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Towards a Unified Worry Exposure Protocol for Generalised Anxiety Disorder: A Pilot Study
- Cameron McIntosh, Rocco Crino
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- Behaviour Change / Volume 30 / Issue 3 / September 2013
- Published online by Cambridge University Press:
- 12 August 2013, pp. 210-225
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Background: Worry exposure is a cognitive–behaviour therapy (CBT) technique frequently used to treat GAD, yet there are only a few studies on its effectiveness. Aim: To compare two worry exposure protocols developed for GAD to make a preliminary determination about the most effective way in which to present the feared stimuli to participants. Method: Nine university students suffering from GAD were administered four 1-hour treatment sessions. Exposure was conducted by either directly imagining (DI) or via audio-recording/playback (AR) exposure to their feared event. General worry and intolerance of uncertainty (IOU) were the primary dependent variables. Results: All participants in the DI and half of the AR condition reported subclinical GAD at post-treatment, with results being maintained at 3-month follow-up and the treatment responders also reported decreased depression, anxiety and stress. Conclusions: The DI protocol was more effective than the AR methodology in this sample, and may be an appropriate standard for worry exposure research and clinical practice.
22 - Generalized anxiety disorder: Clinician Guide
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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- The Treatment of Anxiety Disorders
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- 14 November 2002, pp 407-416
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Summary
The present chapter aims to guide clinicians in the principles of treatment and the use of the treatment Manual, as well as highlight some of the more common problems encountered in therapy. fihile further studies are needed to identify the active components of effective treatment for generalized anxiety disorder, it appears that two core elements are:
•An underlying rationale, based on the ‘coping skills’ model of cognitive
behavioral therapy, where patients are taught skills to manage their anxiety and
to take responsibility for change and control over their thoughts, feelings, and
behavior.
•Cognitive therapy with the goal of bringing the process of worry under the
patients control.
Relaxation training, usually a form of progressive muscle relaxation, is a useful adjunct to treatment, particularly where the effects of chronic and high levels of muscle tension trouble an individual.
Assessment
It is assumed that before the commencement of treatment, a clinical assessment will have ruled out comorbid diagnoses in need of immediate specific treatment, such as a major depressive episode. fihere depression is present, it becomes the treatment priority and the need for further treatment of anxiety symptoms reviewed when the depression is resolved. Given the phenomenological similarities between the two disorders, it is often necessary to establish from historical information whether GAD existed before the onset of a major depressive episode, or to assess whether a GAD continues to exist following effective treatment of the depressive disorder.
fihile patients with a primary diagnosis of GAD will not always meet criteria for another diagnosis, they will often have concerns and behaviors that are characteristic of other anxiety disorders. Panic attacks, social anxiety, phobic avoidance, obsessions, and illness anxiety are common. The treating clinician will therefore need to be able to recognize these different features and address these in the course of treatment. For example, some time can be spent focusing specifically on fears of scrutiny and negative evaluation or fears that a physical sensation is really a sign of a serious, life-threatening illness within the framework of the cognitive behavioral approach. The use of a slow-breathing exercise (possibly due to its meditation-like features) can provide temporary control over acute episodes of high anxiety for many individuals. Hence patients can be relatively quickly provided with an increased sense of control that allows them to recognize the triggers of their anxiety and implement cognitive strategies.
References
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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9 - Social phobia: Treatment
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
Aims of treatment
The aims of treatment are symptom reduction and improved function. Elimination of all anxiety is unlikely (and unnecessary), and the therapist has a role in helping the patient to set realistic goals for therapy. Psychological and pharmacological treatments are available for social phobia. The treatments for which there is most evidence of efficacy are cognitive and exposure-based treatments, social skills training packages, antidepressant medication and benzodiazepine anxiolytics. In general, outcome is related to severity of symptoms at pretreatment. Psychological treatments for social phobia
Social skills training
The role of social skills training in the treatment of social phobia continues to be debated. Prior to the publication of DSM-III, social skills training had demonstrated clinical utility in heterogeneous populations of psychiatric outpatients with social skills difficulties or anxieties (Stravynski et al., 1982;filazlo et al., 1990). Hence it was proposed that these techniques be applied to the treatment of social phobia. Reviewers agree that few of the early studies that examined social skills treatments were methodologically sound (Marks, 1985;Heimberg, 1989; Stravynski and Greenberg, 1989;Mattick et al., 1995); in particular, only rarely was a control condition in evidence. Diagnostic groups were often heterogeneous or poorly defined. No differentiation was made between those with and those without avoidant personality disorder (APD). In addition, strategies referred to as social skills training often included explicit instructions more consistent with exposure therapies, e.g., to regularly confront their fears and to persist in the situation until anxiety diminished (filazlo et al., 1990).
Part of the argument over the role of social skills training centers on whether apparently poor social skills are the result of actual skills deficits, or really due to inhibition of skills expression due to anxiety. Turner et al. (1986) examined thesocial skills of patients with social phobia, comparing those with and without avoidant personality disorder. They found that patients with social phobia alone felt anxious, and perceived that others found them anxious and inadequate, but in fact had appropriate social skills. Those with APD were found to be markedly lacking in social skills. However, the authors were unable to exclude profound inhibition in social situations as the underlying cause giving rise to the appearance of skills deficits: in APD, severe anxiety related to a core schema that social error will lead to rejection can result in profound social inhibition and avoidance.
25 - Posttraumatic stress disorder: Treatment
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
Survivors of trauma who do not recover independently, and who go on to develop longer-term problems as a result of their experiences, may require formal treatment. There is also a mounting body of research suggesting that early interventions with high risk survivors may facilitate the recovery process and reduce the prevalence of subsequent PTSD. The purpose of this chapter is to provide a brief overview of common interventions used in the treatment of acute stress disorder (ASD) and PTSD, and to discuss their application as a preventive strategy.
Aims of treatment
It is reasonable to assume that virtually all human beings will experience a psychological reaction to very frightening or upsetting events. This raises questions about what constitutes an adaptive psychological response to trauma and, as a corollary, what are reasonable treatment goals. Severe traumatic events profoundly affect survivors’ views of themselves and the world. In most cases, it is reasonable to suggest that the survivor will never be the same person again. Equally, those changes need not all be bad. Recovery from trauma can result in personal growth, with the development of improved coping strategies and more adaptive models of the self and the world.
Ideally, treatment would serve to eliminate all the symptoms of PTSD and return the survivor to pretrauma levels of functioning. In reality, that will not always be possible. As with other disorders, factors such as the severity of the condition, chronicity, and comorbidity (particularly in the form of axis II disorders) are likely to affect treatment efficacy. In acute cases of PTSD with few complications, it is reasonable to expect a high degree of success with relatively few sessions (6 to 10). In such cases, elimination of PTSD symptoms, a return to prior functioning, and low risk of relapse would be achievable goals. (Importantly, this is not to imply that the person will never again experience distressing memories of the event but, rather, that such intrusive phenomena will be infrequent and manageable). On the other hand, treatment goals for affietnam veteran with, forexample, a 30-year history of PTSD, high levels of comorbid alcohol abuse, and poor social and occupational functioning, would be more conservative. It may be a question of helping that person to manage the symptoms more effectively, reducing their impact on quality of life, relationships, and general functioning.
28 - Conclusions
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
Part of this book has been quite conventional. The reviews of the syndromes and treatments in relation to panic and agoraphobia, social phobia, specific phobias, obsessive–compulsive disorder, generalized anxiety disorder and posttraumatic stress disorder are brief, succinct overviews designed for busy clinicians. The discussion of general issues in the etiology and treatment of the anxiety disorders is also essential information for the practicing clinician. The Clinician Guides and the Patient Treatment Manuals are, however, quite unusual. These Guides and Manuals need to be placed in context.
There is an art and a science to good medical practice. Because the science tends to predominate, the art of treatment is seldom discussed, either at a general or a specific level. Elsewhere, we have called attention to the need for the elements of good clinical care to be made explicit. Good clinical care needs to be taught to trainee psychiatrists and clinical psychologists for use with patients for whom there is no specific remedy immediately applicable to their disorder (Andrews, 1993a). This book is different. It is about treating persons with chronic anxiety disorders who, if expertly treated with specific remedies, can be expected to recover. This recovery has been made possible by the scientific advances that have occurred in our understanding of the treatment of the anxiety disorders. Much of this book is focused on the cognitive behavioral treatments simply because the instructions for prescribing medications are relatively simple and, courtesy of advertising by the pharmaceutical industry, do not need repeating in a book on the treatment of anxiety disorders. The cognitive behavioral treatments are less well known and, being both nonproprietary and not for profit, are neither as widely promoted nor as readily available as are the drug therapies.
There is a greater problem. The amount of evidence for the efficacy of psychotherapy is less plentiful than the evidence that is routinely provided by the pharmaceutical industry to the national regulatory authorities in each country. This evidence is provided as part of the process of having products cleared for marketing and, in many countries, for subsidy. In the first edition of this book, much of the evidence about the efficacy of cognitive behavioral therapy came from trials in which the progress of treated groups were compared to their own pretreated status, or else were compared to the progress of wait-list or no treatment control groups.
6 - Panic disorder and agoraphobia: Clinician Guide
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
After formal diagnosis and assessment, two issues must be addressed before treatment is planned. First, the clinician, by conducting a thorough behavioral analysis, must identify the factors that trigger and maintain the panic attacks and the avoidance behavior. Second, the clinician must consider the eVects of comorbid disorders on treatment.
Behavioral analysis
The general principles and practice of behavioral analysis have been outlined elsewhere (Kirk, 1989;Schulte, 1997). However, in panic disorder and agoraphobia there are unique details to be considered. In terms of the antecedents of panic attacks, it is necessary to evaluate the physical and psychological triggers. These typically include situations previously associated with panic, certain physical sensations, and particular worrying thoughts (e.g., “Oh no! fihat if I had a panic attack right now?”). In addition, panic attacks will be more likely to occur when the person has been made more physically aroused as a result of being anxious, stressed, hot, smoking, drinking alcohol, taking stimulant drugs (e.g., coffee), and so on. In addition, panic attacks appear more likely when the individual is “run down”, perhaps because of illness (e.g., flu), physical and psychological stress (e.g., childbirth), or sleep deprivation. Once a listing of antecedents has been made, the consequences of panic attacks need to be identified. The consequences can be divided into three categories. First, individuals may respond to panic attacks with avoidance behavior. Commonly avoided agoraphobic situations have been described earlier, but for present purposes it is worth noting that identifying the cognitive link between panic attacks and avoidance will facilitate cognitive behavioral treatment (e.g., “I avoid crowded trains because the air may run out when everyone is breathing it”). Second, the subtle avoidance strategies (e.g., the use of safety signals) need to be identified. Finally, the social consequences of avoidance need to be evaluated. For instance, individuals with dependent traits may welcome the increased support given as a consequence of panic attacks and become more dependent. Such behavioral patterns need to be identified to ensure they do not inhibit progress in treatment.
Management of comorbid disorders
The most frequently comorbid axis I disorders are the other anxiety disorders, especially social phobia (Sanderson et al., 1990). One advantage of cognitive behavioral interventions is their applicability to all the anxiety disorders, in that each disorder responds to various combinations of anxiety-management and exposure strategies.
Abbreviations
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Contents
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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24 - Posttraumatic stress disorder: Syndrome
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
Historical context
Recent years have seen an extraordinary growth in awareness of traumatic stress, not only among health workers but also among the general public. This increased awareness might suggest that mental health professionals have only just discovered the fact that human beings experience a psychological reaction following exposure to trauma or, worse, that the disorder has just been “invented”. It is important, therefore, to understand the historical context of PTSD. The notion that an individual may experience psychological problems following a traumatic experience is not new, with references dating back nearly three thousand years to Homer's Iliad. Shakespeare provided several descriptions of traumatic stress reactions, as have other writers throughout history. It was not until early this century, however, that the condition became the focus of interest from a scientific perspective. Several leading figures in the burgeoning field of psychiatry at that time, such as Freud, Kraepelin, and Janet, commented on the existence and nature of traumatic stress reactions following accidents, fires, and other traumatic events. fiartime experiences, notably in the American Civil fiar and the First fiorld fiar, prompted physicians to speculate on the cause of posttrauma reactions. The condition was thought initially to be a result of organic damage to the brain caused by explosions on the battlefield and thus the term “shell shock” was coined during the First fiorld fiar. It was not until later that the psychological basis of the disorder was widely accepted and clinicians began to recognize that terms such as “shell shock”, “war neurosis”, and “combat fatigue” all referred to the same phenomenon. Gradually, it was acknowledged also that these disorders were essentially no different from traumatic stress reactions seen in civilians following nonmilitary traumas such as transport accidents, fires, natural disasters, and violent assault.
Despite interest in the area over many decades, the disorder was not formally recognized until 1980, with the publication of DSM-III. The term “posttraumatic stress disorder” was proposed and the diagnostic criteria were delineated. fiith that formal recognition, the area became accepted as a legitimate focus of empirical research and theoretical debate. In 1987, the diagnostic criteria were modified significantly in DSM-III-R and further minor changes were made in the latest edition, DSM-IV. The most recent version of the International Classification of Diseases, ICD-10, has included the category of PTSD for the first time.
16 - Obsessive-compulsive disorder: Syndrome
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
Obsessive-compulsive disorder (OCD) was considered a relatively rare syndrome with a reputation for being a chronic, incapacitating, and intractable condition. Epidemiological studies have suggested that OCD is considerably more prevalent than was previously thought, with lifetime estimates ranging between 2% and 3%. More recent studies that have reassessed the diagnosed cases of OCD in epidemiological studies have suggested that the true rate of OCD may be somewhat less, with 1 month prevalence rates of 0.6% (Stein et al., 1997). Similar prevalence rates (0.7%) have been reported in a recent Australian Survey of National Mental Health and fiell-being (Andrews et al., 2001a). The intractability of the disorder has been called into question, with the development of effective psychological and pharmacological interventions that mean that the majority of sufferers can be assisted in controlling their disabling symptoms. The following sections review the current state of knowledge regarding OCD and its treatment. Rather than attempt to be exhaustive in the areas covered, the aim has been to supply the practicing clinician with information that will be of use within clinical practice, particularly in terms of questions often asked by sufferers and significant others, as well as treatment issues and factors that may affect outcome.
Diagnosticc riteria
Obsessions are defined as ideas, thoughts, images and impulses that enter the subject's mind repeatedly. They are recognized as a product of the subject's own mind, are perceived as intrusive and senseless, and efforts are made to resist, ignore or suppress such thoughts. Compulsions are repetitive or stereotyped behaviors that are performed in response to an obsession in order to prevent the occurrence of an unlikely event or to prevent discomfort. Resistance is often evident, but may be minimal in longstanding cases. The diagnosis of OCD is to be made if the individual experiences both obsessions and compulsions, obsessions alone or compulsions alone, given that such symptoms are time consuming or significantly interfere with the person's functioning. A comparison of ICD-10 and DSM-IV diagnostic criteria shows considerable agreement.
CASE VIGNETTE
Patient identification
Mr. P is a 30 year old father of two children who presents with a 9-year history of compulsive behavior. At the time of presentation, he was engaging in extensive checking behavior that significantly interfered with his life.
7 - Panic disorder and agoraphobia: Patient Treatment Manual
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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17 - Obsessive-compulsive disorder: Treatment
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
Although OCD has been recognized for centuries, effective treatment for this condition has been available only for the past four decades. The treatments of choice for OCD are behavior therapy, consisting of exposure and response prevention, and selective serotonin reuptake-inhibiting medications. Recent studies have also included specific cognitive techniques targeting the appraisals of intrusive thoughts, responsibility for harm and threat estimates. fihether the addition of such techniques results in superior efficacy is yet to be demonstrated in further trials. Nevertheless, the use of cognitive techniques to challenge the dysfunctional appraisal of intrusive thoughts is warranted in individuals with cognitive styles that interfere with treatment. Cure of OCD is not commonplace. The primary goal of treatment in the majority of cases is to have the individual control the disorder rather than the obsessional disorder control the individual. Achievement of this goal allows the patient to minimize the impact and effects of the disorder on their daily life and enhances their ability to reach their full potential.
Behavioral therapy
The basic principles of exposure and response prevention include the deliberate exposure to obsessional cues and prevention of the behaviors that the sufferer typically engages in to lessen the anxiety, discomfort, or distress associated with the feared stimuli. Repeatedly employing prolonged exposure (45 minutes to 2 hours) to the obsessional cues, with strict response prevention, allows habituation to take place. Exposure tasks are arranged hierarchically, with treatment commencing with the least anxiety-provoking situation and progressing rapidly through the hierarchy.
In reviewing the results of more than 200 OCD patients treated with behavior therapy in several countries, Foa et al. (1985) reported that 51% of sufferers achieved at least a 70% reduction in symptoms. Thirty-nine percent of patients 347 Obsessive–compulsive disorder: Treatment achieved reductions ranging from 31% to 69%, and 10% were considered failures, failure being defined as patients with an improvement of 30% or less. At follow-up (mean duration 1 year), the number of failures increased from 10% to 24%. However, 76% of patients remained improved to a degree rated as moderately improved or better.
Further evidence for the efficacy of exposure and response prevention is reflected in a long-term follow-up of nine cohorts from five countries conducted by O'Sullivan et al. (1991). Both self- and assessor ratings were used, and two cohorts had received exposure plus either clomipramine or placebo.
The Treatment of Anxiety Disorders
- Clinician Guides and Patient Manuals
- 2nd edition
- Gavin Andrews, Mark Creamer, Rocco Crino, Caroline Hunt, Lisa Lampe, Andrew Page
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In this completely revised 2002 second edition of their well-received book, Gavin Andrews and his team continue to draw upon materials and methods that they have used successfully in clinical practice for 15 years. Over half the material in the second edition is new, and there is an entirely new section covering post-traumatic stress disorder. This is a unique and authoritative overview of the recognition and treatment of anxiety disorders, giving Clinician Guides and Patient Treatment Manuals for each. The Clinician Guides describe how to create a treatment program, and by working through the Patient Treatment Manual together with the clinician enables each patient to understand and put into effect the strategies of cognitive behaviour therapy. The Treatment of Anxiety Disorders offers both a theoretical overview and a framework to help psychiatrists and clinical psychologists build successful treatment programs.
26 - Posttraumatic stress disorder: Clinician Guide
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
PTSD is a complex disorder requiring a multistaged intervention. The core components of treatment – psychoeducation, anxiety management, exposure, and cognitive restructuring – overlap with interventions used in the treatment of many other anxiety disorders. The purpose of this chapter is to discuss the application of those strategies to the specific challenges of PTSD, as well as to highlight some contextual treatment issues. Although the field of acute stress disorder (ASD) is in its infancy, preliminary research indicates that the same treatment protocols are applicable to both disorders. Under most circumstances, however, it would be expected that the treatment of ASD would be simpler, and would proceed at a faster rate, than treatment of more chronic PTSD presentations.
The bulk of this chapter addresses the treatment of PTSD as a disorder in itself. In acute presentations, and in people with good pretrauma functioning and intact support networks, such approaches may be all that is required. In most cases, however, by the time the person seeks treatment, the PTSD has become embedded in a range of comorbid conditions and psychosocial dysfunction. This chapter will begin by addressing some of the issues associated with more complex cases before discussing the primary treatment components in detail.
Assessment issues
A detailed discussion of assessment strategies for PTSD was provided in Chapter 24. The purpose of this section is to elucidate some additional factors to be considered when assessing for treatment purposes. A thorough assessment of the patient's history, current psychosocial functioning, and diagnosis is required before an adequate formulation of the case can be made and a management plan developed. A detailed discussion of psychiatric interviewing is beyond the scope of this chapter and only those issues particularly relevant to survivors of trauma will be discussed in this section. Key issues to look for in the history include previous episodes of psychiatric disorder (or simply “bad nerves”), as well as prior treatment experience and pretrauma coping strategies. Identification of these factors will assist in the formulation of realistic treatment goals and selection of intervention strategies with an improved chance of success. It is important also to take a history of prior traumatic experiences. Clearly, this latter area may be highly sensitive and relevant information may not necessarily emerge in the first session.
Preface to the second edition
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
The first edition of this book was developed from the Patient Treatment Manuals that had been used in the Clinical Research Unit for Anxiety and Depression for the treatment of patients with anxiety disorders. Specialized treatment programs for anxiety disorders were initiated in 1978 modeled on the treatment program for adult stutterers with which Dr. Andrews had long been associated. John Franklin designed and tested the first program for patients with agoraphobia in 1979. Since then programs for panic disorder and agoraphobia, social phobia, specific phobias, generalized anxiety disorder, and obsessive–compulsive disorder have been developed and tested. During these 20 years, many people have contributed to the redevelopment and testing of the Manuals for the various programs. Significant contributions have been made by previous staff members of the unit, in particular John Franklin, Paul Friend, Stephen MacMahon, Richard Mattick, Carmen Moran, Conrad Newman, Susan Tanner, and Morison Tarrant. Robin Harvey was the administrator of the Unit. Advice about the first edition of this book was forthcoming from Alex Blaszczynski, Anette Johansson, Colin MacLeod, Richard Mattick, Hugh Morgan, Michael Nicholas, Cindy Page, Ron Rapee, Mark Ryan, Derrick Silove, Michelle Singh, and Beth Spencer: their help is gratefully acknowledged.
The second edition has been a much easier task. First, knowing that the first edition lacked a credible section on posttraumatic stress disorder, we invited Mark Creamer, the Director of the Australian Centre for Posttraumatic Mental Health, to contribute. Second, having taught from the book to graduate students and to practicing clinicians for some 7 years we had clear ideas about the changes that were necessary. Third, the explosive growth in the literature in the past 7 years meant that revising the chapters was exciting, rather than boring. Fourth, the natural development of the treatment programs in the clinic meant that the treatment manuals are themselves quite altered and we are grateful for advice from Stephanie Rosser and Merran Lindsay on this matter. Last, Dr. Page and Dr. Hunt now work in clinics of other universities so their contributions contain knowledge from those environments. Thus the book now comes from the clinics associatedwith four leading universities and is no longer the partisan view of CRUfAD. Nevertheless we would recommend that readers supplement this book by recourse to the CRUfAD website (www.crufad.org) for themselves and their patients.
10 - Social phobia: Clinician Guide
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Chapter 11 (Social phobia: Patient Treatment Manual) contains the information given to patients in our cognitive behavioral treatment program for social phobia. This chapter discusses the issues of relevance to treatment for the therapist: assessing patients for treatment, the treatment process, and solving problems and difficulties that may be encountered.
fiorking with individuals with social phobia is challenging but rewarding. The treatment program makes significant demands on the patient. Confronting feared situations will generate high levels of anxiety, and doing so consistently is exhausting. To support the person with social phobia in this task requires genuineness, respect, and empathic firmness. Appropriate empathy is assisted by a thorough familiarity with the physiological, cognitive, and behavioral experience of social phobia. Reading case examples can be helpful, but the best learning experience is talking to individuals with a personal experience of social phobia.
Assessment
Diagnosis
This aspect has been covered in detail in Chapter 9. Correct diagnosis is essential. The core cognitions of social phobia differ from those of the other anxiety disorders: the cognitive component of treatment must be directed at the core cognitive distortions of social phobia to be maximally effective.
The presence or absence of comorbid conditions will influence treatment priorities, choice of treatment format and response to treatment.
Comorbid anxiety disorders
Many patients presenting for treatment will meet criteria for more than one anxiety disorder, since such comorbidity is common in the community (Turner et al., 1991;Schneier et al., 1992;Magee et al., 1996;Offord et al., 1996). Simple phobia appears to be the anxiety disorder consistently reported as having the highest rate of comorbidity, with panic disorder, agoraphobia and GAD also frequently reported. Conversely, social anxiety and concerns about negative evaluation occur in other anxiety disorders (Rapee et al., 1988). fihen more than one anxiety disorder is present, the underlying concerns that maintain the anxiety may cover several diVerent cognitive themes. In individual treatment, a comprehensive approach may be planned to cover all areas of concern. Group cognitive behavior therapy (CBT) may be available oVering either general anxiety-management strategies or targeting a specific anxiety disorder.
5 - Panic disorder and agoraphobia: Treatment
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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Summary
In 1988, Barlow examined the evidence from around the world and concluded that “with specifically targeted psychological treatments, panic is eliminated in close to 100% of all cases, and these results are maintained at follow-ups of over 1 year. If these results are confirmed by additional research and replication, it will be one of the most important and exciting developments in the history of psychotherapy” (Barlow, 1988;p. 447). The question facing researchers and clinicians alike is, with the benefit of more than a decade of subsequent research and replication, “Is it possible to concur with Barlow's statement?”. The place to begin this evaluation is by addressing the criteria of effective treatment for panic disorder and agoraphobia.
Aims of treatment
Panic disorder and agoraphobia are currently conceptualized as two separate, but frequently related, disorders. Specifically, panic attacks are considered the “motor” that “drives” the agoraphobic avoidance (e.g., Clarke and Jackson, 1983). Therefore, it would be expected that effective long-term treatment for agoraphobia would require effective long-term management of panic attacks. By extension, the first aim of an effective treatment for agoraphobia (with panic disorder) would be to stop panic attacks and their interference in an individual's life. The second aim would be to reduce any concurrent agoraphobic avoidance. Just as with the specific phobias, avoidance will involve anticipatory anxiety and anxiety triggered upon exposure and treatment will be more than simply “turning off” avoidance. However, an ideal treatment would do more than modify the existing symptoms; it would reduce the vulnerability to the disorder. If the vulnerability to panic disorder and agoraphobia (e.g., trait anxiety) could be modified, relapse would presumably be decreased. In summary, effective treatment of panic disorder and agoraphobia will involve (1) the control of panic attacks, (2) the cessation of fear-driven avoidance, and (3) reduction of the vulnerability.
Nondrug treatments
Exposure
In vivo exposure has been one of the strongest and most consistently demonstrated treatments for agoraphobic avoidance. In fact, it has often been demonstrated to be superior to placebo interventions as well as other credible psychological treatments (e.g., Mathews et al., 1981;Mavissakalian and Barlow, 1981; Emmelkamp, 1982;Teusch and Boehme, 1999) - a none too easy achievement in psychological research. Furthermore, when anti-exposure instructions are included in comparison therapies, the strength of exposure becomes even more evident (e.g., Greist et al., 1980;Telch et al., 1985).
Frontmatter
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
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- Book:
- The Treatment of Anxiety Disorders
- Published online:
- 05 August 2016
- Print publication:
- 14 November 2002, pp i-iv
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11 - Social phobia: Patient Treatment Manual
- Gavin Andrews, University of New South Wales, Sydney, Mark Creamer, University of Melbourne, Rocco Crino, University of New South Wales, Sydney, Caroline Hunt, University of New South Wales, Sydney, Lisa Lampe, University of New South Wales, Sydney, Andrew Page, University of Western Australia, Perth
-
- Book:
- The Treatment of Anxiety Disorders
- Published online:
- 05 August 2016
- Print publication:
- 14 November 2002, pp 197-260
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- Chapter
- Export citation