desorden de panico y agorafobia

7/23/2019 Desorden de Panico y Agorafobia

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anticipating potential challenges in treatment, empiricalguidance on the types of problems commonly encoun-tered that lead to suboptimal response and how theymight be prevented or managed is lacking. In theabsence of this guidance, we decided that it would beuseful to ask expert clinicians what they have found to

contribute to poor treatment outcome and whatstrategies they have found to be useful in the preventionand management of the problems they see. A similarmethod was employed byScott, Pollack, Otto, Simon, &

Worthington (1999) to evaluate psychiatrists responseto treatment-refractory PD when using pharmacological

interventions.

Method

Participants

Participants were members of the Association forBehavioral and Cognitive Therapies (ABCT) who wereselected and invited by the authors to complete an on-line

survey, and who volunteered to participate. Participantswere aware that they would be acknowledged in themanuscript. To identify experts, both authors indepen-

dently reviewed the membership list of ABCT andidentified individuals who made significant contributionsto the study or application of CBT for panic disorder. Theauthors compared their lists and only individuals whowere identified by both authors were included. Of 30members who were invited, 20 participated (see theAppendix for a list of participants).

Procedure

The survey involved two questions to which partici-pants were asked to produce brief answers. Specifically,invited members were emailed the following message:

We have been invited to write a paper on cognitivebehavioral approaches to treatment resistant panicdisorder. As part of this effort, we are conducting abrief survey of identified experts in the field. Wehope you agree that empirically informed clin-

icians, such as the readership of this journal, willvalue the opinion of experts in this area, wheredirect empirical guidance is lacking. We are askingif you would give us a few minutes of your time to

answer two brief questions about how you havecome to approach the problem. We will identifyand acknowledge the assistance of all contributingexperts.Bytreatment resistant,we generally mean a client

who, in response to conventional CBT for panicdisorder (i.e., psychoeducation, relaxation, breath-ing retraining, cognitive restructuring, sensation

and situation exposure), continues to exhibitclinically distressing or disabling features of the

disorder (e.g., panic attacks, agoraphobic avoid-ance, concern over future attacks, change in activi-ties, avoidance of physical sensations), or otherwiseshows incomplete progress. We are interested inwhat your experience with treatment resistance hasbeen, and how you have come to approach it.

1. In your experience, what have been the primaryreasons that some clients have had incompleteresponses to conventional CBT for panic disorder

(top 3 reasons or fewer)?2. Would you please briefly explain how you believeeach of the above problems is best approached

therapeutically?

In some literatures (e.g., treatment of infectious

disease), the term treatment resistance has beendefined more narrowly than we did for this survey.The more narrow definition refers to instances in whichtreatment is delivered as intended (i.e., with goodtreatment fidelity), received by the client (i.e., compli-ance is confirmed), but nonetheless results in a poorer-than-expected response. We intentionally broadened thedefinition to include any factor that the survey takerthought accounted for a poorer-then-expected response.

We did this to get a sense of what experiencedtherapists commonly encounter in their day-to-daypractices. Although this broader definition is alsotermed treatment resistance, we use the termssuboptimal or incomplete response interchangeablybecause they may more accurately reflect what weassessed.

Analyses

Question 1: In your experience, what have been the primary

reasons that some clients have had incomplete responses to

conventional CBT for panic disorder (top 3 reasons or fewer)?

Answers to Question 1 were listed verbatim for eachparticipant along with their ranking. The authors thencategorized answers independently. One of us identified10 categories. The other identified 11 categories, 10 of

which overlapped with the other authors 10. Theremaining category was integrated into an existing one(i.e., Problems With Cognitive Restructuring), leaving10 categories of cited reasons for treatment resistance.

The categories were then ranked as follows: A categoryranked 1by an author received 3 points, a rank of 2received 2 points, and a rank of 3 received 1 point.Ranks were summed for each category across respon-dents. Categories were then ranked from highest to lowest

total points. Alternative methods of ranking did notchange the order.

Question 2: Would you please briefly explain how you believe

each of the above problems is best approached therapeutically?Foreach cause of treatment resistance cited, participants were

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asked to describe how they have come to approach ittherapeutically. Those responses were listed verbatim foreach problem across participants. Redundancies wereremoved, yielding the core recommendations reportedlater in this paper.

Results

Table 1shows the cited causes for treatment resistancein rank order, as well as the total number of points foreach resulting from the ranking procedure. Four tiers ofcauses emerged based on the natural division evident inthe total scores. Lack of Engagement in BehavioralExperiments was far and away the highest rankedcategory with 35 total points. It was cited by more

participants than any other reason (12 of 20), and wasranked as the top cause of treatment resistance by 9 ofthe 12 respondents. Noncompliance ranked a clear

second with 20 points. Eight respondents cited it, 2 ofwhom ranked it as a 1. Causes 3 through 6 were

approximately equal in rank, with total rank pointsranging from 10 to 11. They were cited by an average of 5respondents and ranked as either a 2 or 3 by eachparticipant. Reasons 7 through 10 were approximately

equal in rank, ranging from 1 to 3 total points. One or 2respondents cited these and ranked them as a 2or 3.

Factors Associated with Suboptimal Treatment and

Recommendations

Lack of engagement in behavioral experiments.In CBT forPD, clients are asked to face and challenge their fears,mostly through exposure to sensations or situations thatthey believe will bring about some fearedconsequence (cf.

Barlow & Craske, 2000). The unwillingness of clients,intentional or not, to engage themselves fully in thesebehavioral experiments and risk the consequences theyfear was the most frequently cited cause for a suboptimalresponse to treatment. Many respondents described this interms of subtle avoidance behavior. Examples includeddoing only part of an exposure exercise, provoking onlyless-feared sensations as opposed to pushing oneself

further, using breathing or relaxation to prevent fearedsensations from emerging, and using various forms ofdistraction to minimize anxiety. These various forms ofavoidance were thought to preclude valid testing, restruc-turing, and eventual extinction of fears. Commonly citedexamples of fears that clients were reluctant to test

included losing control, embarrassing oneself, or simplynot wanting to experience the negative affect engenderedby the experiment for various or sometimes unknownreasons.

Suggested recommendations for addressing this obsta-cle were as follows:

1. Education: Use initial and ongoing psychoeducationthat emphasizes the importance of engagement as acrucial goal of therapy.

2. Graduated exposure: Use individualized graduatedexposure tasks as a means to ease wary clients into fullengagement.

3. Directly observe and assess avoidance: Try to observethe clients fearful behavior, as opposed to relyingsolely on self-report, during initial assessment (e.g., abehavioral avoidance test) and during initial and othercritical exposures to identify and confront obstacles toengagement.

4. Consider using motivational enhancement techniques:Motivational enhancement techniques include valida-tion of the clients particular stage of change throughexpression of empathy, identifying discrepanciesbetween the clients goals and problem behaviors(e.g., avoidance), rolling with resistance by emphasiz-ing personal control and approaching treatment as anexperiment, and encouraging self-efficacy by focusingon personal strengths and highlighting positives.

5. Encourage acceptance of negative feelings: Reframenegative feelings as tolerable, acceptable, and neces-sary to reduce the clients avoidance (e.g., no pain, nogain). Use education and support to try to help clientsbetter accept the experience of negative affect asunpleasant but not dangerous. Normalize the experi-ence, suggesting that the client take a monitors(observers) perspective, and encourage the client tosee exposure as an opportunity for building tolerance

of negative affect.

6. Avoid concluding that the client is

resistant: Ironi-cally, the label treatment resistant can be its own

obstacle when clients who are not engaging in therapyare thought of as nonresponders. Therapists may notbe as motivated to work with the client, believing his orher effort will be futile, and risk creating a self-fulfillingprophecy. Although it is possible that some clients maybe resistant to treatment, others may merely requirestrategies, such as those detailed above, to help them

overcome problems with engagement.

Table 1

Rank order of reasons cited for treatment resistance

Rank Cause of treatment resistance (Total Ranking Points )

1 Lack of engagement in behavioral experiments (35 pts.)2 Noncompliance (20 pts.)

3 Comorbidity (11 pts.)

4 Inadequate case formulation or misdiagnosis (10 pts.)

4 External support of PDA behavior (secondary gain, fear of

disruption) (10 pts.)

4 Problems with cognitive restructuring (10 pts.)

7 Presence of other negative life events (3 pts.)

8 Medication complications (2 pts.)

8 Poor delivery of CBT (2 pts.)

10 Therapeutic relationship barriers (1 pt.)

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Noncompliance. The second most cited reason fortreatment resistance in our survey was noncompliance.In clients suffering from anxiety disorders, noncompli-ance is often an expression of avoidance due to fear. Theprevious factor, lack of engagement, could justifiably bedescribed as a form of noncompliance due to fear. We

separated engagement primarily because the respon-dents did. Here we have categorized all other forms ofnoncompliance other than engagement. This categoryalmost entirely refers to instances of noncompletion of

therapeutic homework,such as not doing self-monitor-ing tasks, not doing an assigned BAT, not practicing

somatic strategies, not doing tasks related to identifyingor challenging cognitive biases, or not doing scheduledexposure exercises. Although sometimes fear based, italso includes noncompliance related to other factorssuch as resource limitations, scheduling problems, orforgetfulness.

Most of the recommendations for dealing with non-

compliance aimed at preventing it. Preventative recom-mendations were as follows:

1. Psychoeducation: One of the most frequentlyproposed solutions for this problem was to reviewand expand upon psychoeducation. This was basedon the idea that noncompliance sometimes resultsfrom the individuals lack of understanding of thetherapeutic rationale for a task and/or the essentialrole that the task plays in promoting improvement.For example, the following information would beconveyed to the client to facilitate completion of

restructuring exercise:

Thepurpose of cognitive restructuring is to learn toidentify and challenge irrational anxiety-provokingthoughts, thereby reducing anxiety. Frequently,focusing on these thoughts results in an increasein anxiety at the moment. There is no other wayto reduce anxiety-provoking thoughts, and theyare very unlikely to improve without using a

deliberate process to correct them such ascognitive restructuring. If only practiced in thesession the value will be limited because it isessential to learn to apply it in the majority of

anxiety-provoking situations that occur outside ofthe session.

This information should be discussed with the client toensure it is understood. Similar explanations for othertreatment strategies were recommended.

2. Consider audiotaping sessions: One way to increaseadherence is to audiotape the sessions and ask the

client to listen to it at least once prior to the next

session. Some clients may benefit from the redundantpresentation of the information. Others may processthe information more clearly when merely listening(rather than during the session when they areinteracting with the therapist). It also is a way toapply extra pressure between sessions as they will be

reminded of the assignments while listening to thesession.

3. Increase accountability, if necessary: Some clients may

feel more compelled to engage in treatment strategiesoutside the session if they are asked to be moreaccountable. For some, simply coming in to the next

session and reporting what they did or did not do issufficient. However, for others, asking them tocomplete some type of monitoring form (e.g., a recordof relaxation practice sessions, thought records) orasking them to phone or email when they complete theexercise may increase motivation.

Several recommendations concerned how homeworktasks where assigned, explained, and carried out, as

follows:

4. Be clear and specific: Write down exactly what theclient is expected to do and whena behavioral

prescription. For example, if a clients assignment isto drive 2 miles from home three times in betweensessions, record the assignment and then collaboratewith the client to come up with specific days andtimes this assignment can be completed (e.g.,Monday, Wednesday, and Friday during lunchbreak).

5. Anticipate obstacles with each assignment: Ask theclient questions regarding facilitators and obstaclesfor example, access to the car, having sufficient timeto complete the exercise, hiring a babysitter if neces-saryand generating solutions (or modifying theassignment) to increase the likelihood of thebehavior.

6. Reduce burden: Make homework tasks as easy to carryout as possible. For example, use checkmarks ratherthan narrative or tape record responses rather thanwrite them, depending on the clients preference.

7. Make tasks clearly relevant to goals: Tie homework

directly to a clearly identified therapeutic goal andexplain its rationale as described previously.8. Model tasks: When possible, demonstrate assigned

exercises to minimize compliance problems due to alack of understanding of the task on the clientspart.

9. Prompt the behavior in the environment and reinforceit: Use standard behavioral practices for prompting the

behavior in the natural environment, such as makinga phone call or tying it to another high-frequency

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activity, and then reward it with something of theclients choosing.

10. Review the homework: Communicating to the clientthat their work is important and valued can facilitateadherence.

When addressing existing noncompliance, nearly allrespondents recommended doing a functional analysis ofthe noncompliant behavior. Some suggested contingencycontracting with persistent noncompliance.

1. Functional analysis of existing noncompliance: Try to

identify factors that are interfering with complianceor facilitating noncompliance. Most respondentsreported that in their experience noncompliancewas usually an act of avoidance of a feared activityand was addressed as described under Factor 1. Butother reinforcers of noncompliance were cited aswell, ranging from the subtle, such as not disturbing

existing social relationships, to the obvious, such asmaintaining disability compensation. As noted later,immediately and directly addressing those factors as

obstacles to continuing therapy was the corerecommendation.

2. Consider contingency contracting: Three respon-dents suggested addressing noncompliance withcontingency contracting. Evidence from early studiesof contracting in marital therapy suggests that theprocess of negotiating the contract is as critical to itssuccess as its quid pro quo content (Jacobson, 1978).Recommendations were consistent with this in

emphasizing collaborative exploration of the positiveand negative consequences of compliance andnoncompliance and honestly and directly addressingthe clients motivation and goals.

Comorbidity. The presence of additional mental dis-orders or clinically significant symptoms (i.e., syndromalor symptom comorbidity, respectively) was one of fourcited causes of poor treatment response ranked within the

third tier of causes. Although four respondents citedexamples of difficult comorbid anxiety disorders (e.g.,OCD), the majority discussed comorbid depression.Interestingly, existing data on the impact of comorbidity

on treatment outcome for clients with a principaldiagnosis of PD suggest that in many cases the presenceof another anxiety disorder does not typically diminishthe efficacy of CBT focused on the panic disorder (Brown,Antony, & Barlow, 1995). Factors such as the type and

severity of the comorbid anxiety disorder may mediatethat relationship in individual clients. Studies of comorbiddepression, however, suggest that its presence can

interfere with successful outcome (Brown et al., 1995;McLean, Woody, Taylor, & Koch, 1998).

Recommendations for dealing with comorbidity arestepwise, as follows:

1. If the comorbid condition is judged severe enough tointerfere with participation in the CBT for panic (e.g.,hopelessness precluding engagement or other com-

pliance), then the recommendation is to address thecomorbid condition first. In other words, severity ofinterference may place the comorbid condition first in

line for treatment.2. In the more subtle case of conditions or symptoms

that are coexistent but not as interfering, therecommendation is to treat the panic disorder first,reevaluating it and the comorbidity along the courseof treatment, and treating residual syndromes orsymptoms next. Many comorbid disorders and symp-toms have been shown to remit with successfultreatment of a primary panic disorder (Brown et al.,

1995). Residual conditions or symptoms should betreated based on initial studies showing that thepresence of some comorbid symptoms places clientsat risk for continued or emergent problems (McLeanet al., 1998).

Inadequate case formulation or misdiagnosis.Nearly everyguideline for the treatment of nearly every health carecondition advises practitioners to revisit their diagnosisif a client has not responded as expected (cf.American Psychiatric Association, 1998). Also amongthe third tier of cited causes for a poor treatmentresponse were problems with case formulation. Some

respondents couched recommendations in diagnosticterms, others in terms of behavior analysis.Diagnostically speaking, the decision tree for diag-

nosing PD requires first ruling out symptoms that aredue to the direct physiological effects of a generalmedical condition (e.g., hyperthyroidism) or a sub-stance-induced syndrome (e.g., CNS depressant with-drawal, stimulant intoxication) before making thediagnosis of PD (American Psychiatric Association,

2000). Some of our survey respondents cited examplesin which symptoms of panic that did not respond toCBT were found subsequently to be products ofmedical conditions such as pheochromocytoma or

hyperthyroidism.Unexpected panic attacks, the diagnostic hallmark of

PD, may occur in other mental disorders such asposttraumatic stress disorder, generalized anxiety disor-der, or depression. Some respondents recounted poor

treatment responders who later were found to be betterdescribed by a different anxiety or mood disorder. Forinstance, one respondent described a client who reported

unexpected panic attacks in situations where she feltalone. The client was initially diagnosed with PD and



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agoraphobia. The fear of being alone was seen asreflecting agoraphobic safety and efficacy concerns.Although benefiting somewhat from exposure to thesesituations, her improvement was less than expected. Theclient later disclosed that the fear of being alone beganafter a sexual assault that she had been unwilling to

disclose earlier. When treatment was oriented around thiscontext, her response to it improved. This case highlightstherapeutic trust issues as well as diagnostic conse-quences. Trust issues also appear under Factor 10 later

in the paper.In behavior analytic terms, the most common error

cited was the misidentification or underestimation oftriggers of panic, resulting in exposures that did not targetthe most significant stimuli.

In their recommendations, respondents againemphasized preventive measures, but recommendedrevisiting the initial assessment when nonresponse isevident:

1. Rule out medical and substance etiology: Requirecertain clients to undergo medical and substance

clearance prior to treatment.2. Assess triggers: Do a thorough and ongoing assessment

of triggers of fear.3. Educate clients regarding triggers: Place a strong

emphasis on educating the client about triggers andon identifying them throughout treatment. Assessingseveral examples of the sequencing of the clientsthoughts, sensations, and reactions that spiral intopanic may help identify key themes and triggers to

target through exposure.

All of these recommendations are consistent with theCBT principle of continuing assessment throughouttherapy and adjusting the focus of interventions asneeded.

External support of PD behavior (secondary gain, fear of

disruption). Situations in which the fear and avoidanceof PD are being positively or negatively reinforced

(e.g., disability check, not having to work) or whereovercoming them would cost the client somethingpersonally important (i.e., spousal attention; sympathyfrom others) were cited by some respondents as

barriers to improvement. No one cited malingeringas an example of external support; rather, these factorswere seen as obstacles to improvement of realconditions. Examples included the loss of socialattention, social pressure to remain dependent, and

loss of disability payments, all creating an incentive toremain ill. In some cases, clients were described aslosing their confidence in being able to be return to

the demands of the roles and responsibilities of workor other demands.

Recommendations to address this issue were as follows:

1. Conduct a functional assessment: Identify the func-tional relationship between improvement and itsconsequences. Often the factors supporting non-improvement involve fear and thus nonimprovement

is avoidance. Consider developing a list of pros andcons of improvement.

2. Problem-solve obstacles: Problem-solve anticipated

changes and problems by specifically identifyingthem, generating options for coping, and developinga plan based on the best options. Gradual exposure

may be needed as well. For example, a first goal may beto go back to work part-time, then half-time, and thenfull-time.

3. Directly address gain as a potential obstacle tofurther treatment: Regardless of the factors supportingnonimprovement, one unanimous recommendationwas to address it directly with the client toward the goal

of deciding whether continued therapy is desired (i.e.,does the client really want what comes along with

successful treatment?).

Problems with cognitive restructuring. In broad strokes,cognitive restructuring in the treatment of PD involveselucidating what the client finds threatening, the biasesin that appraisal of threat, and the generation ofalternative appraisals that correct for those biases.These identified fears and alternative appraisals areusually framed as predictions and are tested throughbehavioral experiments. The clinician attempts to

make those tests valid to the client

if not at first,then eventually. Repeated disconfirmation of biasedfear-based predictions helps the client shift fromfearful appraisals to ones more in line with the actualthreat posed by the feared stimulus (e.g., Clark et al.,1994). Difficulties with cognitive restructuring alsoranked fourth among reasons for a poor treatmentresponse. The nature of the problems that were citedvaried.

Several respondents noted that they have seen apoor response when key and often subtle fears are notelucidated. More than one suggested that this is likelyto occur when assessment is rushed and when clients

are asked to endorse from a list

(such as aquestionnaire) rather than produce fearful cognitions.Other respondents noted that although some fears areidentifiable and testable (e.g., heart attack, goingcrazy, embarrassing oneself), others were seen as

more difficult to define and convert into testablepredictions. Examples cited included fading intonothingness and losing oneself. Still others identi-

fied validity problems, most notably difficulty findingvalid alternative appraisals that correct for fearful

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biases and the failure of interoceptive exposureexercises to produce sensations that the client findsvalid. Points made were that some clients expect tosee a shift in the believability of alternatives tooquickly into therapy and that this demoralizes orotherwise disengages them. Similarly, some clients do

not believe that managing the sensations produced byinteroceptive exercises is similar to managing those en-countered during a panic attack, resulting in motivationalproblems.

For difficulties elucidating key and subtle fears,respondents suggested the following: Assess fears compre-hensively and monitor change. That is, take the time to do acomprehensive initial assessment of fearful cognitions,preferably using guided discovery and possibly ques-tionnaires as an adjunct to this assessment (e.g.,Agoraphobic Cognitions Questionnaire, Anxiety Sensi-tivity Index). Periodically revisit this assessment through-out therapy to determine the relevance of cognitions

identified.For problems with the lack of validity of alternative

rational appraisals, the following solutions were

offered:

1. Create realistic expectations: Help the clientunderstand and accept that alternatives may seeminvalid and may be doubted at the beginning oftherapy. Encourage clients to focus their efforts onaccomplishing the behavioral goals of the beha-vioral experiments. Repeated experiential evidenceof safety and manageability drawn through accom-

plishing those goals will facilitate the cognitiveshift.

To address the invalidity of interoceptive exposureexercises, the following was recommended:

2. Rule out subtle avoidance: Ensure that the client ischallenging him-or herself with the exercises instead ofsubtly avoiding sensations.

3. Use a multipurpose rationale: Explain that theexercises have multiple purposes and that the clientneed not find that the symptoms mimic panic tobenefit from the them. For example, part of the

rationale for sensation exposure can include that itprovides an opportunity for the repeated experienceof raising and lowering of symptoms under controlledconditions, that it is an arena to practice calmingstrategies, and that it allows for repeated testing of

anticipatory fears of what might happen during theexercise.

4. Use sensations evoked during naturalistic exposures:

Respondents agreed that persistent validity problemswith interoceptive exposure should be addressed by

moving on to naturalistic situational exposures (pho-bic situations) and working with the symptomsproduced there.

Presence of negative life events/circumstances. Although thediagnosis of PD may be the reason an individual presents

for treatment, co-existing negative life events may also bepresent and need to be addressed to allow the client tobenefit from treatment. Commonly cited negative life

events included relationship distress (e.g., marital pro-blems), job stress, and financial problems. Negative lifeevents can exacerbate the severity of the primary

condition and distract the client from engagement inthe therapy.

All respondents who highl ight ed this prob lemindicated that they first address the negative lifecircumstances before moving to the panic disorder.For example, for the client with significant maritaldistress who finds it difficult to focus on the treatment

of panic, it was suggested to first address the maritalissues, including consideration of marital therapy,

before starting or continuing CBT for PD. Likewise, aclient with job stress may benefit from some level ofstress management training prior to addressing thepanic.

Medication complications. Many clients who begin CBTfor PD are also on medication for PD, often antidepres-sants, benzodiazepines, or both. The presence ofmedication during CBT can interfere with the CBTthrough several potential means (see Otto, Smits, &Reese, 2005, for a review). For example, symptom

attenuation or suppression through the use of medica-tion may reduce motivation to do the work of CBT. Also,in CBT, sensations of anxiety and panic are treated asphobic cues and targeted for exposure. The presence ofmedication during exposure can place the client at riskfor relapse after discontinuation of the medication(Marks et al., 1993).

Recommendations for managing the presence ofmedication during CBT were as follows:

1. Educate the client: Educate the client regarding thebenefits and risks of concurrent medication use,discuss discontinuation or continuation options, then

coordinate with the prescriber.2. Engage the prescriber: Contact the prescriber, edu-

cate, and engage their support in the managementplan.

3. Use empirically supported discontinuation protocols:

The respondents who noted this cause indicated thatthey follow the protocols used in studies showing thatmedication discontinuation can be facilitated and

relapse prevention enhanced by integrating CBT intomedication discontinuation in particular ways (see



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Spiegel & Bruce, 1997, for a review). For a treatmentmanual describing these methods see Otto et al.(2000).

Poor delivery of treatment. Of course, before determin-ing that a client is not responding to a treatment, it

needs to be determined that the treatment is beingdelivered and received. Poor delivery was not ahighly cited obstacle to a good treatment response,but was mentioned by a three participants. The

common theme of examples cited was that some-times therapists do not push themselves or clients to

get the most from each phase of treatment. Forinstance, it was noted that a therapists reluctance tohave clients challenge themselves strongly duringexposure may make them an unintentional hindranceto progress.

Recommendations were as follows:

1. Conduct high-fidelity treatment: Attend to deliveringeach of the primary emphases of CBT for PD (i.e.,psychoeducation, somatic skills, cognitive restructur-

ing, and exposure) in a way that maximizes the gain aclient can receive from them.

2. Exposure for the exposer: As the reader might guess,one recommendation for therapists who find them-selves hesitant to encourage clients to challengethemselves was to expose themselves to asking clientsto do just that. Being a participant model may makethis easier to do.

3. Consult with colleagues: Consulting with a colleague

may reveal suggested changes that could improveones treatment delivery.4. Continuing education: Observing experts through

workshops or videotapes offers opportunities to learntried and tested methods.

Therapeutic relationship barriers. In CBT, therapists askclients to do things that may make the clients feelvulnerable to some distress. For this and other reasons

common to all therapies, a clients trust in a therapistis obviously important. Two respondents cited a lack ofclient trust as one reason for treatment resistance.Fears of being controlled or harmed in one way or

another were cited as examples of impediments totrust.

The cor e r ecom mendat io n wa s t o wo rk o neliciting, evaluating, and responding to specific fearsand conducting small manageable behavioral experi-

ments that the client is willing to do that test andultimately disconfirm the fears. More time than usualspent on rapport building may be important with

clients who have difficulty trusting or connecting withothers.

Discussion

In discussing treatment resistance, we find it helpfulto think first about what an optimal treatment responselooks like. In this, perhaps hypothetical, optimalresponse scenario, the clients problems directly relatedto their distress and disability are accurately assessed.This case formulation leads to a treatment plan that isdelivered as intended. The client complies and engages

in the treatment. And, the targeted problems showimprovement that corresponds with reductions in thedistress and disability. It seems that problems at any ofthese steps could potentially lead to a suboptimalresponse.

Results from this survey of experienced CBT thera-pists for PD suggest that problems with compliance andengagement are the most frequently encounteredreasons for a poor treatment response. Participants

Table 2Guidelines for preventing or managing treatment resistance of panic

disorder

1. Do a thorough initial evaluation.

Rule out general medical and substance conditions that may be

causing the presentation.

Assess for comorbid psychiatric disorders, particularly

depression, substance use, and other anxiety disorders.

Do a comprehensive review of psychosocial systems and life

circumstances that could influencethe clinical picture or treatment

plan.

Do a thorough functional assessment of fears, triggers, and

avoidance strategies, facilitated when possible by guided

discovery, direct observation, and psychometric measurement.

2. Deliver CBT with integrity to the model and with sensitivity toward

its difficulty.

Build the trust of the client.

Clarify and emphasize the goals for each phase of therapy.

Explain rationales for prescribed practices.

Emphasize continuing education of key concepts.

Explain, model, and shape the development of the therapeutic

skills being taught.

Emphasize and facilitate engagement in valid behavioral

experiments.

Graduate tasks, as needed.

Assess obstacles and facilitators; functionally analyze and

problem solve barriers.

3. Facilitate treatment adherence.

Make homework specific, clear, and relevant to clearly stated

goals.

Explain, model, and shape the development of homework taskbeing assigned.

Prompt desired behavior in the natural environment (e.g., by

making a phone call or tying it to another high-frequency

activity), and reinforce it when it has been completed.

Gradate or simplify tasks that are likely or proving to be

difficult.

4. Reconsider the case formulation if progress is not seen when

expected.

Reevaluate the functional assessment of fears and triggers.

Reevaluate diagnostic accuracy.

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described addressing this issue by making engagement aprimary goal of therapy and the facilitation of adherencea consideration in every therapeutic prescription (cf.Meichenbaum & Turk, 1987).

Also common were problems with case formulation,which appeared in several forms: misdiagnosis, missed

comorbid diagnoses, other life circumstances not takeninto consideration, or inaccuracies in behavioral analysisof triggers. Although not cited as strongly as complianceand engagement problems, formulation problems were

endorsed by nearly half of respondents. These resultssuggest that when treatment response is poorer than

expected but fidelity and compliance appear good,revisiting the case formulation may be helpful.

Interestingly, poor treatment delivery did not appearfrequently in survey results. That may be a partial productof sampling bias, in that you might expect to see less ofthose problems as therapists become more experienced.Of course, every therapist should first consider his or her

role in the clients lack of response, before moving toother considerations.

Table 2contains a summary of the recommendations

offered by the survey participants in the form ofguidelines for preventing or managing treatment resis-tance. They ring familiar as the kinds of practicesadvocated by every good clinical training program. It isreassuring to note that our findings overlap with severalnonempirical attempts to provide further information toclinicians regarding improving treatment outcome forCBT of PD (e.g., Huppert & Baker-Morissette, 2003;McCabe & Antony, 2005; Otto & Gould, 1996).

Appendix A. Survey Participants

Anne Marie AlbanoDavid AntonuccioMarty AntonyDeborah BeidelJudith BeckCheryl CarminBruce Chorpita

Frank M. DattilioThomas EllisSteven FriedmanRobert GoismanJames HerbertJonathan HuppertRolf JacobSteven SafrenLisa Smith

Steven TaylorDavid TolinJulia TurovskySheila Woody

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McCabe, R. E., & Antony, M. M. (2005). Panic disorder andagoraphobia. In M. Antony, D. R. Ledley, & R. Heimberg (Eds.),Improving Outcomes and Preventing Relapse in Cognitive BehavioralTherapy.New York: The Guilford Press.

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Spiegel, D. A., & Bruce, T. J. (1997). Benzodiazepines and exposure-based cognitive behavior therapies for panic disorder: conclu-sions from combined treatment trials. American Journal of Psychiatry, 154, 773781.

The authors would like to thank the survey participants, listed in the

Appendix, who generously offered their valuable time and clinical

perspectives.

Address correspondence to William C. Sanderson, Department of

Psychology, Hofstra University, Hempstead, NY 11549 USA; e-mail:

[email protected].

Received: December 22, 2005

Accepted: April 6, 2006

Available online 30 November 2006

35Panic Disorder
mailto:CBPRA59S1077-06)001211016/j.cbpra.2006.04.020Causes%20and%20Management%20of%20Treatment-esistant%20Panic%20Disorder%20and%20Agoraphobia:%20A%20Survey%20of%20Expert%20TherapistsWilliam%[email protected]%20J.BrucebaHofstra%20UniversitybUniversity%20of%20Illinois%20College%20of%20MedicineNCorrespondence%20concerning%20this%20article%20should%20be%20sent%20to%20William%20C.%20Sanderson,%20Department%20of%20Psychology,%20Hofstra%20University,%20Hempstead,%20NY%2011549%20USA.AbstractCognitive%20behavior%20therapy%20(CBT)%20is%20recognized%20as%20an%20effective%20psychological%20treatment%20for%20panic%20disorder%20(PD).%20Despite%20its%20efficacy,%20some%20clients%20do%20not%20respond%20optimally%20to%20this%20treatment.%20Unfortunately,%20literatures%20on%20the%20prediction,%20prevention,%20and%20management%20of%20suboptimal%20response%20are%20not%20well%20developed.%20Considering%20this%20lack%20of%20empirical%20guidance,%20we%20decided%20that%20it%20would%20be%20useful%20to%20survey%20expert%20cognitive%20behavioral%20therapists%20about%20what%20they%20have%20found%20in%20their%20practices%20to%20contribute%20to%20a%20poor%20treatment%20response%20and%20what%20strategies%20they%20have%20found%20helpful%20in%20preventing%20or%20managing%20these%20problems.%20Ten%20factors%20associated%20with%20suboptimal%20responding%20emerged.%20Listed%20in%20order%20of%20reported%20frequency,%20they%20were%20as%20follows:%20lack%20of%20engagement%20in%20behavioral%20experiments,%20noncompliance,%20comorbidity,%20inadequate%20case%20formulation/misdiagnosis,%20secondary%20gain,%20problems%20with%20cognitive%20restructuring,%20presence%20of%20other%20negative%20life%20events,%20medication%20complications,%20poor%20delivery%20of%20treatment,%20and%20therapeutic%20relationship%20barriers.%20The%20current%20paper%20discusses%20these%20factors%20and%20details%20treatment%20suggestions%20to%20improve%20outcome%20provided%20by%20the%20survey%20participants.Panic%20disorder%20(PD)%20is%20a%20distressing%20and%20disabling%20anxiety%20disorder%20characterized%20by%20an%20onset%20of%20recurrent%20unexpected%20panic%20attacks.%20Panic%20attacks%20involve%20a%20sudden%20rush%20of%20intense%20fear%20that%20is%20accompanied%20by%20a%20variety%20of%20physical%20(e.%E4%A7%AE,%20palpitations,%20dizziness,%20sweating)%20and%20cognitive%20(i.%E4%A5%AE,%20fear%20of%20dying,%20losing%20control,%20or%20going%20crazy)%20symptoms%20(American%20Psychiatric%20Association,%202000).%20Clients%20with%20PD%20fear%20subsequent%20attacks%20and%20become%20preoccupied%20with%20potential%20%1Ccatastrophic%1D%20consequences%20of%20panic%20attacks%20(e.%E4%A7%AE,%20the%20panic%20attack%20will%20cause%20a%20heart%20attack,%20stroke,%20fainting,%20loss%20of%20control).%20Many%20clients%20suffering%20from%20PD%20develop%20agoraphobia,%20which%20refers%20to%20fear%20and/or%20avoidance%20of%20activities%20or%20situations%20that%20they%20believe%20will%20provoke%20an%20attack,%20where%20escape%20may%20be%20difficult%20(e.%E4%A7%AE,%20airplanes,%20elevators,%20trains),%20or%20where%20help%20may%20be%20unavailable%20in%20the%20event%20of%20a%20panic%20attack%20(e.%E4%A7%AE,%20being%20at%20home%20alone,%20in%20an%20airplane,%20far%20from%20home).%20The%20severity%20of%20panic%20attacks%20and%20agoraphobia%20can%20range%20from%20multiple%20daily%20attacks%20and%20houseoundness%20to%20infrequent%20attacks%20and%20endurance%20of%20feared%20situations%20with%20discomfort,%20respectively.Cognitive%20behavior%20therapy%20(CBT)%20is%20well%20established%20as%20an%20effective%20psychological%20treatment%20for%20PD.%20It%20is%20a%20firstine%20treatment%20option%20according%20to%20guidelines%20of%20best%20practice%20(cf.%20American%20Psychiatric%20Association,%201998).%20Although%20there%20are%20several%20different%20CBT%20%1Cpackages%1D%20for%20PD%20%20%20%20%20%20%20%20%20%20%20%20%20(cf.%20Margraf,%20Barlow,%20Clark,%20&%20Telch,%201993),%20most%20CBT%20treatments%20include%20the%20following%20components:%EA%B0%B3ychoeducation%20about%20PD%20and%20CBT;%EA%B0%A1nic%20management%20strategies%20such%20as%20relaxation%20and%20breathing;%EA%A3%AFgnitive%20restructuring%20of%20fearased%20thought%20content%20and%20processes;%EA%A5%B8posure%20to%20feared%20bodily%20sensations%20(interoceptive%20exposure);%EA%A5%B8posure%20to%20feared%20situations%20(exteroceptive%20exposure)For%20most%20clients%20undergoing%20treatment,%20CBT%20has%20been%20shown%20to%20reduce%20panic%20attacks,%20generalized%20anxiety,%20agoraphobic%20avoidance,%20and%20depression%20(e.%E4%A7%AE,%20Barlow,%20Gorman,%20Shear,%20&%20Woods,%202000).%20Although%20results%20across%20studies%20vary%20slightly,%20most%20show%20that%20CBT%20results%20in%20a%20panicree%20rate%20of%20approximately%2075%%20to%2090%%20(Barlow,%20Raffa,%20&%20Cohen,%202002).Despite%20the%20efficacy%20of%20CBT%20for%20PD,%20some%20clients%20show%20a%20suboptimal%20response%20to%20it%20in%20that%20they%20either%20do%20not%20respond%20or%20respond%20only%20partially%20(Rosenbaum,%20Pollack,%20&%20Pollack,%201996).%20The%20literatures%20on%20the%20prediction,%20prevention,%20and%20management%20of%20suboptimal%20treatment%20response%20are%20not%20advanced.%20Studies%20of%20factors%20associated%20with%20poor%20outcome%20were%20recently%20reviewed%20by%20McCabe%20and%20Antony%20(2005),%20who%20identified%20three%20factors%20with%20consistent%20support:%20symptom%20severity,%20comorbid%20depression,%20and%20a%20comorbid%20personality%20disorder.%20Although%20this%20information%20is%20useful%20to%20the%20practicing%20clinician%20in%20anticipating%20potential%20challenges%20in%20treatment,%20empirical%20guidance%20on%20the%20types%20of%20problems%20commonly%20encountered%20that%20lead%20to%20suboptimal%20response%20and%20how%20they%20might%20be%20prevented%20or%20managed%20is%20lacking.%20In%20the%20absence%20of%20this%20guidance,%20we%20decided%20that%20it%20would%20be%20useful%20to%20ask%20expert%20clinicians%20what%20they%20have%20found%20to%20contribute%20to%20poor%20treatment%20outcome%20and%20what%20strategies%20they%20have%20found%20to%20be%20useful%20in%20the%20prevention%20and%20management%20of%20the%20problems%20they%20see.%20A%20similar%20method%20was%20employed%20by%20Scott,%20Pollack,%20Otto,%20Simon,%20&%20Worthington%20(1999)%20to%20evaluate%20psychiatrists%19%20response%20to%20treatment-efractory%20PD%20when%20using%20pharmacological%20interventions.MethodParticipantsParticipants%20were%20members%20of%20the%20Association%20for%20Behavioral%20and%20Cognitive%20Therapies%20(ABCT)%20who%20were%20selected%20and%20invited%20by%20the%20authors%20to%20complete%20an%20onine%20survey,%20and%20who%20volunteered%20to%20participate.%20Participants%20were%20aware%20that%20they%20would%20be%20acknowledged%20in%20the%20manuscript.%20To%20identify%20experts,%20both%20authors%20independently%20reviewed%20the%20membership%20list%20of%20ABCT%20and%20identified%20individuals%20who%20made%20significant%20contributions%20to%20the%20study%20or%20application%20of%20CBT%20for%20panic%20disorder.%20The%20authors%20compared%20their%20lists%20and%20only%20individuals%20who%20were%20identified%20by%20both%20authors%20were%20included.%20Of%2030%20members%20who%20were%20invited,%2020%20participated%20(see%20the%20Appendix%20for%20a%20list%20of%20participants).ProcedureThe%20survey%20involved%20two%20questions%20to%20which%20participants%20were%20asked%20to%20produce%20brief%20answers.%20Specifically,%20invited%20members%20were%20emailed%20the%20following%20message:We%20have%20been%20invited%20to%20write%20a%20paper%20on%20cognitive%20behavioral%20approaches%20to%20treatment%20resistant%20panic%20disorder.%20As%20part%20of%20this%20effort,%20we%20are%20conducting%20a%20brief%20survey%20of%20identified%20experts%20in%20the%20field.%20We%20hope%20you%20agree%20that%20empirically%20informed%20clinicians,%20such%20as%20the%20readership%20of%20this%20journal,%20will%20value%20the%20opinion%20of%20experts%20in%20this%20area,%20where%20direct%20empirical%20guidance%20is%20lacking.%20We%20are%20asking%20if%20you%20would%20give%20us%20a%20few%20minutes%20of%20your%20time%20to%20answer%20two%20brief%20questions%20about%20how%20you%20have%20come%20to%20approach%20the%20problem.%20We%20will%20identify%20and%20acknowledge%20the%20assistance%20of%20all%20contributing%20experts.By%20%1Ctreatment%20resistant,%1D%20we%20generally%20mean%20a%20client%20who,%20in%20response%20to%20conventional%20CBT%20for%20panic%20disorder%20(i.%E4%A5%AE,%20psychoeducation,%20relaxation,%20breathing%20retraining,%20cognitive%20restructuring,%20sensation%20and%20situation%20exposure),%20continues%20to%20exhibit%20clinically%20distressing%20or%20disabling%20features%20of%20the%20disorder%20(e.%E4%A7%AE,%20panic%20attacks,%20agoraphobic%20avoidance,%20concern%20over%20future%20attacks,%20change%20in%20activities,%20avoidance%20of%20physical%20sensations),%20or%20otherwise%20shows%20incomplete%20progress.%20We%20are%20interested%20in%20what%20your%20experience%20with%20treatment%20resistance%20has%20been,%20and%20how%20you%20have%20come%20to%20approach%20it.1.%20In%20your%20experience,%20what%20have%20been%20the%20primary%20reasons%20that%20some%20clients%20have%20had%20incomplete%20responses%20to%20conventional%20CBT%20for%20panic%20disorder%20(top%203%20reasons%20or%20fewer)?2.%20Would%20you%20please%20briefly%20explain%20how%20you%20believe%20each%20of%20the%20above%20problems%20is%20best%20approached%20therapeutically?In%20some%20literatures%20(e.%E4%A7%AE,%20treatment%20of%20infectious%20disease),%20the%20term%20%1Ctreatment%20resistance%1D%20has%20been%20defined%20more%20narrowly%20than%20we%20did%20for%20this%20survey.%20The%20more%20narrow%20definition%20refers%20to%20instances%20in%20which%20treatment%20is%20delivered%20as%20intended%20(i.%E4%A5%AE,%20with%20good%20treatment%20fidelity),%20received%20by%20the%20client%20(i.%E4%A5%AE,%20compliance%20is%20confirmed),%20but%20nonetheless%20results%20in%20a%20poorer-hanxpected%20response.%20We%20intentionally%20broadened%20the%20definition%20to%20include%20any%20factor%20that%20the%20survey%20taker%20thought%20accounted%20for%20a%20poorer-henxpected%20response.%20We%20did%20this%20to%20get%20a%20sense%20of%20what%20experienced%20therapists%20commonly%20encounter%20in%20their%20day-oay%20practices.%20Although%20this%20broader%20definition%20is%20also%20termed%20%1Ctreatment%20resistance,%1D%20we%20use%20the%20terms%20%1Csuboptimal%1D%20or%20%1Cincomplete%20response%1D%20interchangeably%20because%20they%20may%20more%20accurately%20reflect%20what%20we%20assessed.AnalysesQuestion%201:%20In%20your%20experience,%20what%20have%20been%20the%20primary%20reasons%20that%20some%20clients%20have%20had%20incomplete%20responses%20to%20conventional%20CBT%20for%20panic%20disorder%20(top%203%20reasons%20or%20fewer)?%20Answers%20to%20Question%201%20were%20listed%20verbatim%20for%20each%20participant%20along%20with%20their%20ranking.%20The%20authors%20then%20categorized%20answers%20independently.%20One%20of%20us%20identified%2010%20categories.%20The%20other%20identified%2011%20categories,%2010%20of%20which%20overlapped%20with%20the%20other%20author%19s%2010.%20The%20remaining%20category%20was%20integrated%20into%20an%20existing%20one%20(i.%E4%A5%AE,%20%1CProblems%20With%20Cognitive%20Restructuring%1D),%20leaving%2010%20categories%20of%20cited%20reasons%20for%20treatment%20resistance.%20The%20categories%20were%20then%20ranked%20as%20follows:%20A%20category%20ranked%20%1C1%1D%20by%20an%20author%20received%203%20points,%20a%20rank%20of%20%1C2%1D%20received%202%20points,%20and%20a%20rank%20of%20%1C3%1D%20received%201%20point.%20Ranks%20were%20summed%20for%20each%20category%20across%20respondents.%20Categories%20were%20then%20ranked%20from%20highest%20to%20lowest%20total%20points.%20Alternative%20methods%20of%20ranking%20did%20not%20change%20the%20order.Question%202:%20Would%20you%20please%20briefly%20explain%20how%20you%20believe%20each%20of%20the%20above%20problems%20is%20best%20approached%20therapeutically?%20For%20each%20cause%20of%20treatment%20resistance%20cited,%20participants%20were%20asked%20to%20describe%20how%20they%20have%20come%20to%20approach%20it%20therapeutically.%20Those%20responses%20were%20listed%20verbatim%20for%20each%20problem%20across%20participants.%20Redundancies%20were%20removed,%20yielding%20the%20core%20recommendations%20reported%20later%20in%20this%20paper.ResultsTable%201%20shows%20the%20cited%20causes%20for%20treatment%20resistance%20in%20rank%20order,%20as%20well%20as%20the%20total%20number%20of%20points%20for%20each%20resulting%20from%20the%20ranking%20procedure.%20Four%20tiers%20of%20causes%20emerged%20based%20on%20the%20natural%20division%20evident%20in%20the%20total%20scores.%20%1CLack%20of%20Engagement%20in%20Behavioral%20Experiments%1D%20was%20far%20and%20away%20the%20highest%20ranked%20category%20with%2035%20total%20points.%20It%20was%20cited%20by%20more%20participants%20than%20any%20other%20reason%20(12%20of%2020),%20and%20was%20ranked%20as%20the%20top%20cause%20of%20treatment%20resistance%20by%209%20of%20the%2012%20respondents.%20%1CNoncompliance%1D%20ranked%20a%20clear%20second%20with%2020%20points.%20Eight%20respondents%20cited%20it,%202%20of%20whom%20ranked%20it%20as%20a%20%1C1.%1D%20Causes%203%20through%206%20were%20approximately%20equal%20in%20rank,%20with%20total%20rank%20points%20ranging%20from%2010%20to%2011.%20They%20were%20cited%20by%20an%20average%20of%205%20respondents%20and%20ranked%20as%20either%20a%20%1C2%1D%20or%20%1C3%1D%20by%20each%20participant.%20Reasons%207%20through%2010%20were%20approximately%20equal%20in%20rank,%20ranging%20from%201%20to%203%20total%20points.%20One%20or%202%20respondents%20cited%20these%20and%20ranked%20them%20as%20a%20%1C2%1D%20or%20%1C3.%1DFactors%20Associated%20with%20Suboptimal%20Treatment%20and%20RecommendationsLack%20of%20engagement%20in%20behavioral%20experimentsIn%20CBT%20for%20PD,%20clients%20are%20asked%20to%20face%20and%20challenge%20their%20fears,%20mostly%20through%20exposure%20to%20sensations%20or%20situations%20that%20they%20believe%20will%20bring%20about%20some%20feared%20consequence%20(cf.%20Barlow%20&%20Craske,%202000).%20The%20unwillingness%20of%20clients,%20intentional%20or%20not,%20to%20engage%20themselves%20fully%20in%20these%20behavioral%20experiments%20and%20risk%20the%20consequences%20they%20fear%20was%20the%20most%20frequently%20cited%20cause%20for%20a%20suboptimal%20response%20to%20treatment.%20Many%20respondents%20described%20this%20in%20terms%20of%20subtle%20avoidance%20behavior.%20Examples%20included%20doing%20only%20part%20of%20an%20exposure%20exercise,%20provoking%20only%20lesseared%20sensations%20as%20opposed%20to%20pushing%20oneself%20further,%20using%20breathing%20or%20relaxation%20to%20prevent%20feared%20sensations%20from%20emerging,%20and%20using%20various%20forms%20of%20distraction%20to%20minimize%20anxiety.%20These%20various%20forms%20of%20avoidance%20were%20thought%20to%20preclude%20valid%20testing,%20restructuring,%20and%20eventual%20extinction%20of%20fears.%20Commonly%20cited%20examples%20of%20fears%20that%20clients%20were%20reluctant%20to%20test%20included%20losing%20control,%20embarrassing%20oneself,%20or%20simply%20not%20wanting%20to%20experience%20the%20negative%20affect%20engendered%20by%20the%20experiment%20for%20various%20or%20sometimes%20unknown%20reasons.Suggested%20recommendations%20for%20addressing%20this%20obstacle%20were%20as%20follows:1.Education:%20Use%20initial%20and%20ongoing%20psychoeducation%20that%20emphasizes%20the%20importance%20of%20engagement%20as%20a%20crucial%20goal%20of%20therapy.2.Graduated%20exposure:%20Use%20individualized%20graduated%20exposure%20tasks%20as%20a%20means%20to%20ease%20wary%20clients%20into%20full%20engagement.3.Directly%20observe%20and%20assess%20avoidance:%20Try%20to%20observe%20the%20client%19s%20fearful%20behavior,%20as%20opposed%20to%20relying%20solely%20on%20self-eport,%20during%20initial%20assessment%20(e.%E4%A7%AE,%20a%20behavioral%20avoidance%20test)%20and%20during%20initial%20and%20other%20critical%20exposures%20to%20identify%20and%20confront%20obstacles%20to%20engagement.4.Consider%20using%20motivational%20enhancement%20techniques:%20Motivational%20enhancement%20techniques%20include%20validation%20of%20the%20client%19s%20particular%20stage%20of%20change%20through%20expression%20of%20empathy,%20identifying%20discrepancies%20between%20the%20client%19s%20goals%20and%20problem%20behaviors%20(e.%E4%A7%AE,%20avoidance),%20%1Crolling%20with%20resistance%1D%20by%20emphasizing%20personal%20control%20and%20approaching%20treatment%20as%20an%20experiment,%20and%20encouraging%20selffficacy%20by%20focusing%20on%20personal%20strengths%20and%20highlighting%20positives.5.Encourage%20acceptance%20of%20negative%20feelings:%20Reframe%20negative%20feelings%20as%20tolerable,%20acceptable,%20and%20necessary%20to%20reduce%20the%20client%19s%20avoidance%20(e.%E4%A7%AE,%20%1Cno%20pain,%20no%20gain%1D).%20Use%20education%20and%20support%20to%20try%20to%20help%20clients%20better%20accept%20the%20experience%20of%20negative%20affect%20as%20unpleasant%20but%20not%20dangerous.%20Normalize%20the%20experience,%20suggesting%20that%20the%20client%20take%20a%20monitor%19s%20(observer%19s)%20perspective,%20and%20encourage%20the%20client%20to%20see%20exposure%20as%20an%20opportunity%20for%20building%20tolerance%20of%20negative%20affect.6.Avoid%20concluding%20that%20the%20client%20is%20%1Cresistant%1D:%20Ironically,%20the%20label%20%1Ctreatment%20resistant%1D%20can%20be%20its%20own%20obstacle%20when%20clients%20who%20are%20not%20engaging%20in%20therapy%20are%20thought%20of%20as%20nonresponders.%20Therapists%20may%20not%20be%20as%20motivated%20to%20work%20with%20the%20client,%20believing%20his%20or%20her%20effort%20will%20be%20futile,%20and%20risk%20creating%20a%20selfulfilling%20prophecy.%20Although%20it%20is%20possible%20that%20some%20clients%20may%20be%20resistant%20to%20treatment,%20others%20may%20merely%20require%20strategies,%20such%20as%20those%20detailed%20above,%20to%20help%20them%20overcome%20problems%20with%20engagement.NoncomplianceThe%20second%20most%20cited%20reason%20for%20treatment%20resistance%20in%20our%20survey%20was%20noncompliance.%20In%20clients%20suffering%20from%20anxiety%20disorders,%20noncompliance%20is%20often%20an%20expression%20of%20avoidance%20due%20to%20fear.%20The%20previous%20factor,%20lack%20of%20engagement,%20could%20justifiably%20be%20described%20as%20a%20form%20of%20noncompliance%20due%20to%20fear.%20We%20separated%20engagement%20primarily%20because%20the%20respondents%20did.%20Here%20we%20have%20categorized%20all%20other%20forms%20of%20noncompliance%20other%20than%20engagement.%20This%20category%20almost%20entirely%20refers%20to%20instances%20of%20noncompletion%20of%20therapeutic%20%1Chomework,%1D%20such%20as%20not%20doing%20selfonitoring%20tasks,%20not%20doing%20an%20assigned%20BAT,%20not%20practicing%20somatic%20strategies,%20not%20doing%20tasks%20related%20to%20identifying%20or%20challenging%20cognitive%20biases,%20or%20not%20doing%20scheduled%20exposure%20exercises.%20Although%20sometimes%20fear%20based,%20it%20also%20includes%20noncompliance%20related%20to%20other%20factors%20such%20as%20resource%20limitations,%20scheduling%20problems,%20or%20forgetfulness.Most%20of%20the%20recommendations%20for%20dealing%20with%20noncompliance%20aimed%20at%20preventing%20it.%20Preventative%20recommendations%20were%20as%20follows:1.Psychoeducation:%20One%20of%20the%20most%20frequently%20proposed%20solutions%20for%20this%20problem%20was%20to%20review%20and%20expand%20upon%20psychoeducation.%20This%20was%20based%20on%20the%20idea%20that%20noncompliance%20sometimes%20results%20from%20the%20individual%19s%20lack%20of%20understanding%20of%20the%20therapeutic%20rationale%20for%20a%20task%20and/or%20the%20essential%20role%20that%20the%20task%20plays%20in%20promoting%20improvement.%20For%20example,%20the%20following%20information%20would%20be%20conveyed%20to%20the%20client%20to%20facilitate%20completion%20of%20restructuring%20exercise:%1CThe%20purpose%20of%20cognitive%20restructuring%20is%20to%20learn%20to%20identify%20and%20challenge%20irrational%20anxiety-rovoking%20thoughts,%20thereby%20reducing%20anxiety.%20Frequently,%20focusing%20on%20these%20thoughts%20results%20in%20an%20increase%20in%20anxiety%20at%20the%20moment.%20There%20is%20no%20other%20way%20to%20reduce%20anxiety-rovoking%20thoughts,%20and%20they%20are%20very%20unlikely%20to%20improve%20without%20using%20a%20deliberate%20process%20to%20correct%20them%20such%20as%20cognitive%20restructuring.%20If%20only%20practiced%20in%20the%20session%20the%20value%20will%20be%20limited%20because%20it%20is%20essential%20to%20learn%20to%20apply%20it%20in%20the%20majority%20of%20anxiety-rovoking%20situations%20that%20occur%20outside%20of%20the%20session.%1DThis%20information%20should%20be%20discussed%20with%20the%20client%20to%20ensure%20it%20is%20understood.%20Similar%20explanations%20for%20other%20treatment%20strategies%20were%20recommended.2.Consider%20audiotaping%20sessions:%20One%20way%20to%20increase%20adherence%20is%20to%20audiotape%20the%20sessions%20and%20ask%20the%20client%20to%20listen%20to%20it%20at%20least%20once%20prior%20to%20the%20next%20session.%20Some%20clients%20may%20benefit%20from%20the%20redundant%20presentation%20of%20the%20information.%20Others%20may%20process%20the%20information%20more%20clearly%20when%20merely%20listening%20(rather%20than%20during%20the%20session%20when%20they%20are%20interacting%20with%20the%20therapist).%20It%20also%20is%20a%20way%20to%20apply%20extra%20pressure%20between%20sessions%20as%20they%20will%20be%20reminded%20of%20the%20assignments%20while%20listening%20to%20the%20session.3.Increase%20accountability,%20if%20necessary:%20Some%20clients%20may%20feel%20more%20compelled%20to%20engage%20in%20treatment%20strategies%20outside%20the%20session%20if%20they%20are%20asked%20to%20be%20more%20accountable.%20For%20some,%20simply%20coming%20in%20to%20the%20next%20session%20and%20reporting%20what%20they%20did%20or%20did%20not%20do%20is%20sufficient.%20However,%20for%20others,%20asking%20them%20to%20complete%20some%20type%20of%20monitoring%20form%20(e.%E4%A7%AE,%20a%20record%20of%20relaxation%20practice%20sessions,%20thought%20records)%20or%20asking%20them%20to%20phone%20or%20email%20when%20they%20complete%20the%20exercise%20may%20increase%20motivation.Several%20recommendations%20concerned%20how%20homework%20tasks%20where%20assigned,%20explained,%20and%20carried%20out,%20as%20follows:4.Be%20clear%20and%20specific:%20Write%20down%20exactly%20what%20the%20client%20is%20expected%20to%20do%20and%20when%14a%20%1Cbehavioral%20prescription.%1D%20For%20example,%20if%20a%20client%19s%20assignment%20is%20to%20drive%202%20miles%20from%20home%20three%20times%20in%20between%20sessions,%20record%20the%20assignment%20and%20then%20collaborate%20with%20the%20client%20to%20come%20up%20with%20specific%20days%20and%20times%20this%20assignment%20can%20be%20completed%20(e.%E4%A7%AE,%20Monday,%20Wednesday,%20and%20Friday%20during%20lunch%20break).5.Anticipate%20obstacles%20with%20each%20assignment:%20Ask%20the%20client%20questions%20regarding%20facilitators%20and%20obstacles%14for%20example,%20access%20to%20the%20car,%20having%20sufficient%20time%20to%E2%A3%AFmplete%20the%20exercise,%20hiring%20a%20babysitter%20if%20necessary%14and%20generating%20solutions%20(or%20modifying%20the%20assignment)%20to%20increase%20the%20likelihood%20of%20the%20behavior.6.Reduce%20burden:%20Make%20homework%20tasks%20as%20easy%20to%20carry%20out%20as%20possible.%20For%20example,%20use%20checkmarks%20rather%20than%20narrative%20or%20tape%20record%20responses%20rather%20than%20write%20them,%20depending%20on%20the%20client%19s%20preference.7.Make%20tasks%20clearly%20relevant%20to%20goals:%20Tie%20homework%20directly%20to%20a%20clearly%20identified%20therapeutic%20goal%20and%20explain%20its%20rationale%20as%20described%20previously.8.Model%20tasks:%20When%20possible,%20demonstrate%20assigned%20exercises%20to%20minimize%20compliance%20problems%20due%20to%20a%20lack%20of%20understanding%20of%20the%20task%20on%20the%20client%19s%20part.9.Prompt%20the%20behavior%20in%20the%20environment%20and%20reinforce%20it:%20Use%20standard%20behavioral%20practices%20for%20prompting%20the%20behavior%20in%20the%20natural%20environment,%20such%20as%20making%20a%20phone%20call%20or%20tying%20it%20to%20another%20highrequency%20activity,%20and%20then%20reward%20it%20with%20something%20of%20the%20client%19s%20choosing.10.Review%20the%20homework:%20Communicating%20to%20the%20client%20that%20their%20work%20is%20important%20and%20valued%20can%20facilitate%20adherence.When%20addressing%20existing%20noncompliance,%20nearly%20all%20respondents%20recommended%20doing%20a%20functional%20analysis%20of%20the%20noncompliant%20behavior.%20Some%20suggested%20contingency%20contracting%20with%20persistent%20noncompliance.1.Functional%20analysis%20of%20existing%20noncompliance:%20Try%20to%20identify%20factors%20that%20are%20interfering%20with%20compliance%20or%20facilitating%20noncompliance.%20Most%20respondents%20reported%20that%20in%20their%20experience%20noncompliance%20was%20usually%20an%20act%20of%20avoidance%20of%20a%20feared%20activity%20and%20was%20addressed%20as%20described%20under%20Factor%201.%20But%20other%20reinforcers%20of%20noncompliance%20were%20cited%20as%20well,%20ranging%20from%20the%20subtle,%20such%20as%20not%20disturbing%20existing%20social%20relationships,%20to%20the%20obvious,%20such%20as%20maintaining%20disability%20compensation.%20As%20noted%20later,%20immediately%20and%20directly%20addressing%20those%20factors%20as%20obstacles%20to%20continuing%20therapy%20was%20the%20core%20recommendation.2.Consider%20contingency%20contracting:%20Three%20respondents%20suggested%20addressing%20noncompliance%20with%20contingency%20contracting.%20Evidence%20from%20early%20studies%20of%20contracting%20in%20marital%20therapy%20suggests%20that%20the%20process%20of%20negotiating%20the%20contract%20is%20as%20critical%20to%20its%20success%20as%20its%20quid%20pro%20quo%20content%20(Jacobson,%201978).%20Recommendations%20were%20consistent%20with%20this%20in%20emphasizing%20collaborative%20exploration%20of%20the%20positive%20and%20negative%20consequences%20of%20compliance%20and%20noncompliance%20and%20honestly%20and%20directly%20addressing%20the%20client%19s%20motivation%20and%20goals.ComorbidityThe%20presence%20of%20additional%20mental%20disorders%20or%20clinically%20significant%20symptoms%20(i.%E4%A5%AE,%20syndromal%20or%20symptom%20comorbidity,%20respectively)%20was%20one%20of%20four%20cited%20causes%20of%20poor%20treatment%20response%20ranked%20within%20the%20third%20tier%20of%20causes.%20Although%20four%20respondents%20cited%20examples%20of%20difficult%20comorbid%20anxiety%20disorders%20(e.%E4%A7%AE,%20OCD),%20the%20majority%20discussed%20comorbid%20depression.%20Interestingly,%20existing%20data%20on%20the%20impact%20of%20comorbidity%20on%20treatment%20outcome%20for%20clients%20with%20a%20principal%20diagnosis%20of%20PD%20suggest%20that%20in%20many%20cases%20the%20presence%20of%20another%20anxiety%20disorder%20does%20not%20typically%20diminish%20the%20efficacy%20of%20CBT%20focused%20on%20the%20panic%20disorder%20(Brown,%20Antony,%20&%20Barlow,%201995).%20Factors%20such%20as%20the%20type%20and%20severity%20of%20the%20comorbid%20anxiety%20disorder%20may%20mediate%20that%20relationship%20in%20individual%20clients.%20Studies%20of%20comorbid%20depression,%20however,%20suggest%20that%20its%20presence%20can%20interfere%20with%20successful%20outcome%20(Brown%20et%20al.,%201995;%20McLean,%20Woody,%20Taylor,%20&%20Koch,%201998).Recommendations%20for%20dealing%20with%20comorbidity%20are%20stepwise,%20as%20follows:1.If%20the%20comorbid%20condition%20is%20judged%20severe%20enough%20to%20interfere%20with%20participation%20in%20the%20CBT%20for%20panic%20(e.%E4%A7%AE,%20hopelessness%20precluding%20engagement%20or%20other%20compliance),%20then%20the%20recommendation%20is%20to%20address%20the%20comorbid%20condition%20first.%20In%20other%20words,%20severity%20of%20interference%20may%20place%20the%20comorbid%20condition%20first%20in%20line%20for%20treatment.2.In%20the%20more%20subtle%20case%20of%20conditions%20or%20symptoms%20that%20are%20coexistent%20but%20not%20as%20interfering,%20the%20recommendation%20is%20to%20treat%20the%20panic%20disorder%20first,%20reevaluating%20it%20and%20the%20comorbidity%20along%20the%20course%20of%20treatment,%20and%20treating%20residual%20syndromes%20or%20symptoms%20next.%20Many%20comorbid%20disorders%20and%20symptoms%20have%20been%20shown%20to%20remit%20with%20successful%20treatment%20of%20a%20primary%20panic%20disorder%20(Brown%20et%20al.,%201995).%20Residual%20conditions%20or%20symptoms%20should%20be%20treated%20based%20on%20initial%20studies%20showing%20that%20the%20presence%20of%20some%20comorbid%20symptoms%20places%20clients%20at%20risk%20for%20continued%20or%20emergent%20problems%20(McLean%20et%20al.,%201998).Inadequate%20case%20formulation%20or%20misdiagnosisNearly%20every%20guideline%20for%20the%20treatment%20of%20nearly%20every%20health%20care%20condition%20advises%20practitioners%20to%20revisit%20their%20diagnosis%20if%20a%20client%20has%20not%20responded%20as%20expected%20(cf.%20American%20Psychiatric%20Association,%201998).%20Also%20among%20the%20third%20tier%20of%20cited%20causes%20for%20a%20poor%20treatment%20response%20were%20problems%20with%20case%20formulation.%20Some%20respondents%20couched%20recommendations%20in%20diagnostic%20terms,%20others%20in%20terms%20of%20behavior%20analysis.Diagnostically%20speaking,%20the%20decision%20tree%20for%20diagnosing%20PD%20requires%20first%20ruling%20out%20symptoms%20that%20are%20due%20to%20the%20direct%20physiological%20effects%20of%20a%20general%20medical%20condition%20(e.%E4%A7%AE,%20hyperthyroidism)%20or%20a%20substancenduced%20syndrome%20(e.%E4%A7%AE,%20CNS%20depressant%20withdrawal,%20stimulant%20intoxication)%20before%20making%20the%20diagnosis%20of%20PD%20(American%20Psychiatric%20Association,%202000).%20Some%20of%20our%20survey%20respondents%20cited%20examples%20in%20which%20symptoms%20of%20panic%20that%20did%20not%20respond%20to%20CBT%20were%20found%20subsequently%20to%20be%20products%20of%20medical%20conditions%20such%20as%20pheochromocytoma%20or%20hyperthyroidism.Unexpected%20panic%20attacks,%20the%20diagnostic%20hallmark%20of%20PD,%20may%20occur%20in%20other%20mental%20disorders%20such%20as%20posttraumatic%20stress%20disorder,%20generalized%20anxiety%20disorder,%20or%20depression.%20Some%20respondents%20recounted%20poor%20treatment%20responders%20who%20later%20were%20found%20to%20be%20better%20described%20by%20a%20different%20anxiety%20or%20mood%20disorder.%20For%20instance,%20one%20respondent%20described%20a%20client%20who%20reported%20unexpected%20panic%20attacks%20in%20situations%20where%20she%20felt%20alone.%20The%20client%20was%20initially%20diagnosed%20with%20PD%20and%20agoraphobia.%20The%20fear%20of%20being%20alone%20was%20seen%20as%20reflecting%20agoraphobic%20safety%20and%20efficacy%20concerns.%20Although%20benefiting%20somewhat%20from%20exposure%20to%20these%20situations,%20her%20improvement%20was%20less%20than%20expected.%20The%20client%20later%20disclosed%20that%20the%20fear%20of%20being%20alone%20began%20after%20a%20sexual%20assault%20that%20she%20had%20been%20unwilling%20to%20disclose%20earlier.%20When%20treatment%20was%20oriented%20around%20this%20context,%20her%20response%20to%20it%20improved.%20This%20case%20highlights%20therapeutic%20trust%20issues%20as%20well%20as%20diagnostic%20consequences.%20Trust%20issues%20also%20appear%20under%20Factor%2010%20later%20in%20the%20paper.In%20behavior%20analytic%20terms,%20the%20most%20common%20error%20cited%20was%20the%20misidentification%20or%20underestimation%20of%20triggers%20of%20panic,%20resulting%20in%20exposures%20that%20did%20not%20target%20the%20most%20significant%20stimuli.In%20their%20recommendations,%20respondents%20again%20emphasized%20preventive%20measures,%20but%20recommended%20revisiting%20the%20initial%20assessment%20when%20nonresponse%20is%20evident:1.Rule%20out%20medical%20and%20substance%20etiology:%20Require%20certain%20clients%20to%20undergo%20medical%20and%20substance%20clearance%20prior%20to%20treatment.2.Assess%20triggers:%20Do%20a%20thorough%20and%20ongoing%20assessment%20of%20triggers%20of%20fear.3.Educate%20clients%20regarding%20triggers:%20Place%20a%20strong%20emphasis%20on%20educating%20the%20client%20about%20triggers%20and%20on%20identifying%20them%20throughout%20treatment.%20Assessing%20several%20examples%20of%20the%20sequencing%20of%20the%20client%19s%20thoughts,%20sensations,%20and%20reactions%20that%20spiral%20into%20panic%20may%20help%20identify%20key%20themes%20and%20triggers%20to%20target%20through%20exposure.All%20of%20these%20recommendations%20are%20consistent%20with%20the%20CBT%20principle%20of%20continuing%20assessment%20throughout%20therapy%20and%20adjusting%20the%20focus%20of%20interventions%20as%20needed.External%20support%20of%20PD%20behavior%20(%1Csecondary%20gain,%1D%20fear%20of%20disruption)Situations%20in%20which%20the%20fear%20and%20avoidance%20of%20PD%20are%20being%20positively%20or%20negatively%20reinforced%20(e.%E4%A7%AE,%20disability%20check,%20not%20having%20to%20work)%20or%20where%20overcoming%20them%20would%20cost%20the%20client%20something%20personally%20important%20(i.%E4%A5%AE,%20spousal%20attention;%20sympathy%20from%20others)%20were%20cited%20by%20some%20respondents%20as%20barriers%20to%20improvement.%20No%20one%20cited%20malingering%20as%20an%20example%20of%20external%20support;%20rather,%20these%20factors%20were%20seen%20as%20obstacles%20to%20improvement%20of%20real%20conditions.%20Examples%20included%20the%20loss%20of%20social%20attention,%20social%20pressure%20to%20remain%20dependent,%20and%20loss%20of%20disability%20payments,%20all%20creating%20an%20incentive%20to%20remain%20%1Cill.%1D%20In%20some%20cases,%20clients%20were%20described%20as%20losing%20their%20confidence%20in%20being%20able%20to%20be%20return%20to%20the%20demands%20of%20the%20roles%20and%20responsibilities%20of%20work%20or%20other%20demands.Recommendations%20to%20address%20this%20issue%20were%20as%20follows:1.Conduct%20a%20functional%20assessment:%20Identify%20the%20functional%20relationship%20between%20improvement%20and%20its%20consequences.%20Often%20the%20factors%20supporting%20nonimprovement%20involve%20fear%20and%20thus%20nonimprovement%20is%20avoidance.%20Consider%20developing%20a%20list%20of%20pros%20and%20cons%20of%20improvement.2.Problem-olve%20obstacles:%20Problem-olve%20anticipated%20changes%20and%20problems%20by%20specifically%20identifying%20them,%20generating%20options%20for%20coping,%20and%20developing%20a%20plan%20based%20on%20the%20best%20options.%20Gradual%20exposure%20may%20be%20needed%20as%20well.%20For%20example,%20a%20first%20goal%20may%20be%20to%20go%20back%20to%20work%20part-ime,%20then%20half-ime,%20and%20then%20full-ime.3.Directly%20address%20%1Cgain%1D%20as%20a%20potential%20obstacle%20to%20further%20treatment:%20Regardless%20of%20the%20factors%20supporting%20nonimprovement,%20one%20unanimous%20recommendation%20was%20to%20address%20it%20directly%20with%20the%20client%20toward%20the%20goal%20of%20deciding%20whether%20continued%20therapy%20is%20desired%20(i.%E4%A5%AE,%20does%20the%20client%20really%20want%20what%20comes%20along%20with%20successful%20treatment?).Problems%20with%20cognitive%20restructuringIn%20broad%20strokes,%20cognitive%20restructuring%20in%20the%20treatment%20of%20PD%20involves%20elucidating%20what%20the%20client%20finds%20threatening,%20the%20biases%20in%20that%20appraisal%20of%20threat,%20and%20the%20generation%20of%20alternative%20appraisals%20that%20correct%20for%20those%20biases.%20These%20identified%20fears%20and%20alternative%20appraisals%20are%20usually%20framed%20as%20predictions%20and%20are%20tested%20through%20behavioral%20experiments.%20The%20clinician%20attempts%20to%20make%20those%20tests%20valid%20to%20the%20client%14if%20not%20at%20first,%20then%20eventually.%20Repeated%20disconfirmation%20of%20biased%20fearased%20predictions%20helps%20the%20client%20shift%20from%20fearful%20appraisals%20to%20ones%20more%20in%20line%20with%20the%20actual%20threat%20posed%20by%20the%20feared%20stimulus%20(e.%E4%A7%AE,%20Clark%20et%20al.,%201994).%20Difficulties%20with%20cognitive%20restructuring%20also%20ranked%20fourth%20among%20reasons%20for%20a%20poor%20treatment%20response.%20The%20nature%20of%20the%20problems%20that%20were%20cited%20varied.Several%20respondents%20noted%20that%20they%20have%20seen%20a%20poor%20response%20when%20key%20and%20often%20subtle%20fears%20are%20not%20elucidated.%20More%20than%20one%20suggested%20that%20this%20is%20likely%20to%20occur%20when%20assessment%20is%20rushed%20and%20when%20clients%20are%20asked%20to%20endorse%20from%20a%20%1Clist%1D%20(such%20as%20a%20questionnaire)%20rather%20than%20produce%20fearful%20cognitions.%20Other%20respondents%20noted%20that%20although%20some%20fears%20are%20identifiable%20and%20testable%20(e.%E4%A7%AE,%20heart%20attack,%20going%20crazy,%20embarrassing%20oneself),%20others%20were%20seen%20as%20more%20difficult%20to%20define%20and%20convert%20into%20testable%20predictions.%20Examples%20cited%20included%20%1Cfading%20into%20nothingness%1D%20and%20%1Closing%20oneself.%1D%20Still%20others%20identified%20validity%20problems,%20most%20notably%20difficulty%20finding%20valid%20alternative%20appraisals%20that%20correct%20for%20fearful%20biases%20and%20the%20failure%20of%20interoceptive%20exposure%20exercises%20to%20produce%20sensations%20that%20the%20client%20finds%20valid.%20Points%20made%20were%20that%20some%20clients%20expect%20to%20see%20a%20shift%20in%20the%20believability%20of%20alternatives%20too%20quickly%20into%20therapy%20and%20that%20this%20demoralizes%20or%20otherwise%20disengages%20them.%20Similarly,%20some%20clients%20do%20not%20believe%20that%20managing%20the%20sensations%20produced%20by%20interoceptive%20exercises%20is%20similar%20to%20managing%20those%20encountered%20during%20a%20panic%20attack,%20resulting%20in%20motivational%20problems.For%20difficulties%20elucidating%20key%20and%20subtle%20fears,%20respondents%20suggested%20the%20following:%20Assess%20fears%20comprehensively%20and%20monitor%20change.%20That%20is,%20take%20the%20time%20to%20do%20a%20comprehensive%20initial%20assessment%20of%20fearful%20cognitions,%20preferably%20using%20guided%20discovery%20and%20possibly%20questionnaires%20as%20an%20adjunct%20to%20this%20assessment%20(e.%E4%A7%AE,%20Agoraphobic%20Cognitions%20Questionnaire,%20Anxiety%20Sensitivity%20Index).%20Periodically%20revisit%20this%20assessment%20throughout%20therapy%20to%20determine%20the%20relevance%20of%20cognitions%20identified.For%20problems%20with%20the%20lack%20of%20validity%20of%20alternative%20%1Crational%1D%20appraisals,%20the%20following%20solutions%20were%20offered:1.Create%20realistic%20expectations:%20Help%20the%20client%20understand%20and%20accept%20that%20alternatives%20may%20seem%20invalid%20and%20may%20be%20doubted%20at%20the%20beginning%20of%20therapy.%20Encourage%20clients%20to%20focus%20their%20efforts%20on%20accomplishing%20the%20behavioral%20goals%20of%20the%20behavioral%20experiments.%20Repeated%20experiential%20evidence%20of%20safety%20and%20manageability%20drawn%20through%20accomplishing%20those%20goals%20will%20facilitate%20the%20cognitive%20shift.To%20address%20the%20invalidity%20of%20interoceptive%20exposure%20exercises,%20the%20following%20was%20recommended:2.Rule%20out%20subtle%20avoidance:%20Ensure%20that%20the%20client%20is%20challenging%20himr%20herself%20with%20the%20exercises%20instead%20of%20subtly%20avoiding%20sensations.3.Use%20a%20multipurpose%20rationale:%20Explain%20that%20the%20exercises%20have%20multiple%20purposes%20and%20that%20the%20client%20need%20not%20find%20that%20the%20symptoms%20mimic%20panic%20to%20benefit%20from%20the%20them.%20For%20example,%20part%20of%20the%20rationale%20for%20sensation%20exposure%20can%20include%20that%20it%20provides%20an%20opportunity%20for%20the%20repeated%20experience%20of%20raising%20and%20lowering%20of%20symptoms%20under%20controlled%20conditions,%20that%20it%20is%20an%20arena%20to%20practice%20calming%20strategies,%20and%20that%20it%20allows%20for%20repeated%20testing%20of%20anticipatory%20fears%20of%20what%20might%20happen%20during%20the%20exercise.4.Use%20sensations%20evoked%20during%20naturalistic%20exposures:%20Respondents%20agreed%20that%20persistent%20validity%20problems%20with%20interoceptive%20exposure%20should%20be%20addressed%20by%20moving%20on%20to%20naturalistic%20situational%20exposures%20(phobic%20situations)%20and%20working%20with%20the%20symptoms%20produced%20there.Presence%20of%20negative%20life%20events/circumstancesAlthough%20the%20diagnosis%20of%20PD%20may%20be%20the%20reason%20an%20individual%20presents%20for%20treatment,%20coxisting%20negative%20life%20events%20may%20also%20be%20present%20and%20need%20to%20be%20addressed%20to%20allow%20the%20client%20to%20benefit%20from%20treatment.%20Commonly%20cited%20negative%20life%20events%20included%20relationship%20distress%20(e.%E4%A7%AE,%20marital%20problems),%20job%20stress,%20and%20financial%20problems.%20Negative%20life%20events%20can%20exacerbate%20the%20severity%20of%20the%20primary%20condition%20and%20distract%20the%20client%20from%20engagement%20in%20the%20therapy.All%20respondents%20who%20highlighted%20this%20problem%20indicated%20that%20they%20first%20address%20the%20negative%20life%20circumstances%20before%20moving%20to%20the%20panic%20disorder.%20For%20example,%20for%20the%20client%20with%20significant%20marital%20distress%20who%20finds%20it%20difficult%20to%20focus%20on%20the%20treatment%20of%20panic,%20it%20was%20suggested%20to%20first%20address%20the%20marital%20issues,%20including%20consideration%20of%20marital%20therapy,%20before%20starting%20or%20continuing%20CBT%20for%20PD.%20Likewise,%20a%20client%20with%20job%20stress%20may%20benefit%20from%20some%20level%20of%20stress%20management%20training%20prior%20to%20addressing%20the%20panic.Medication%20complicationsMany%20clients%20who%20begin%20CBT%20for%20PD%20are%20also%20on%20medication%20for%20PD,%20often%20antidepressants,%20benzodiazepines,%20or%20both.%20The%20presence%20of%20medication%20during%20CBT%20can%20interfere%20with%20the%20CBT%20through%20several%20potential%20means%20(see%20Otto,%20Smits,%20&%20Reese,%202005,%20for%20a%20review).%20For%20example,%20symptom%20attenuation%20or%20suppression%20through%20the%20use%20of%20medication%20may%20reduce%20motivation%20to%20do%20the%20work%20of%20CBT.%20Also,%20in%20CBT,%20sensations%20of%20anxiety%20and%20panic%20are%20treated%20as%20phobic%20cues%20and%20targeted%20for%20exposure.%20The%20presence%20of%20medication%20during%20exposure%20can%20place%20the%20client%20at%20risk%20for%20relapse%20after%20discontinuation%20of%20the%20medication%20(Marks%20et%20al.,%201993).Recommendations%20for%20managing%20the%20presence%20of%20medication%20during%20CBT%20were%20as%20follows:1.Educate%20the%20client:%20Educate%20the%20client%20regarding%20the%20benefits%20and%20risks%20of%20concurrent%20medication%20use,%20discuss%20discontinuation%20or%20continuation%20options,%20then%20coordinate%20with%20the%20prescriber.2.Engage%20the%20prescriber:%20Contact%20the%20prescriber,%20educate,%20and%20engage%20their%20support%20in%20the%20management%20plan.3.Use%20empirically%20supported%20discontinuation%20protocols:%20The%20respondents%20who%20noted%20this%20cause%20indicated%20that%20they%20follow%20the%20protocols%20used%20in%20studies%20showing%20that%20medication%20discontinuation%20can%20be%20facilitated%20and%20relapse%20prevention%20enhanced%20by%20integrating%20CBT%20into%20medication%20discontinuation%20in%20particular%20ways%20(see%20Spiegel%20&%20Bruce,%201997,%20for%20a%20review).%20For%20a%20treatment%20manual%20describing%20these%20methods%20see%20Otto%20et%20al.%20(2000).Poor%20delivery%20of%20treatmentOf%20course,%20before%20determining%20that%20a%20client%20is%20not%20responding%20to%20a%20treatment,%20it%20needs%20to%20be%20determined%20that%20the%20treatment%20is%20being%20delivered%20and%20received.%20Poor%20delivery%20was%20not%20a%20highly%20cited%20obstacle%20to%20a%20good%20treatment%20response,%20but%20was%20mentioned%20by%20a%20three%20participants.%20The%20common%20theme%20of%20examples%20cited%20was%20that%20sometimes%20therapists%20do%20not%20push%20themselves%20or%20clients%20to%20get%20the%20most%20from%20each%20phase%20of%20treatment.%20For%20instance,%20it%20was%20noted%20that%20a%20therapist%19s%20reluctance%20to%20have%20clients%20challenge%20themselves%20strongly%20during%20exposure%20may%20make%20them%20an%20unintentional%20hindrance%20to%20progress.Recommendations%20were%20as%20follows:1.Conduct%20highidelity%20treatment:%20Attend%20to%20delivering%20each%20of%20the%20primary%20emphases%20of%20CBT%20for%20PD%20(i.%E4%A5%AE,%20psychoeducation,%20somatic%20skills,%20cognitive%20restructuring,%20and%20exposure)%20in%20a%20way%20that%20maximizes%20the%20gain%20a%20client%20can%20receive%20from%20them.2.Exposure%20for%20the%20exposer:%20As%20the%20reader%20might%20guess,%20one%20recommendation%20for%20therapists%20who%20find%20themselves%20hesitant%20to%20encourage%20clients%20to%20challenge%20themselves%20was%20to%20expose%20themselves%20to%20asking%20clients%20to%20do%20just%20that.%20Being%20a%20participant%20model%20may%20make%20this%20easier%20to%20do.3.Consult%20with%20colleagues:%20Consulting%20with%20a%20colleague%20may%20reveal%20suggested%20changes%20that%20could%20improve%20one%19s%20treatment%20delivery.4.Continuing%20education:%20Observing%20experts%20through%20workshops%20or%20videotapes%20offers%20opportunities%20to%20learn%20tried%20and%20tested%20methods.Therapeutic%20relations

desorden de panico y agorafobia

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