID) Length of sobriety determination , 289–290 ADAMS , 152 behavioral treatment components , 153–155 clinical case study , 156–158 M cognitive treatment components , 155 Major depressive disorder (MDD) , 111, 243 diagnostic interviews and behavioral observation Meridian tapping (MT) , 384 tasks , 152–153 Metacognitive Training for OCD (myMCT) , 385 FSAMR , 151–152 Motivational interviewing (MI) , 232–233, 267–269 GAS-ID , 151 Motivation for behavior change OCD , 150–151 anxiety-related distress , 257–258 pharmacotherapy , 155–156 attention , 257 risk factors , 150 CBT , 257 self-report measures , 151 motivational interviewing speci fi c phobias , 150 CBT , 268–269 treatment strategy , 153, 154 ef fi cacy of , 267 Intentional self-injury , 204–205 empathy and validation , 268 Interactive-voice-response (IVR) technology , 380 fostering self-ef fi cacy , 268 410 Index

Motivation for behavior change (cont.) elevated schizotypy scores , 226 goals and behavior discrepancy , 268 OCD treatment failure , 225–226 presentational style , 267 self help pretreatment interventions , 269 bibliotherapy (see Bibliotherapy, OCD) tenets , 267 clinical outcomes , 379 OCD , 258 symptom expression , 127 stages of , 256–257 tic disorders Mowrer’s two-factor theory , 4–5 academic performance , 142 Multichannel exposure therapy (MET) , 313 in adults , 138–139 axis I disorder , 138 cognitive training , 142–143 O contamination-related symptoms , 144–145 Obsessive–compulsive disorder (OCD) , 10–11 CY-BOCS checklist , 141–142 age appropriate vs. potentially disordered behavior , DSM-IV fi eld trial , 138 125–126 prevalence of , 138 anorexia nervosa psychoeducation , 142 clinical presentation , 343–344 treatments , 342 diagnostic features , 337 Obsessive–compulsive personality disorder (OCPD) ERP , 342–343 diagnostic criteria , 350 etiological overlap , 340 interpersonal control in , 350 etiology , 339 OCD familial aggregation , 337 CBT, clinical perfectionism , 356, 358 genetic studies , 339 clinical course , 351 neurobiological mechanisms , 339–340 EX/RP treatment , 357 phenomenological overlap , 338 interpersonal circumplex theory , 355 phenotypic characteristics , 337 prevalence , 351 prevalence , 338–339 spectrum model , 353 psychotherapy , 343 symptom severity and decreased CBT vs. SRI medication , 46 functioning , 351 clinical case study , 130–131 treatment impact , 352 cognitive behavior therapy prevalence , 350 dependence of children, caregivers , 129 developmental differences , 129 ERP , 129 P family functioning , 129–130 Panic disorder (PD) , 13–14 parent behavioral training , 129 adults , 24 comorbidity rates , 126–127 empirically supported treatment , 59, 61 complication nature and description , 13–14 developmental considerations , 127–128 transdiagnostic treatments , 312–313 family involvement , 128 Paranoid personality disorder , 224, 227–228 computer-and phone-assisted therapy Parent–child con fl ict , 329 BT Steps system , 380–382 anxiety compulsive hoarding , 380 externalizing symptoms , 328 human–computer interaction , 380 interparental con fl ict , 328 OC-CHECK program , 379–380 relationship quality , 327–328 webcam-delivered CBT program , 382 anxious hesitation and doubting , 327 CY-BOCS ratings , 46–47 exacerbated anxiety symptoms , 327 depression parents’ psychological autonomy , 327 clomipramine , 247 Pathoplastic model , 353 imipramine , 247 Patient Global Improvement (PGI) , 381 ERP , 59, 61 Patient-therapist mismatch gender distribution , 126 behavioral mismatches , 258–261 immune related (see Pediatric autoimmune coping orientation , 262 neuropsychiatric disorder associated with essential participants , 262 Streptococcus (PANDAS)) ethnic mismatch , 259 randomized controlled trials , 379 gender match , 259–260 remission rate , 62, 63 interpersonal style , 262 remission rates , 47 patient and therapist factors , 258 schizotypal PD patient pace and content , 261–262 clinical presentations , 236 patient-speci fi c preferences , 261 Index 411

perception of problem , 262 cluster C disorders , 25–26 (see also Cluster C psychoeducation , 258 personality disorder) structural mismatches , 258, 259 dependent personality disorder treatment approach fears of autonomy , 350 behavioral mismatches , 270–271 social phobia , 356, 357 CBT framework , 271–272 interpreting ﬁ ndings , 27–28 children and adolescents , 272–273 linear models , 25 clinical presentation , 273–277 OCPD (see Obsessive-compulsive personality ethnic mismatch , 270 disorder (OCPD)) idiographic variability , 269 prognosis of , 26–27 overarching priorities , 271 Posttraumatic stress disorder (PTSD) , 11–12 patients overall functioning , 271 and borderline personality disorder pediatric psychological treatments , 273 abuse and trauma , 206 vocational interference , 271 axis I dissociative disorders , 205–206 treatment rationale , 262 dialectical behavior therapy (see Dialectical treatment roles , 260–261 behavior therapy (DBT)) Pediatric autoimmune neuropsychiatric disorder emotion dysregulation , 206–207 associated with Streptococcus (PANDAS) exposure-based treatments , 204 clinical characteristics intentional self-injury , 204–205 identical siblings , 194 sequential treatments , 209 vs. OCD and tics , 194, 195 single-diagnosis treatments , 209 clinical evaluation , 196 substance use , 205 clinical history therapist factors , 208 group A streptococcal infections , 193 trauma memory characteristics , 207–208 molecular mimicry , 193–194 treatment noncompliance , 208 neuroimaging , 194 empirically supported treatments , 62 Sydenham’s chorea , 193 humanitarian aid online clinical presentation , 197–198 cognitive reappraisal , 391 clinical symptoms , 193 self-confrontation , 390–391 immune triggers social sharing and farewell ritual , 391–392 infectious agents , 196 internet pharyngitis , 194, 196 evidence-based programs , 386 PITANDS , 196 portability of information , 386 treatment self-help program , 386–387 antibiotic therapy , 197 traumatic events , 385–386 cognitive behavioral therapy , 196–197 web sites , 386 intravenous immunoglobulin , 197 substance use disorders (see Substance use disorders selective serotonin reuptake inhibitors , 197 (SUDs)) Pediatric Infection-Triggered Autoimmune web-enhanced therapist-driven interventions Neuropsychiatric Disorders Arabic health-related web sites , 389–390 (PITANDS) , 196 cognitive behavior therapy , 389 Personality disorder (PD) DE-STRESS , 389 avoidant personality disorder (see Avoidant IES , 388 personality disorder (AVPD)) interapy program , 388–389 borderline personality disorder and PTSD writing protocol , 388 abuse and trauma , 206 Preschool age psychiatric assessment instrument axis I dissociative disorders , 205–206 (PAPA) , 111 dialectical behavior therapy (see Dialectical Psychiatric-psychological help system behavior therapy (DBT)) complementary medicine , 375 emotion dysregulation , 206–207 conventional health-care system , 375 exposure-based treatments , 204 internet (see Internet-based therapy) intentional self-injury , 204–205 lack of insurance coverage , 376 sequential treatments , 209 pharmacotherapy , 375 single-diagnosis treatments , 209 self-help books substance use , 205 academic peer-review system , 377 therapist factors , 208 best sellers , 377 trauma memory characteristics , 207–208 bibliotherapy (see Bibliotherapy, OCD) treatment noncompliance , 208 shame and doubt , 376 cluster A personality disorders (see Cluster A treatment cost , 376 personality disorders) Psychoeducation , 313–314 412 Index

S dependent personality disorder Schizoid personality disorder , 224 interpersonal therapy , 356 Schizotypal personality disorder and OCD medication-free residential CT , 356, 357 clinical presentation , 236 depression and anxiety , 245 elevated schizotypy scores , 226 empirically supported treatments , 58 treatment failure , 225–226 transdiagnostic treatments , 311–312 Selective serotonin reuptake inhibitors (SSRIs) , 39, 99 Speci fi c phobia , 14–15, 312 anxiety children adolescents , 170, 171 cognitive self-control vs. contingency child , 155–156 management , 42–43 and depression , 247–248 one-session treatment , 43–44 PANDAS , 197 predictors of , 44–45 Self-blame , 324–325 intellectual disability , 150 Self-help books Spectrum model , 353 academic peer-review system , 377 Spillover hypothesis , 326 best sellers , 377 Strength and dif fi culties questioinnaire (SDQ) , 112–113 bibliotherapy (see Bibliotherapy, OCD) Substance dependence PTSD therapy (SDPT) , 297 Separation anxiety disorder (SAD) , 16 Substance use disorders (SUDs) behavioral treatment , 104–105 annual cost , 286 CBT treatment , 58, 60 lifetime prevalence rates , 285–286 pharmacological treatment , 104 posttraumatic stress disorder Serotonergic (5-HT) systems , 339–340 client-related factors , 291 Sibling con fl ict clinical complexities , 299 adjustment problems , 329 clinical presentation , 299–300 anxious children , 328 clinical symptoms , 286 factors in fl uencing , 328–329 clinician factors , 292 family stress and peer rejection , 329 cognitive abilities , 290 Social anxiety disorder , 236. See also Social cognitive modi fi cation , 297 phobia behavioral symptoms , 179, 181 concurrent treatment , 298 clinical case study , 186–188 coping skills training , 297 cognitive symptoms , 179, 180 data supporting models , 288–289 socialization emotional dif fi culties , 287 avoidance , 183 exposure-based therapy , 297 behavioral inhibition , 181, 183 future aspects , 300–301 negative expectations , 184 integrated treatment , 297–299 negative peer interactions , 183–184 lack of treatment availability and access , 291–292 peers play , 181, 182 length of sobriety determination , 289–290 social functioning de fi cits , 183 lifetime estimate , 286–287 withdrawal , 181, 183 prolonged exposure , 297 somatic symptoms , 179 relapse prevention strategies , 297 and substance use disorders (see Substance use SDPT treatment protocol , 297 disorders (SUDs)) secondary gain , 290–291 treatment approaches self-medication hypothesis , 296 cognitive restructuring , 186 sequential treatment , 296 comprehensive cognitive-behavioral interventions , suicidal ideation and attempts , 287 184, 185 transcend , 298 coping strategy , 186 traumatic events , 286 exposure and friendship promotion , and social anxiety disorder 184–185 client-related factors , 291 social skills instruction , 186 clinical presentation , 295–296 Social phobia. See also Social anxiety disorder clinician factors , 292 avoidant personality disorder cognitive abilities , 290 CBT , 352 cognitive-behavioral approaches , 293 clinical course , 351–352 concurrent treatment approach , 293, 294 cognitive therapy , 356 data supporting models , 288–289 interpersonal therapy , 356 epidemiological reports , 286 prevalence of co-occurrence , 351 future aspects , 300–301 spectrum model , 353 integrated treatment model , 293–295 treatment conditions , 356 lack of treatment availability and access , 291–292 cognitive behavioral therapy , 164, 352 length of sobriety determination , 289–290 Index 413

psychiatric comorbidity rates , 286 prevalence of , 136 psychosocial and pharmacologic interventions , 293 quality of life , 137 secondary gain , 290–291 severity and frequency , 137 sequential treatment approach , 293, 294 social hindrances , 137 symptoms , 286 vocal tics , 136 substance abuse , 285 Tics , 193, 195 substance dependence , 285 Tourette syndrome. See Tic disorders and Tourette treatment syndrome cognitive-behavioral therapy , 292–293 Trauma memory, BPD and PTSD combined behavioral intervention , 293 poor quality , 207–208 motivational enhancement therapy , 292 quantity , 207 social support , 292 Triple vulnerability theory , 8–9 Suicidal behavior and NSSI , 204–205 Sydenham’s chorea (SA) , 193 W Webcam-delivered CBT program (W-CBT) , 382 T Work/Social Adjustment Scale (WSAS) , 381 Therapeutic alliance alliance-building behaviors , 265 alliance rupture and exposure procedure , 266–267 Y fl exible therapist , 265–266 Yale-Brown Obsessive Compulsive Scale (Y-BOCS) , positive therapeutic alliance , 263 249, 381 teamwork-oriented collaborative stance , 265 Young children therapist-parent alliance CGAS score , 116–117 anxiety-provoking situations , 264 clinical case study , 117–119 CBT , 263 cognitive behavioral treatment approach , 114 emotional connection , 264 cultural impact on , 113 therapist interpersonal skills , 265 diagnosis of therapist rapport-building behaviors , 265 behaviorally inhibited , 111 treatment approach , 266 DSM criteria , 110–111 youth treatment participation , 263 MDD , 111 Tic disorders and Tourette syndrome preschool mental health , 111 academic functioning , 137 emotional and cognitive responses , 112 comorbidity of , 139–140 emotion socialization practices , 120 clinical decision-making , 140–141 obsessive-compulsive disorder functional impairment , 140 age appropriate vs. potentially disordered primary symptoms of , 139 behavior , 125–126 hyperkinetic movement disorders , 136 clinical presentation , 130–131 impaired family functioning , 137 cognitive behavior therapy , motor tics , 136 129–130 OCD comorbidity rates , 126–127 academic performance , 142 developmental considerations , in adults , 138–139 127–128 axis I disorder , 138 family involvement , 128 cognitive training , 142–143 gender distribution , 126 contamination-related symptoms , 144–145 symptom expression , 127 CY-BOCS checklist , 141–142 parental counseling , 114 DSM-IV fi eld trial , 138 SDQ , 112–113 prevalence of , 138 temperamental pro fi le , 120 psychoeducation , 142 threats , 112