Editors: Gabbard, Glen O.; Beck, Judith S.

; Holmes, Jeremy Title: Oxford Textbook of Psychotherapy, 1st Edition Copyright 2005 Oxford University Press
> Tabl e of Contents > Secti on II - Psychotherapy in psychi atri c disorders > 13 Anxiety disorders

The behavioral and cognitive models of phobia and an xiety have witnessed a substantial de velopment over the last 35 years. More detailed descriptions of specific mode ls of each anxie ty disorder are provided in th is chapte r. However, ear lier models of acquisition of ph obia were in itially based on the model of classical condition ing, outlined by Pavlov. The supposition was that neutral stimu li were inadvertently paired with noxiou s outcomes (such as injury or unpleasant experiences), and that these associations were learned and the previously neutral stimu lus was later avoided. Mowrer (1939, 1960) later viewed this simple association ist model as inadequate to explain the maintenance of fear of situations that were avoided, as the simple associationist mode l wou ld imply that the strength of the fear shou ld decline with longer avoidance. Mowrer posited a two-factor theory (explained below) that accounted for the acquisition of fear through classical associationist condition ing an d the maintenance of fear through the anxiety reduction repeatedly expe rienced through escape of avoidance in the presence of anticipation of the feared stimu lus. Utilization of e xposure par adigmswhereby the patie nt was urged to engage in exposure to the feared stimu lus without the opportunity to escapewas expected to lessen the anxiety or fear as the patient experienced no harm during the exposu re. Initially Wolpe advocated a form of reciprocal inhibition, pair in g responses such as relaxation, assertion, or the sexu al response, in the presence of the fear ed stimu lus. The rationale is that relaxation wou ld be incompatible with fear and would replace fear as a response. Subsequent research on exposure to feared stimuli indicated that relaxation was not an important or eve n useful component of exposure. The behavioral model emph asized the deve lopment of response and stimu lus h ierarchies that reflected increasingly more anxiety or fear for specific stimuli. Th erapists were urged to begin with mode ling the ir own exposu re to the feared stimu lus, while the patient later imitated th is coping behavior. Use of exposurewh ile preventing escape or neutralization would provide th e patient with an exper ience of habituation to the feared stimulus andin cogn itive termsthe disconfir mation that the stimu lus needed to be avoided because it conferred danger. This model was expanded to the treatment of specific phobia, SAD, and OCD. Beck and E mery's cogn itive model stressed both the biological preparedness of certain fears and the cogn itive distortions

13 Anxiety disorders
Robert L. Leahy Lata K. McGinn Fredric N. Busch Barbara L. Milrod

Introd uction
Anxiety disorders are one of the most common psychological disorders found in national surveys of the prevalence of psych iatr ic problems. Man y anxiety disorders are persistent rather than episodic, with a large percentage of patients with generalized anxiety, social anxiety disorder (SAD), or obsessive-compu lsive disorder (OCD) reporting difficu lties lasting years. In many cases, the existence of an an xiety disorder will precede the e mergence of a later depressive disorder, perhaps because there is a common diathesis or because the demoralization of having a long-lasting anxiety disorder contr ibutes to self-cr iticism, withdrawal, loss of rewards, and general feelin gs of he lplessness and hopelessness. Indeed, man y individuals suffering from these anxiety disorders rely on alcoh ol or other drugs as anxiety managemen t, thereby complicating their proble ms. In this chapter we have brought to the reader two qu ite different theoretical and clin ical or ientations to understanding and treating anxiety disordersspecifically, cognitive-behavioral therapy (CBT) and psychodynamic therapy. We attempt to provide theoretical mode ls and clin ical strategies drawn independently from these mode ls. Because of the differences in these mode ls, we have chosen to let them stand in dependently from one another and leave it to the reader to explore the possibility of clinical integration.

Cognitiv e-beh avio ral theo ry and mo del of anx iety di sorde rs

associated with these fears. Thus, Beck was able to identify the role of the individual's interpretations, e.g., catastr ophic interpretations of events or symptoms (I won't be able to stand it, I'll get so anxious I will die), mislabeling (I am crazy), and fortune-telling (something terrible will happen). The in itial cogn itive approach advocated by Beck stressed the use of exposure in the context of identifying the patients pr edictions and testing them out through behavioral exposure. Subsequent cognitive and behavioral models attempte d to specify specific cogn itive compone nts for each of the anxiety disorders indeed, argu ing for a specific refined mode l for each diagn ostic category. As a consequence of th is greater specificity of the mode l, we describe how th e CBT mode l is applied for each of the anxiety disorders in th is chapter.

these manuals suggest that the psychodynamic approach is a promising treatment for panic disorder (Wiborg and D ahl, 1996; Milrod et al., 2000, 2001) and PTSD (Lindy et al., 1983). P.138 In this section, we shall de scribe basic psychodynamic prin ciples that can be used to deve lop psychodynamic mode ls and treatment approaches to specific an xiety disorders.

Relev ant co re d yn amic co ncepts

In order to understand psychodynamic theor ies and approaches to anxiety disorders, it is use ful to review certain core dynamic concepts.

T raum atic anx iet y versu s s ign al a nx i ety

Freud (1926/1959) described two types of anxiety: th e traumatic form, in which the ego is overwhelmed by anxiety and stimu li that it cannot contain, an d a signal form (signal an xiety), wh ich alerts the ego to the presence of wishes, impu lses, or feelin gs that are considered dangerous.

T he psyc hodyn ami c unde rst andi ng a nd treatme nt of anx i e ty diso rde rs
Having deve loped several psychological models of anxiety, psychoanalysts have on ly r ecently begun to focus on the treatment of specific anxiety disorder s. Syste matic placebo-controlled studies of specific an xiety disorders with psychodynamic approaches have n ot yet been accomplished. Nevertheless, psychodynamic theory has significant clin ical explanatory potential for anxiety disorders through its focus on intrapsych ic conflicts, unconscious fantasies, defense mechanisms, and the compromise function of symptoms, factors that are not central to other psychological or neurobiological theories. In addition, the clin ical techniques of focus on the transference, examin ing the emotional impact of the patient's developmental history, explor ing the meaning of symptoms, and the technique of using free association provide a broad array of th erapeutic tools for potentially lessening symptoms and vu lnerability to recurrence of disorders. For systematic studies to be performed, psychoanalysts and psychoanalytic researchers must deve lop specific treatments, described in treatment man uals, for anxiety disorders focusing on dynamics specific to each of these disor ders, as we ll as the particu lar treatment approaches tailored to these dyn amics. As of the writing of this chapter, manuals of this sort for anxiety disorders have on ly been developed for pan ic disorder (Wiborg an d Dahl, 1996; Milrod et al., 1997) and posttraumatic str ess disorder (PTSD) (Lindy et al., 1983; We iss and Marmar, 1993; Marmar et al., 1995). As will be discu ssed be low, preliminary stu dies using

T he trip art ite mo d el of the min d

According to the structural theory, deve loped by Freud (1923/1961), the mind is divided into three relative ly stable structures with discrete functions: the ego, the id, and the superego. The id su bsumes the instinctual drives that emerge as the individual's needs and wishes, conscious or uncon scious. The ego mediates between the drives and external reality, in part through the operation of defenses (see be low). The superego includes the conscience an d moral ideals and precepts, with both rewarding and pun ish ing fu nctions.

Defens es
Signal anxiety triggers characteristic defense, means of warding off or disgu ising dangerous wishes and impu lses to re nder them less threatening. If the ego is ineffective at warding off the danger felt from internal wishes and unconscious fantasies (Shapiro, 1992), traumatic anxiety, in the form of overwhelmin g anxiety or panic, can resu lt. Another outcome might be that the patient develops symptoms that bind anxiety, such as a phobia or obsession s. By attach ing th e anxiety to specific symptoms, it will be experienced as more controllable, and the fr ightening unconscious wishes are more disguised. In phobias, for example,

the internal fear converts to a specific external danger that can be avoided (see Specific phobia section be low).

individual to develop an anxiety disorder. A temperamental fearfulness can affect the individual's perceptions of themselves and others, as we ll as the sense of safety of feelings and fantasies. Kagan and colleagues (Rosenbaum et al., 1988; Biederman et al., 1990; Kagan et al., 1990) identified a group of behaviorally inhibited ch ildren who de monstrated fear responses in the setting of environ mental novelty. Ch ildren fe lt to be at risk for the development of pan ic disorder (offsprin g of parents with panic disorder and agoraphobia) were found to have h igh rates of behavioral inh ibition compared with a control gr oup, and ch ildren with behavioral inh ibition were likewise found to have an increased rate of anxiety disorders. T hus, this fearfu lness may h ave a genetic or igin that in interaction with a particu lar set of psychological and environ mental factors can trigger th e development of anxiety disorders.

T he unco nscio us
In psychoanalytic theory, mental life operates on both conscious and unconsciou s (out of awareness) leve ls (Breuer and Freud, 1895/1955). Wishes, fantasies, and impu lses that may be considered dangerous to th e ego are frequently uncon scious, and it is their potential e mergence into consciousness that is exper ienced as threatening. Anxiety disorders arise in part from u nconscious factors.

Comprom ise form a tion

In order to dimin ish the risk from threatening fantasie s or impu lses, the ego synthesizes a compromise between the wish and the defense that is be ing e mployed to avert the threat from the wish (Breuer and Freud, 1895/1955). Psychiatric symptoms, as well as fantasies and dreams, are compromise formations that symbolically represent both the wishes and the defenses.

Psychodyn am ic tre atment o f anx iety disor ders

Psychodynamic psych otherapy operates through the identification of the unconscious and con scious fantasies and con flicts underlying anxiety disorder symptoms, br inging them into the therapeutic dialogue, where they can be understood and rendered less threatening. These fan tasies can be brought to the surface by exploring the mean ings of symptoms, the stressors th at precede or exacerbate symptom on set, and the fantasies an d fee lings that emerge in the re lationsh ip with the therapist (the transference). As these fantasies and conflicts are rendered less catastrophic, the symptoms often diminish and resolve. An important component of this form of therapy is he lping patients to become aware of, more tolerant of, and more effective in expressing the ir dr ives and wishes. Exploration of underlying dynamic mean ings of symptoms provides important clues about unconscious fantasies and conflicts that fue l anxiety symptoms. A lthough patients with anxiety disorders share general sets of symptoms, individual var iations in the syndromes are an important source of information about uncon scious significance. For instance, one patient's fear of chokin g dur ing panic attacks when drin king liqu ids was linked to intense, exciting, and fr ightening struggles for control with her father when she was a child regarding how much food and dr ink she shou ld have at the dinner table. The exploration of this symptom led to an understanding of angr y and sexualized feelings in her relationship

T he pl eas ure pr inc iple

According to Freud's formu lation, in dividuals unconsciously avoid unpleasurable feelings and fantasies via the mental operation of repression and other defen ses (Freud, 1911/1958). In subsequent writings, Freud (1920/1955) modified the idea of the pleasure principle to include the notion that discharging intense emotions was more fundamental than the pursuit of pleasure. According to the psychoanalytic theory of the pleasure pr inciple, anxiety disorder symptoms are less distressing than the uncon scious conflicts underlyin g the symptoms.

Repre sent ation s o f se lf and other s

Over the course of deve lopment, people internalize representations (mental images and concepts) of themselves and others, and themselves in relation to others. Patients with anxiety disorders often have representations of others (object representations) as being demanding, controlling, threatening, and an xiety inducing. These object representations add to the exper ience of fantasies and feelings as dangerous. Anger is often exper ienced as a danger to attachments, an d attach ments feel insecure.

Neuro phys iolo gica l vul ner ab ility a nd psychody nam ic f a ctors i n anx iety di sorde rs
Evidence suggests that neurophysiological vulnerabilities may trigger a psychological state that can increase the potential of an

with her father that she experienced as dangerous, yet needed to reexperience over and over in the for m of symptoms. Circumstances preceding symptom onset, feelings experienced other than anxiety, and defense mechanisms employed provide additional clues about the psychological or igins of symptoms. Use of the transference is a core component of psych oanalytic treatment. In the phenomenon of transference, components of central relationsh ips are u nconsciously exper ienced as deriving from current relationsh ips (Freud, 1909/1953). Th is process takes place with the therapist as well. Understanding the patient's fantasies about the therapist and the treatment can be of value in any form of treatment, but from a psychodynamic perspective, the transference situation has far-reaching effects, and n ecessarily influences therapeutic outcome. For example, a patient's fear that he will be abandoned by significant people in h is life if he expresses his rage or frustration can be examined in the con text of a stable, reassuring relationsh ip with the therapist. Therapists also explore with patie nts how current perceptions or misperceptions of others, inclu ding the therapist, are linked with perceptions of sign ificant others in childhood. For instance, patients who experience othe rs and the P.139 therapist as shaming them may descr ibe having exper ienced shaming behavior from their parents. Fantasies and dr eams provide crucial infor mation about intrapsych ic conflicts, as we ll as the transference. There is an emphasis in psychodynamic psychotherapy on mon itor ing one's own reactions to patients, referred to as the countertransference (Gabbard, 1995). Negative, cr itical, or distancin g behavior, of which the therapist may or may not be aware, can have a disruptive impact on the therapeutic alliance, and can limit the impact of any treatment. A lthough awareness of one's own reactions to a patient is of value in any treatment, psychodynamic psychotherapists scan their own reactions as additional clues to understanding patients. For instan ce, the therapist may be aware of his own discomfort and avoidance when a patient with PTSD appears to be on the verge of discussing a particu lar ly painfu l aspect of the trauma she exper ienced. Not all reactions to patients, h owe ver, are indu ced by particu lar patient behavior and attitudes, an d psychodynamic psychoth erapists attempt to learn about the variou s fee lings different patients,

conflicts, and disorders may elicit in them. With patients with anxiety disorders, therapists shou ld be particu lar ly concerned about fantasies and fears of exacerbating a patient's anxiety symptoms.

Specific pho bi a Diag nostic fe ature s

The defin ing characteristics of specific phobia are intense fear of anxiety in the presence of a specific stimu lus or situation, where this fear results in impairment or discomfort, and the individual realizes that the fear is excessive. T ypical specific ph obias include fears of animals, blood or injection, he ights, water, in sects, rats, and other stimu li or exper iences. About 11% of the general popu lation has a lifetime prevalence of specific phobia (Wittchen et al., 1994).

Evalu ation
Specific phobia is intense fear and arousal in the presence of a specific stimu lus or feared object (such as heights, an imals, water). Th is is distingu ishe d from panic disorder (where the fear is that the individual's ar ousal will go out of control and cause a medical emergency or in sanity) and from SAD where the individual fears that the symptoms of anxiety will be observed by others resulting in humiliation or embarrassment. Specific phobia is also distingu ished from PTSD in that patients with PTSD fe ar intrusive memor ies or images. Specific ph obia can be evaluated by use of a variety of instruments, including the Fear Questionnaire (Marks and Mathews, 1979) and th e Fear Survey Schedule (Wolpe and Lang, 1964).

T heoretic al mode l s
The most wide ly used theor etical mode l of specific ph obia is based on learning theory. S ince Watson's (1919) observations of a conditioned fear of furry objects in a young ch ild (by pair ing shock with a rabbit), behavior th erapy has vie wed specific phobia as resulting from a learned association of a negative consequence paired with a neutral stimulus. This classical, or Pavlovian, mode l was later modified in the two-factor theory of con servation of fear proposed by Mowrer (1960). According to Mowrer, the in itial fear was established throu gh classical conditionin g (e .g., the neutral stimu lus of the stove was paired with the negative experience of be ing burned). However, avoidance of the stove in the future was based on operant condition ingthat is, when the

individual approached the stove there was an increase of fear. Avoiding or escaping was associated with reduction of fear (thereby negative ly rein for cing the operant of escape or avoidan ce through the consequence of fear reduction). The two-factor mode l thus accounted for the acquisition of fear through classical condition ing and the avoidance of feared stimu li through the negative rein force ment of reducing fear through the operants of escape of avoidance. Fear was thereby conserved. The implication of the classical and operant mode ls was that fear could be overcome by direct exposure without escape. In addition, Wolpe (1958) introduced th e idea of responses in compatible with fear or anxiety with the concept of reciprocal inhibition. This refers to the fact that certain responses (or experiences) (e.g., relaxation, sexual behavior , and assertiveness) are in compatible with the response of fear. By pair ing these incompatible responses (e.g., inducing relaxation in the presence of the feare d stimu lus) the individual can decondition the learned fear. Related to th is mode l is the use of habituation techn iques and extinctionthat is, repeated exposure of the stimu lus will reduce its potentiatin g effect (habituation) or repe ated exposure without rein forcement (e.g., escape is negative ly reinforcing) reduces the acquired associative lin k of the conditioned stimu lus (CS) (e.g., the stove) with the learned (condition ed) response (e.g., fear). While recogn izing the value of condition ing and negative reinforcement for escape and avoidan ce, there has be en a growing recognition of the importance of prepared behaviors (Seligman, 1971), innate fears, or innate predispositions. According to these Darwin ian influenced ethological mode ls there are certain stimu li that the human in fant is predisposed to fear. These stimuli reflect dangers in the evolutionary expected environ mentthat is, the primitive environment of danger from predators, natu ral catastrophes, and abandon ment. For example, research on the distribution of fears in var ious cu ltures reveals that the same stimu li are largely equally feared and that these stimuli reflect primitive dangers. This non random distribution of fears, with heights, water, an imals, th under/lightening topping th e list, suggests that hu man infants and children are preadapted to fear events that confer danger. The Dunedin study in Ne w Zealand offers further support to th e ethological mode l of fear. In th is study a lar ge number of children were followed fr om early in fancy to early adu lthood and records of the ir fears an d their experiences with feared events was obtained. Contrary to the lear ned fear

mode l proposed by association ist and operant theories, ch ildren who previously have su ffered injur ies from falling wer e less afraid of falling in the future. The learn ing mode ls would have predicted the oppositebut the ethological mode l suggests that fears may be protective and innately pre disposed. Moreover, an overwhelmin g high percentage of parents of ch ildren who feared water were afraid of the water on the very first presentation of a pool of water. Now, despite the ar gument that fears may be predisposed through evolution, the ethological mode l argues for some plasticitythat is, fears can be unlearned through exposure. The cognitive mode l of spe cific phobia suggests that, in addition to the two-factor theory and the ethological mode l, there are specific cogn itions and behaviors that may add to fear and avoidance. These include be liefs that the threat/danger of a stimulus is related to the fear that it elicits (see Ost, 1997; Ost and Hugdahl, 1981) and that safety behaviors may protect the individual from the threat. Examples of the se cogn itive distortions in fear include the following: If I am anxious, then it must be dangerous and I must get r id of the anxiety immediately. Safety behaviors include superstitious behaviors or thoughts that attempt to n eutralize the fear or provide some protection from the fear. Examples of safety behavior s that fearfu l individuals may utilize include r epeated selfassurance (praying, se lf-talk), magical rituals (wearin g specific clothing on an air plane), h ypervigilant scann ing of the environment (e.g., checkin g for sounds and movemen ts on an airplane), collecting information about danger (e.g., checking the weather forecasts or safety records of air lines), and r equirin g someone to accompany the m when in the presence of a feared stimu lus. The cogn itive model of specific phobia suggests that these safety behaviors act as a disattribution errorthat is, The only reason that I am safe is that I engaged in my safety behavior s. Thus, safety be havior s might reduce the e fficacy of the exposure used in behavioral treatmenta supposition now supported by e mpirical data.

Empiric al sup port for tre atme nts

There is overwhelming support for the efficacy of behavioral exposure treatment for spe cific phobiain some cases, over 90% of patients being effectively treated with exposure treatment with some u se of anxiety management techniques (Ost, 1997). Most fears can be successfu lly treated in fe wer than five se ssions, with massed practice or prolonged exposure yie lding more rapid results. P.140

breathing, meditative techniques). Patients are traine d in identifying Subjective Units of D istress (SUDs), ratin g their fear or

Ration al e for tre at ment and inte rven tions

Given the importance of the role of avoidance and escape in the maintenance of fear, behavioral treatments re ly on re peated exposure to feared stimu li. The rationale for treatment is to identify the feared situations or stimu li, introduce the use of relaxation techn iques (if n eeded), and engage the patient in gradual but prolonged exposure to the stimu lus. We have found it helpfu l to educate the patient about the evolutionary significance of ph obiasthat is, that most of the stimu li that are feared (e.g., heights, water, insects, animals) would confer danger in a primitive environment where these feared stimu li were present and dangerous. This preparedn ess of phobia leads to the emergence of a fear later, but that the u se of behavioral exposure can reverse this process. The two-factor theory of anxiety conservation outlined by Mowrer (1939, 1960) can be helpfu l in un derstanding that fears may be acqu ired through be ing paired with a noxiou s experience, but that they are maintained or con served through the anxiety reduction of escape or avoidance.

anxiety from 0 to 100% (or 010), with h igher numbers corresponding to greater fe ar. Imaginal exposure is used whereby the patient begins with imagin ing, in session, the least feared situation in the hierarchy and holding th is image in mind until SUDs are reduced by 50% or more and then moving u p the hierarchy to gradually mor e feared stimu li. In vivo exposure involves actual exposure to the feared stimu lus. It is useful to obtain initial S UDs r ight be fore, dur ing, and after the exposure and to e licit predictions from the patient about what h e or she fears will happen (e.g., the elevator will crash or I will dr ive off the bridge). Safety behaviors are important impediments to exposure efficacy and these can be identified by asking patients if they do anyth ing to make themse lves feel safer. For e xample, asking th e patient, When you dr ive across the bridge, when you are afraid, do you do any of the following to make yourself feel safertalk to yourself, avoid looking to the side, clench the steering wheel, slow down, or anything e lse? As the patient is able to tolerate situation s h igher in the hierarchy the therapist can indicate that continued e xposurefar beyond normal exper iences with the stimu lussh ould be continued after treatment has been completed. For e xample, a patient with a fear of e levators shou ld be told to continue taking e levator s up and down for weekse ven whe n it is not necessaryin order to overpractice exposure. Any setbacks or relapses should be followed by re-in itiating th e program of exposure. Re laxation should be continued on a daily basis in order to reduce physiological arousal.

Strateg ies a nd tec hniqu es

Behavioral treatment of specific phobia follows a set pattern of interventions. During the assessment phase the therapist evaluates wh ich stimu li or situations are avoided or e xperienced with discomfort. The Fear Survey is a u seful assessment measure as is the Initial Fear Evalu ation for Patients (Leahy and Hollan d, 2000). The patient's Fear H ierarchy (see Leahy and Holland) provides in formation for th e assessment of a ranking or hierarchy of feared situation s as we ll as the rating of degree of fear and whether the situation is actually avoided. A lthough an xiety management (such as breathing exercises and re laxation) are helpfu l, they are not necessary for exposure to the feared stimu lus.

Case ex am ple
The patient was an executive in his fifties who had su ffered from fear of he ights for 9 yearswith th is fear increasin g in the past 3 years. The patient indicated that he feared crossing bridges, climbing mountains, dr ivin g in the mountains, and standing close to the edge of precipices. He indicated very little fear of flying and pointed out that h is fear of heights was due to h is fear that he might lose control of the vehicle or h imse lf and fall over the side. He utilized a number of safety behaviors that he belie ved lessened his fear, including having h is wife dr ive or accompany him as a passenger (She cou ld take over the dr iving), plann in g far ahead so as to anticipate trouble, avoiding looking to the side of the

Brie f p lan of t reat ment

Socialization to treatment begins with providing the patient with the Information for Patients about Specific Phobia (Leahy and Holland, 2000) or by informing the patient of the nature of acquired an d predisposed fear. Patients often find the Darwinian mode l provides them with a demystifying and n onstigmatizing explanation of their fear. Initial interventions involve train ing the patient in relaxation techn iques (deep muscle re laxation,

bridge, clench ing the steering wheel, dr iving very slowly, alternating with the break and acce lerator, talking to himself, avoiding the rear-vie w mirror, and avoiding br idges or heights totally. The therapist explained to the patient both the Dar winian mode l and the learnin g theory model and provided h im with the information sheet from Leahy and Holland (2000). He was quite skeptical of both mode ls and said he wou ld take a wait and see attitude. The therapist encouraged this and suggested, Let's collect some data about wh at happens with your fear as we proceed. A fear h ierarchy for heights was obtained and the first intervention was imaginal exposure for thin king abou t specific bridges. The in-session imaginal exposure suggested little in itial fear, so the imagined stimulus was changed to th inking about himself standing at the edge of a cliff. Th is immediately increased fear, wh ich abated with prolonged exposure. Specific safety behaviors were targeted. The therapist explained how these safety behaviors made h im believe that he could not face the situation without these magical behaviors and thoughts and then relin quishin g them wou ld be important. The therapist utilized a role-play where the therapist played the role of the safety behavior thoughts (e.g., You need to clench the steering wheel or you will go over the side) wh ile the patient argued against these thoughts. Furthermore, the patient was asked to imagine and later actually produce the opposite behaviors of h is safety behaviors. For example, rather than clench ing the wheel, he was asked to loosen h is grip, rather than driving slower, he was to drive normally, rather than avoid the rear view mirror, he was to look at it on and off, and r ather than avoiding looking over the side, he was to gaze on an d off over the side. These were first practiced with imaginal training and later with in vivo training. Finally, he was to write out his predictions of what would happen and the actual outcome for various e xposures. Closer question ing reveale d that the patient was inadvertently hyperventilating by taking very deep breaths during these experiences. Apparently he had heard that you sh ould take deep breaths to calm yourself. It was explained that th is might add to his sense of light-headedness and that he shou ld breathe normally. After seven sessions (spaced over a 3 -month period) after the in itial intake, the patient h ad engaged in all of the fe ared behavior s in h is hierarchy, including dr iving across nu merous long bridges, dr ivin g for hours in the mountains, and standing at the

edge of cliffs. These exposures became boring in themse lves, but he was encouraged to continue to look for further opportunities after his treatment was completed.

Psychody nam ic m odel for spec ific p hobi a

From the psychodynamic viewpoint, specific phobias develop from the ego's response to the threatened emergence of forbidden aggressive or sexual wishe s. When these wishes tr igger signal anxiety, certain defense mechanisms characteristic of phobias are activated to repress and disguise these wishes: displacement, projection, and avoidance (Gabbard, 2000). For example, in Freud's case of Little Hans (Freud, 1909/1955), a ch ild deve loped a phobia of horses, wh ich in Freud's view had come to symbolically represent his father. The child's fear of aggressive an d competitive wishes toward h is father was displaced (to horses) an d projected: the horse was going to damage h im, rather than that he was going to damage the horse (father). Then the anxiety cou ld be dimin ished by the avoidance of hor ses. Thus, the phobic symptom symbolically replaced the anxiety from unconscious wishes.

Psychody nam ic tre atment of s pecif ic phobi a

In psychodynamic psych otherapy, the therapist seeks to elucidate the meanings of the specific symptom, and the de fenses that contribute to it, P.141 and uses them as gu ides for disentangling the unconscious threatening wishes. E xploring the circumstances surrounding symptom onset an d what comes to mind about a specific symptom aids in th is process. In this context the frightening un conscious wishes can be brou ght into consciousness an d rendered less threatening. For example, when Freud communicated to Hans h is aggressive and competitive wishes toward h is father, his phobic symptoms resolved.

O bsess ive-comp ul sive dis orde r Diag nostic fe ature s

The DSM-IV [A merican Psychiatr ic A ssociation (APA), 1994] defines obsession s as persistent and recurrent thoughts, ideas, images, or impu lses that are experienced as intrusive an d

inappropriate, that are n ot simply excessive worries about real-life problems, and that cause marked anxiety or distress (e.g., thoughts of killing a ch ild, becoming contaminated). The person recogn izes that they are a product of h is own mind an d attempts to suppress or ignore the obsessions or to neutralize them with some other thought or action. Compu lsions are defined as repetitive behaviors (e.g., checkin g the stove, handwash ing) or me ntal acts (e.g., counting numbers) that the person feels driven to perform in response to an obsession or according to rigid ru les. The compu lsion is aimed at preventing or reducing distress or preventing some dreaded situation; however, the compu lsions are either unrealistic or clearly excessive. Insight into illness is n o longer necessary for the diagnosis so lon g as the excessiveness or senselessness of obsessions and compulsions is recogn ized at some point during the course of the disorder.

the Interpretation of Intrusions In ventory, have been developed by an international consortiu m of researchers to identify and rate cogn itive aspects of intrusive thoughts and obsessions (Obsessive Compu lsive Cognitions Wor king Group, 1997, 2001). Other measures to assess for general se verity of illness include the Beck Anxiety In ventory (BAI; Beck et al., 1988a) and the Beck Depression Inventory (BDI; Beck et al., 1988b). Patie nts may also be given general measures of disability such as the Sheehan Disability Scale (Leon et al., 1992) to assess the degree to wh ich the symptoms are interfering with the patient's functioning. Treatment forms utilized over the course of treatment included the automatic and revised thou ght log, the obsession-compulsion mon itor ing form, the imaginal and in vivo exposure form, and the exposure monitorin g form (McGinn and Sanderson, 1999).

Cognitiv e-beh avio ral mode ls of ob se ssivecompuls ive diso rd er Beh avior al mod els : two- stag e the ory
Mowrer's two-stage theoretical model of the acqu isition and maintenance of fear and avoidance behaviors (Mowrer, 1939, 1960) has been further elaborated to explain the onse t and maintenance of symptoms in OCD (Dollar d and Miller, 1950). Th is mode l proposes that a stimulus that does n ot automatically e licit anxiety or fear (a neutral stimulus) becomes associate d with a stimu lus (an unconditioned stimulus or UCS) that natu rally e licits anxiety or fear (an unconditioned response or UCR) by being paired with it. Through this pairing, the previously ne utral stimu lus (the CS) now becomes capable of e liciting fear or anxiety on its own (the conditioned response or CR). Obsessive fears, which take the form of recurrent and intrusive thoughts, images, ideas, or impu lses are proposed to deve lop via th is condition ing process. For example, Jim may become anxious about eating meat if he deve lops salmone lla poison ing. Eating meat (NS) becomes associated with salmone lla poison ing (UCS) and becomes capable of e liciting fear on its own (CS). In explain ing how fear or anxiety maintains itself, the model proposes that individuals develop avoidance and escape behaviors (e.g., avoid eating meat, repetitively wash hands if they come into contact with meat) to redu ce the anxiety elicited by the CS (e.g., meat), and by doing so, be come negative ly rein forced by the cessation of anxiety that follows. In other words, despite the fact that the CS (e.g., meat) is no longer paired with the initial

Diag nostic an d ass essme nt me as ures

OCD may be diagnosed using semistructured clin ical interviews such as the Structured Inte rvie w for the DSM (SCID-P; Spitzer et al., 1987) or the Anxiety D isorders Interview Schedule (ADIS-IV ; DiNardo and Barlow, 1988; DiNardo et al., 1993). D imensional measures may also be u sed to assess for the severity and content of symptoms. The Yale-Brown Obsessive-Compu lsive S cale is the most wide ly used rating scale in assessing severity of OCD symptoms (Y-BOCS; Goodman et al., 1989a,b). Other rating scales include the Mandsle y ObsessiveCompu lsive In ventory (Hodgson and Rach man, 1977), the Padua Inventory (Sanavio, 1988), the Obsessive-Compu lsive Inve ntory (Foa et al., 1998b), and the Compu lsive A ctivity Checklist (Freund et al., 1987). Finally, two recent questionnaires, the Obsessional Be liefs Questionnaire and

traumatic stimu lus or UCS (e.g., salmonella poisoning), the conditioned fear response continues because the individual is negative ly re infor ced by th e experience of reduced an xiety that follows the escape or avoidance behaviors, including compu lsive rituals. As a resu lt, the fear response does not extinguish because the individual does not learn that the CS is no lon ger paired with the UCS and that it is not dangerous in and of itself. Compu lsive rituals are conceptualized as avoidance behaviors that are developed to reduce this e licited an xiety. Because obsessions are intrusive, passive avoidan ce and escape behaviors are usually insufficient in alleviating the anxiety associated with their arousal. Hence, active avoidance behavior s (compulsions) are developed by individuals in order to redu ce the anxiety created by the CS (in this case, meat), and are maintained by the ir su ccess in doin g so. Evidence for Mowrer's two-stage theory of the deve lopment of fear is insufficient. Not on ly do a major ity of patients with anxiety disorders, including OCD, deny a link between symptom on set and specific traumatic events (Rachman an d Wilson, 1980), th is model does not take into account other modes of onset repor ted by patients such as infor mational learning (e.g., becomin g fearful of germs after hearing about a news report on the breakout of Escherich ia coli among sch ool children) or observational learning (e.g., growing up with a parent who is constantly afraid of catching a disease) (Foa and Kozak, 1986). By contrast, there is far more support for Mowrer's two-stage conceptualization of the maintenance of fear. Studies have demonstrated that environ mental cues tr igger anxiety (Hodgson and Rach man, 1972; Hornsveld et al., 1979) and that obsession s increase distress (Rabavilas and Bou lougour is, 1974; Boulougouris et al., 1977). Research has also demonstrated that performing handwash ing and checking rituals following an urge to ritualize leads to decreases in anxie ty (Hodgson and Rachman, 1972; Roper et al., 1973; Roper and Rachman, 1976; Hornsve ld et al., 1979).

(Rach man and de Silva, 1978). A lthough se veral cogn itive theor ies have been used to explain OCD symptoms (A. T. Beck, 1976; Beech and Lidde ll, 1974; Carr, 1974; McFall and Wollersheim, 1979; Guidano and Liotti, 1983; Foa and Kozak, 1985; Reed, 1985; Salkovskis, 1985; Pitman, 1987; Wegner, 1989; Warren and Zgourides, 1991), the two most comprehensive cognitive theor ies are described here in some detail (Foa and Kozak, 1985; Salkovskis, 1985). For a su mmar y account of other cognitive theories, interested P.142 readers are invited to read Riggs and Foa (1993), Steketee (1993b), or Jakes (1996).

Foa and Koz ak' s in format ion proce ssi ng model

Based on Lang's model (1979), Foa and Kozak (1985) conceive of fear as an infor mation network that exists in memor y. Th is memor y networ k contains r epresentations about fear cues, fear responses, and their meaning. Accordin g to them, all anxiety disorders have the followin g impair ments in these networks: (1) faulty estimate of threat (e.g., perceiving danger or threat when there is objectively none); (2) excessive negative valence for the feared event (e.g., excessive degree of affective response); (3) extreme response to danger or threat (e.g., physiological reactivity); and (4) persistence of fears (e.g., continu ing to perceive danger despite evidence to the contrary). Foa and Kozak suggest that, alth ough all anxiety disorders have specific impair ments in the ir memor y network, OCD differs fr om other anxiety disorders in that their inferential judgments about harm appear to be impaired. Accordingly, an individu al suffer ing from OCD will conclude that an event or situation is dangerous unless it is pr oven safe without a doubt. Furthermore, even if information suggests that a situation is n ot dangerou s, or e ven if harm does not occur after exposure to a certain event or situation, individuals with OCD still fail to learn from direct e xperience and will fail to conclude that th e particu lar event or situation is safe. As a result, r ituals designe d to reduce the occurrence of harm do not provide ultimate safety and must be performed repeatedly. Foa and Kozak also indicate that specific types of fears are unique to OCD (Riggs and Foa, 1993). Some individuals with OCD develop excessive connections between anxiety and a particu lar stimu lus

Cognit ive th eor ies

Cognitive models generally hypothesize that a fau lty appraisal style may underlie the dysfunction in obsessional th in king (Beech and Lidde ll, 1974; Carr, 1974; A. T. Beck, 1976; McFall and Wollersheim, 1979; Gu idan o and Liotti, 1983; Foa and Kozak, 1985; Reed, 1985; Salkovskis, 1985; Pitman, 1987; Wegner, 1989; Warren and Zgour ides, 1991). Having obsessions is not believed to be dysfunctional in and of itself. In fact, research shows that u p to 90% of the normal popu lation report having cogn itive intrusions

(e.g., garbage can), and overestimate the threat harm related to the feared stimu lus (e.g., I will catch a disease if I take out the garbage). Other individuals fear the mean ing of certain acts (e.g., books should always be lined up in order of height) and not the stimu lus itse lf (e.g., book). In other words, it is the asymmetry that induces the anxiety in this case an d not the books themselves. While there is some suppor t for the notion that individuals with OCD tend to overestimate threat, no clear evidence ye t exists to suggest that they exh ibit a stronger negative valence for feared situations (Steketee, 1993a) and preliminary research disproves the observation that individuals with OCD have higher physiological reactivity than normals (Foa et al., 1991). Other theoretical propositions espoused by Foa and Kozak (1985) (e.g., persistence of fear) have yet to be tested.

same as having caused the harm in the fir st place; (3) responsibility is not attenuated by other factors (e.g., low probability of occurrence); (4) not neutralizing when an intrusion has occurred is similar or e quivalent to seeking or wanting the harm involved in that intrusion to happen; (5) one should (and can) exercise control over one's thoughts. Preliminary research supports Salkovskis contention that individuals with OCD have an increased sense of responsibility and self-blame regarding harm (Salkovskis, 1989). A rece nt study found that change in beliefs preceded change in OCD symptoms in cogn itive and behavior therapy, wh ich also pr ovides support for the cognitive mode l (Rheaume and Ladouceur, 2000). However, critics argue that appraisals and neutralizing behaviors do not complete ly explain why obsessions become abnormal and further contend that the proposed themes of responsibility an d se lf-blame explain some obsessive-compu lsive the mes (e.g., aggressive, sexual, blasphemous thoughts) better than others (e.g., contamination fears, cleaning rituals) (Jakes, 1996). Finally, critics also note that a successfu l intervention (e.g., reducing the sense of responsibility and self-blame) does not imply causation (i.e., that an increased sense of responsibility caused the obsession s to occur in the first place) (Jakes, 1996). For instance, although the Rheaume and Ladoucer found that change in beliefs preceded change in treatment, their study found that successfu l treatment with both cogn itive and behavior therapy also led to a subsequent change in be liefs.

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Salkov sk is cog niti ve mode l

According to th is model (S alkovskis, 1985, 1989) intr usive obsessional thoughts by th emselves do not lead to in creased anxiety or distress. However, in individuals with OCD whose underlying be lief systems are characterized by respon sibility and self-blame, such th oughts trigger (secondary) negative automatic thoughts that lead to anxiety or distress. In other words, individuals with OCD experience dysfunctional, anxiety-provoking automatic thoughts (e.g., my baby will die) in the presence of intrusive obsessions (e.g., obsessional image of baby dying), which in turn, are based on certain core assu mptions and beliefs they hold (e.g., if I have an obsession, it will come true, I bear responsibility for harm; only immoral people have such thoughts). Hence, the dysfunction lies not in the obsession s themse lves but in the way these obsessions are processed or appraised. Owin g to this fau lty appraisal, these individuals e xperience gre ater anxiety in response to the obsessions, find it more difficu lt to dismiss them or ignore them, and e nd up r itualizing in order to alleviate the anxiety associated with obsessions. In th is mode l, ritualized or compulsive behaviors are performed in order to reduce this sense of responsibility and se lf-blame, which in turn, reduce s the distress associated with th e obsessions. According to Salkovskis (1985, p. 579), the OCD patient's exaggerated sense of responsibility and self-blame is characterized by the followin g dysfunctional assumptions: (1) having a thought about an action is like performing the action ; (2) failing to prevent (or failing to try to prevent) harm to se lf or others is the

Psychody nam ic m odel of ob ses sivecompuls ive di sord er

Psychodynamic focus on OC D, wh ile sign ificant in the early development of psychoanalysis, has been limited in recent years (Esman, 1989, 2001). As with pan ic disorder and social phobia, struggles with an gry and competitive feelings and fan tasies are considered central to the development of the disorder, with a focus on fears of loss of control. The punitive superego, characteristic of these patients, increases the danger they feel from the potential experience of these feelings. In the psychoanalytic literature, OCD has been descr ibed as occu rring alongside a regression to an earlier stage of ego deve lopment, in which the individual fears that her thoughts and fantasies might damage someone else. Defenses include undoing, in an attempt to symbolically and magically make restitution for angry feelings via compulsive

behavior s. A lso, patients tend to intellectualize or be come preoccupied to avert the experience of fr ightening fee lings. OCD symptoms have also been described as representing a compromise formation. For instance, Freud (1909/1961) described a patient who became obse ssed with whether to remove a stone from the road that he feared might lead to damage of the carriage of the woman he loved, who would su bsequently be dr iving on the road. He removed the stone from the center of the road, where he feared her carriage might h it it, symbolically protecting her, but then decided that th is was absurd and replaced the stone, as he struggled with h is ambivale nce and aggressive feelings. Thus, as noted above, the compu lsive act may attempt to undo aggressive fantasies and do penance to avert gu ilt and anxiety. Salzman (1985, p. 13) summar izes the obsessive compu lsive dynamic as a need for control in all aspects of life: The obsessive compu lsive dynamism is a device for preventing any feeling or th ought that might produce shame, loss of pr ide or status or a feeling of weakness or deficiency whether such feelings are aggr essive, sexual or otherwise. Some recent authors (Brandchaft, 2001; Meares, 2001) have focused on the impact of disruption s in the infant and child caregiver re lationsh ip as a source of obsessive and compu lsive symptoms. In th is view, th e aggression and gu ilt described above are secondary to deve lopmental traumas from unresponsive and/or unempathic caretakers. Obsessional preoccupations re present both the experience of the in secure relationsh ips with pare nts and attempts to control the ongoing threat of loss of the attachment figure; Meares (2001) specifically re lates parental overprotectiveness to the failure of the ch ild to test adequately h is conceptions of the environ ment and reality, predisposing the child to magical th inking an d OCD.

Beh avior the rap y

many sites throughout the world attests to the effectiveness of behavior therapy (i.e., exposure and response prevention) as a treatment for OCD (see McGinn and Sanderson, 1999; Barlow, 2002; Gr iest and Baer, 2002 for a review). These and other trials, conducted to examine the efficacy of exposure and re sponse prevention, generally sh ow that between 50% and 75% of patients with obsessions and compu lsion exh ibit a substantial decrease in their symptoms, and a majority appear to maintain gains in treatment even years after they discontinue treatment (for a comprehensive and detaile d review of studies de monstrating the efficacy of behavior therapy, please see Foa et al., 1985, 1998a; Steketee, 1993b; Foa and Kozak, 1996; Abramowitz, 1997; Foa and Franklin, 2001; Gr iest and Baer, 2002). A meta-analysis by Abramowitz (1997) examin ing on ly controlled tr ials confir ms the

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Over 30 uncontrolled and controlled research tr ials conducted over

finding that combined exposure and response prevention leads to a substantial impr ovement in patients with OCD, and fin ds that the effectiveness of behavioral treatments in crease with therapistguided, direct exposure (A bramowitz, 1997). Another metaanalysis de monstrated the efficacy of behavior therapy over placebo and reported a lar ge average effect size of 1.46 for behavior therapy (van B lakom et al., 1994). In addition, a recent summar y of five studies sh owed that many patients did not meet criteria for OCD following treatment, and demon strated min imal relapse following treatment discontinuation (Steketee and Frost, 1998). Finally, pre liminary findings show that results from controlled trials appear to be generalizable to outpatient, fee-forservice settings (Kirk, 1983; Franklin et al., 2000). Overall, recent controlled trials demonstrate that beh avior therapy may be as or more effective than medication alone, and that behavior therapy is associated with a comparably lower rate of relapse (Rach man et al., 1979; Marks et al., 1980; Mawson et al., 1982). Further con firmation comes fr om a meta-analysis conducted by Abramowitz (1997) wh o found an overall advantage of behavior therapy over se lective serotonin reuptake inh ibitors in the studies reviewed. Studies also suggest that combin ing medication and behavior therapy may n ot confer a benefit over behavior therapy alone but may be more beneficial than medication alone, especially in preventing re lapse (Mar ks et al., 1988; Cottraux e t al., 1990; van Balkom et al., 1998; Simpson et al., 1999; Kozak et al., 2000).

Empiric al sup port for tre atme nts

Traditionally considered to be refractory to treatment, many treatments now effective ly treat OCD. Treatments that have demonstrated efficacy P.143 include cogn itive and behavioral therapies and serotonergic medications. Psychodynamic psychotherapy and many psychotr opic medications have not prove n effective in treatin g OCD (Kn ight, 1941; B lack, 1974; Malan, 1979; Perse, 1988) and he nce should not be con sidered first-line treatments.

An examination of the relative e fficacy of behavioral techniques for the treatment of obsessive th oughts indicates that obsessive thoughts respond pr imar ily to exposure (Mills et al., 1973; Foa et al., 1980a, 1984) and that combined in vivo and imaginal exposure appear to be superior at maintain ing long-term gains, particular ly for those patients who cognitive ly avoid their catastrophic fears (Foa et al., 1980b). E xposure appears somewhat less effective in the treatment of pure obsessionals (patients who present with obsessive ruminations but no compu lsion s) (Emme lkamp and Kwee, 1977; Stern, 1978; Kasvikis and Marks, 1988; Steketee, 1993b; Salkovskis and Kirk, 1997). However, experts be lieve that many pure obsessionals may present with covert rituals that are not classified as su ch and hence the untreated rituals may serve to hinder the treatment of obsessions (Steketee, 1993b). Efficacy studies also indicate that r itualized behaviors and thoughts respond pr imarily to response prevention (Mills et al., 1973; Foa et al., 1980b, 1984; Turner et al., 1980).

1985, 1986), especially pure obsessionals or patients without overt rituals who tend not to respond we ll to just exposure and response prevention (Salkovskis and Kirk, 1997). However, more controlled research trials are needed to determine better the effectiveness of cogn itive therapy as a treatment for OCD.

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T reatment r ation al e a nd st rate gie s

Symptoms treated with in a cogn itive-behavioral framework include the obsessive th oughts, images, impulses, or urges, and the compulsions that may take the form of ritualized thou ghts or behavior s. A lso targeted in treatment are the secondary automatic thoughts that deve lop among patients with OCD (e.g., I am a bad person for having su ch thoughts). Essentially, two pr imary goals of cogn itive-behavioral strategies are to (1) alleviate th e anxiety associated with obsessions, thereby reducing the frequ ency and persistence of these thoughts, images, impu lses, or u rges, and (2) reduce compulsions and alleviate fee lings of relief associated with compulsions. Before treatment is initiate d, detailed infor mation is obtained on the nature and exact count of the patient's external (e.g., knives) and internal (e.g., images) triggers of obsessive anxiety, catastrophic fears (e.g., my baby will die), compu lsive rituals (e.g., checks 25 times a day), and passive avoidance or escape behavior s (e.g., does not cook).

Cognit ive th er apy

A number of case reports initially suggested that cognitive therapy is an effective treatment for OCD (Salkovskis, 1983; Headland and McDonald, 1987; Salkovskis and Westbrook, 1989; Roth and Church, 1994), especially when used adjunctive ly with behavioral techniques such as exposur e and response prevention (Salkovskis and Warwick, 1985, 1986; Kearney and Silverman, 1990; Freeston, 1994). Evidence from early controlled studies con firmed that cogn itive strategies used in rational-e motive therapy are effective in reducing OCD symptoms but found that they did not confer an accrued benefit over exposure and response prevention (Emmelkamp et al., 1988; Emme lkamp an d Beens, 1991). More recently, several controlled tr ials using Beck's cognitive mode l not on ly con firmed that cogn itive strategies ar e effective in treating OCD but found that they may be as effective as behavioral strategies when used alone (Van Oppen et al., 1995; Jones and Menzies, 1998; Cottraux et al., 2001). A meta-analysis combin ing only controlled trials confir ms the finding that cogn itive strategies are at least as effective as behavioral treatments (Abramowitz, 1997). Finally, a study by Freeston et al. (1997) de monstrated that combined cognitive restructuring, exposure, and response prevention was substantially better than a wait -list control, and produced an 84% success r ate that was maintained a year later. Cognitive therapy has also been used to treat patients who are resistant to behavior therapy alone (Salkovskis and Warwick,

Psychoed ucati on
Following assessment, the first phase of treatment is in itiated where patients learn strategies to nor malize the ir obsessions and compulsions an d manage their anxiety. In psychoeducation, the patient is directly educated about the disorder, including the defin ition, demograph ics, etiology, treatment, etc. Educating patients enables them to le arn that they suffer from an illness shared by others and reduces their sense of shame about their symptoms. Se lf-help books are also prescribed to comple ment strategies learned in therapy and patients are encouraged to join organizations in order to receive ongoing education an d support.

Cognit ive restr uct urin g

Cognitive restructurin g (A. T. Beck, 1976; J. S. Beck, 1995; Salkovskis and Kirk, 1997) attempts to modify the secondary dysfunctional automatic th oughts (e.g., I am a bad person for having such thoughts) that individuals with OCD have following their obsessional images, thoughts, urges, or impulses (e.g., images of mother being stabbed). Automatic th oughts stemming

from maladaptive be liefs about responsibility and self-blame are restructured as we ll as those arising from other beliefs identified in OCD and an xiety disorde rs in general, inclu din g vu lnerability to threat, perfection ism, morality, r igidity, doubt, and un certainty (see McGinn and Sanderson, 1999 for a revie w). As th ese automatic thoughts are rigorously and continually replaced by thoughts based on empirical evidence and rational examination (e.g., imagining that my baby is stabbed does not make me a bad person, I love my baby and I cannot control all the thoughts that pass through my head), anxiety declines, and con sequently, obsession s and compu lsion s gradually lessen over time. Successfu l cogn itive restructuring P.144 leads to the modification of underlying be lie fs to reflect an appropr iate degree of responsibility, blame, vu lnerability to threat, and so on.

of anxiety as they con front low-grade ph obic situations and then ultimate ly face more anxiety-provoking stimuli.

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Respon se preve nti on

Exposure is admin istered in conjunction with response prevention (Riggs and Foa, 1993; Steketee, 1993b), wh ich attempts to block compulsions (e.g., not washing hands after touching garbage). The goal of respon se prevention is to break the association between ritualized behaviors and thoughts and the subsequent feelings of relief or reduced anxiety. Rituals are identified, patients are given a rationale for respon se pr evention, presented with specific ru les, and are generally assisted by family members to comply. A lthough many graded forms of response prevention may be administered (e.g., reducing nu mber of r ituals), the ultimate goal is complete cessation of r itual perfor mance. Strategies recently developed to help individuals engage in response prevention (e.g., response cost for performance of rituals) may also be used to facilitate response prevention (McGinn and Sanderson, 1999). If possible, response prevention begins in the first treatment session. By the end of treatment, patients are presented with guidelin es for normal behavior because many do not know what constitutes normal behavior (e.g., what amount of handwashing is appropriate). Acute treatment is discontinued when obsessions an d compulsions become in frequent and do not impair function ing. Str ategies to maintain gains and prevent relapse are implemented and treatment is slowly tapered over time.

Ex posure
During the secon d phase of treatment, exposure techn iques (Riggs and Foa, 1993; Steketee, 1993b) break the association between obsession s and an xiety by directly exposing patients to the anxiety triggers rather than by challenging the dysfunctional automatic thoughts that follow obsessions or precede rituals. Exposure may be conducted in imagination or in vivo or both, depen ding on wh ich is indicated and/or practical to implement (see McGinn and Sanderson, 1999 for a full description and indications of imaginal versus in vivo e xposure). T ypically, individuals are exposed systematically over a pr olonged period of time to in creasingly anxiety-provoking phobic stimu li (e.g., garbage) that trigger obsessive anxiety (e.g., I will die from salmonella poisoning if I take the garbage out) until their anxiety reaction is e liminated. The success of systematic exposure is attr ibuted to the fact that as patients tolerate prolon ged con frontation with anxiety triggers without trying to escape or neutralize the thought with some other thought or action, they learn that their catastroph ic fears do not occur (in this case, contact with garbage does not lead to salmonella poisoning and eventual death), and as a re sult, their anxiety associated with these obsessions u ltimately dissipates. As they become habituated to anxiety triggers (e.g., contact with garbage does n ot create anxiety), patients e xperience a reduction in obsessive thoughts. Because exposure is done in a systematic, hierarchical fash ion, patients learn to tolerate manage able leve ls

Case i llu strat ion

Miche le is a 28-year-old woman who presented with longstanding obsessive fears of becoming contaminated by germs. She washed her hands mu ltiple times a day and used gloves to attend to the simplest of household chor es. More recently, she reported developin g obsessive fears about her baby coming to h arm. Miche le began to r itualistically repeat a series of numbers (e.g., 6, 6, 6, 6, 6, 6), phrases (I repent), and images (e.g., imagined her baby playing with his toys) fair ly continuously thr oughout the day. She dropped out of graduate school during her first semester, could not leave the house without her baby, stopped cooking (I can't touch knives), an d cleaning (I feel the germs will seep into my pores). During the initial treatment session, Michele was give n a simple but detailed descr iption of OCD, including facts and figures on

demograph ics, prevalence, etiology, and so on. The cognitivebehavioral model was explained to Miche le along with a descr iption of the strategies she wou ld learn in treatment. The importance of completing in between sessions was emphasized and h er husband was identified as a co-therapist to facilitate completion of weekly assignments. Michele was prescribed Foa and Wilson's book (1991) titled Stop obsessing! How to overcome your obsessions and compulsions an d was encou raged to join the Anxiety D isorders Association of America (http://www.adaa.org) and the Obsessive Compu lsive Foundation (http://www.ocfoundation.org). Using a thought log, Miche le learned to identify and monitor secondary automatic thoughts during per iods of obsessive anxiety. Miche le learned that these habitually occurr ing though ts and images typically followed obsessional thoughts and stimuli and typically led to an xiety and the urge to r itualize. Illustrative automatic thoughts were identified such as if I eat this meat, I (or my baby) will get germs and die, the fact that I imagined my baby getting stabbed mean s that he will die unless I think of him safely playing with h is toys, or I am immoral for th inking that he is dead. It soon became e vident that these thoughts reflected her underlying dysfunctional beliefs that she was fundamentally evil, vulnerable to creating and experiencing harm, was pe rsonally responsible for any misfortune that befell her or her family and incapable of coping well du ring adversity. As her maladaptive automatic thoughts were re placed to reflect an appropriate degree of responsibility and vu lnerability to har m, and as her beliefs about her morality and ability to cope were modified through rational se lf-examination, her anxiety associated with obsessions and compu lsion s began to decline. Within a fe w weeks, Miche le's obsession s and compu lsion s became less frequent. As a result of daily practice in her own environ ment, Miche le grew adept at restructuring her cogn ition s and soon began to feel confident that she cou ld reduce her anxie ty on her own. Her list of an xiety tr iggers was n ow organ ized hierarchically from least to most an xiety provoking on a scale of 1100 (e .g., garbage, meat, knives) an d a working h ierarchy was created to reflect increasing contact (and anxiety) with each ite m (e.g., imagining touching garbage, touching garbage). Prolonged, systematic exposure was in itiated with the least anxie ty-provoking item until she habituated to it, after wh ich she was e xposed to the next item and so on. For e xample, Michele first imagined touching garbage, then touched the lid with gloves, then without gloves.

When she was successfu lly able to handle garbage u sing her bare was selected (e.g., knives) and was again organ ized hierarchically to reflect increasing contact (and anxiety) with that item (e.g., looking at a picture of a knife, imagining holding a knife, looking at a knife. As Miche le also presented with obsessive fears that could not be implemented through in vivo exposure (e .g., obsessions of baby being stabbed), she was exposed to increasingly anxiety-pr ovoking scenes in her imagination until her anxiety declined (imaginal exposure). Because Miche le could not tolerate the anxiety associated with complete ly abstain ing from rituals at the outset, a gr aded response prevention was formulated an d administered in

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hands with min imal anxiety, the next item on her over all h ierarchy

conjunction with exposure. Michele was proh ibited from performing rituals to neutralize the an xiety associated with items currently or previou sly the subject of e xposure but was permitted to ritualize to items to wh ich she had yet to be e xposed. Although Miche le was able successfu lly to tolerate exposure and was able to abstain from performing r ituals during exposure sessions, she found it difficult to conduct exposure and refrain from perfor ming r ituals at home, even with her husband's assistance. To facilitate response prevention, a weekly contingency plan was instituted wherein Michele rewarded herself for conducting exposure sessions at home (e.g., bought herself a CD) and a response cost was in stituted when she performed rituals (e.g., was not able to watch her favorite show, had to send money to a despised politician). S elf critical thoughts were also modified to reduce feelings of excessive gu ilt on the occasions she inadvertently performed r ituals. Miche le's overall mood improved as her anxiety began to decline. As Michele's obsessions an d compu lsions declined to manageable leve ls and she was able to go about her daily life with min imal impairment, sessions now focused on helping her main tain gains and prevent relapse. For example, Michele was encou raged to take charge of her continued treatment with less P.145 and less gu idan ce from the therapist, understand the difference between symptom recurrence and relapse, learn how to cope with symptom recurrence, and encouraged to pursue new activities to fill in the long gaps of time that she had previously spent performing her r ituals. Sessions were tapered down to biweekly,

and then month ly sessions and so on as Miche le learned to manage her symptoms on her own. Miche le was encouraged to identify stressors that led to increased symptoms and contact the therapist if she exper ienced a resurgence in between sessions.

through her schoolwork she felt that he still rejected h er. Her that she had to take care of her mother rather than receive maternal comfort. Furthering her problems, social unr est in her country of origin forced th e family to move to the US when she was age 11. Thus she had to cope with the loss of fr ie nds and her home, and adapt to a strange new environment, a task that she found at times to be overwhelming.

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mother was an anxious and preoccupied woman, an d Linda believed

Psychodyn am ic tre atment o f ob ses si vecompuls ive diso rd er

Although with our present state of knowledge treatment of severe OCD should be pr imarily psychopharmacological or cognitivebehavioral (Stein, 2002), psychodynamic approaches can provide additional understanding and in sights into the illness, particular ly in milder or more moderate for ms (Gabbard, 2000, 2001). Patients may benefit from explor ing the meanings and defensive functions of obsessions and compu lsions. Shame or embarrassment about symptoms and the fantasie s associated with them can interfere with treatment. The atmosphere of safety with the therapist and the therapist's nonjudgmental exploratory stance can aid the patient in easing h is intense self-cr iticisms and more openly discussing his symptoms. Identifying and reducing these sources of resistance to treatment can also in crease complian ce with medication and CBT. OCD symptoms are h igh ly disruptive of relationships; proble matic interactions with others secondary to the symptoms can be produ ctively examined in the transference countertranserence work of the therapy (Gabbard, 2000, 2001).

The therapy explored the many functions of Linda's symptoms. She and her therapist noted that her feelings of helplessness and uncertainty that were triggered by the loss of her job reminded her of the upheaval she experienced when she had to leave her home as a ch ild. The checking behavior was a coping mechanism to control these feelings of he lplessness, by displacing them to potential fantasied disasters (fire, burglary) that she could avert by her r ituals. In addition, Linda fe lt deeply threatened by her growing ties to her boyfrie nd and possible marr iage. In particu lar, she felt certain at times that he wou ld reject her once she committed to him, just as her father rejected her despite her efforts. She attempted to ward off this expected disaster with her rituals as we ll with horoscope checking, wh ich focused on whether others with her sign were h aving proble ms with re lationships. Helping Linda to understand the or igins of her fears and the function of her obsessions and compu lsion s aided in the further reduction of her symptoms. In particu lar, he lping her to tolerate her feelings of he lplessness, and linkin g them to the anxiety and frustration of her childhood traumas, led her to feel le ss threatened by her current life challenges.

Case ex am ple
Linda was a 40-year-old single woman who presented with mu ltiple rituals and obsessional thoughts for many years that had become disruptive of her daily routine in the preceding 3 mon ths. These included knocking on wood, checking the stove and locks, and being preoccupied with Zodiac signs to tr y to gain information as to whether something terrible was about to happen to her, spending about an hour a day on these r ituals. In addition, Linda felt threatened by a very close relationsh ip with her boyfr iend, fearful of his betraying and rejecting her despite h is e xpressing interest in marrying her. She had lost her job 4 months pr ior to presentation, apparently u nrelated to her OCD symptoms, and was concerned about finding a new one. A lthough sertraline provided some re lief, her symptoms continued at a reduced level and her fears about her boyfriend persisted. Linda reported a difficult childhood with a father whom she experienced as neglectful or only interested her academic achievement. A lthough she made many efforts to gain his affection

Socia l anx iety di s order DSM -IV defi nitio n

The hallmark feature of SAD (for merly social phobia) is excessive and persistent anxiety (or panic attacks) in situations in wh ich the person is exposed to unfamiliar people or subjected to scrutiny by others wh ile performing specific tasks (e.g., public speaking, eating in a restaurant). Such in dividuals fear that they will act in a way (or display visible anxiety symptoms) that will be humiliating or embarrassing. DSM-IV (APA, 1994) require that individuals recogn ize that their fears are excessive or unreasonable. According to the DSM, exposure to the feared social situation almost invar iably provokes anxiety and hence these situations are avoided or e ndured with dread. As a re sult, these

symptoms create significan t distress and impair ment in functioning. In dividuals with SAD suffer fr om extreme lone liness and isolation and report impair ment in social, occupational, marital, and other spheres of the ir life. Commonly feared situations include formal speaking or interactions (70%), informal speaking or interactions (46%), problems with assertion (31%), and be ing observed by others (22%) (Holt et al., 1992). In dividuals with SA D may fear one or two specific social situations such as public speaking, but the vast majority present with evaluative fears in mu ltiple social situations. Fin ally, a small proportion of individuals fe ar almost any social contact with others and if such broad-based fe ars are present, the individual is classified as having Generalized Social An xiety D isorder (APA, 1994).

Treatment forms utilized over the course of treatment included the automatic and revised thou ght log, the imaginal and in vivo exposure form, and the exposure mon itor ing for m (McGinn and Sanderson, 1999; Leahy an d Holland, 2000).

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Cognitiv e-beh avio ral mode ls of soc i al anx i ety disor der Beh avior al mod els
In explain ing how social anxiety may be acqu ired and maintained, Mowrer's two-stage theory proposes that direct exper ience with a traumatic P.146 experience (e.g., a socially embarrassing interaction) (UCS) that naturally e licits an xiety (UCR) may lead to the de velopment of social anxiety via classical condition ing. According to this model, anxiety becomes conditione d to social situations (neutral stimu li) via association with the in itial traumatic social situation (UCS). Hence, these social situations (now CS) become capable of producing fear on their own. Through higher-order condition ing and stimu lus generalization , the number of social cues that lead to anxiety increases over time, and thereby creates sign ificant impairment over time. In explain ing the maintenance of social anxiety, th is mode l suggests that avoidance of social situations perpetuates social anxiety in the long run. B y avoiding social situations, individuals experience a temporary reduction in anxiety, wh ich serves to reinforce the avoidance be havior. However, this avoidance prevents them from learn ing that negative social consequences do not always occur, and hence their fears continue unabated. In other words, by avoiding the social situat ions, individuals with social anxiety fail to realize that the CS (social situations) is no longer paired with the UCS (initial traumatic social situation) and hence the fears do not get extingu ished. Current behavioral models of social an xiety suggest that social fears may be the resu lt of an evolutionarily determined preparedness to associate fear with anger, cr iticism, r ejection, or other means of social disapproval, wh ich have important implications for the survival of the organism (Se ligman, 1971; Barlow, 2002). However, biological and psychological vulnerabilities are cited as necessary predisposing factors in the development of SAD. Conte mporary mode ls also recognize that

Diag nostic an d ass essme nt me as ures

SAD may be diagnosed usin g semistructured clinical in terviews such as the Structured Inte rvie w for the DSM (SCID-P; Spitzer et al., 1987) or the Anxiety D isorders Interview Schedule (ADIS-IV ) (DiNardo and Bar low, 1988; D iNardo et al., 1993). These interviews also help clin icians rule out other disor ders that may explain the presenting symptoms and ru le in other disorders that may co-occur with SAD. Th e Fear of Negative E valuation Scale (FNE ) and the Social Avoidance and Distress Scale (SADS) may be used in conjunction with diagnostic tools to measure concerns with social-evaluative threat an d distress and avoidance in situations (D. Watson and Fr iend, 1969). The Le ibowitz Social An xiety Scale (LSAS) is a newer scale and is wide ly used to assess the range of performance and social difficu lties experienced by individuals with social anxiety (Liebowitz, 1987). Behavioral assessment tests are also frequently used. Such tests typically ask individu als to roleplay a social situation (e.g., give a speech or con verse with a stranger) wh ile the therapist monitors their discomfor t leve l on several indices, including their subjective rating of distress, as well as behavioral (e.g., speed of performance), and psychophysiological (e.g., heart rate is monitored) measures. The BAI (A. T. Beck et al., 1988a) may also be used to measure general anxiety leve ls and given the high rate of depr ession among individuals with social anxiety, the BDI (A. T. Beck et al., 1988b) is often admin istered. The Sheehan Disability Scale (Leon et al., 1992) may also be used to assess the degree to wh ich the symptoms are interfering with the patient's function in g.

social anxiety may develop via mu ltiple routes (Bar low, 2002). For example, Bar low su ggests that for vulnerable people, relatively minor negative social or pe rformance situations may also lead to anxiety. Further, alth ough research suggests that many individuals link their on set to an in itial trau matic event, a sign ificant proportion implicate recall vicarious learning exper iences in the development of the ir anxie ty (Ost and Hugdah l, 1981).

impressions they are creating on others, underestimate their own performance, overestimate the degree to wh ich the ir anxiety is visible, and tend to interpret negative ly ambiguous social situations (Stopa and C lark, 1993, 2000; C lark and Wells, 1995; Heimberg and Ju ster, 1995; Leary and Kowalski, 1995; Rapee,

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1995; We lls et al., 1998; Wells and Papageorgiou, 1999). Research also suggests that such individuals tend to interpret catastrophically mild negative feedback, are more like ly to remember negative feedback and will be more likely to respond to treatment if the fear of negative evaluation is modified.

Cognit ive mo del s

Contemporary mode ls emphasize the role of cogn itive processes in the development and maintenance of SAD and note th at the hallmar k symptom of SAD, the fear of negative evaluation, is itse lf a cogn itive feature (Heimberg and Barlow, 1991; Butler and We lls, 1995; Clar k and We lls, 1995; Barlow, 2002). Cogn itive mode ls propose that social anxiety is maintained by dysfunctional th inking and biased information processing. Specifically, this mode ls suggest that individuals with SAD believe they are in danger of revealing anxiety symptoms or behaving ineptly, and that such behavior will have disastrous consequences in terms of loss of status, loss of worth, and r ejection (C lark and Wells, 1995; Rapee and Heimberg, 1997; Turk et al., 2001). Dysfunctional assumption s underlying such cogn itions include perfection istic standards of performance and an excessive need for approval and typical core be lie fs include self-schemas of incompetence or undesirability and be liefs that others are inherently critical and evaluative (Leahy and Holland, 2000; Turk et al., 2001). Such dysfunctional be lie fs are perpetuated because individuals with SAD disregard or overlook positive feedback, avoid social situations altogether or use safety-se eking behaviors to reduce their anxiety, thereby preventing disconfirmation of negative be liefs. In addition, cogn itive mode ls have emphasized the role of se lf-focused attention in the maintenance of social anxiety. A ccording to th is mode l, individuals with social anxiety are not focused on external events such as the task at hand or an on going conver sation and instead, are more like ly to imagine what others are thinking of them or how they look and sound to others. In a se lf-fulfilling prophecy, th is se lf-focused attention leads to poorer social performance and increases the like lihood of negative appraisals by observers. The cognitive mode l has received empir ical support fr om several experimental studies. Rese arch studies have demonstr ated that individuals with SAD report more negative and fe wer positive thoughts durin g social inte ractions, more thoughts about the

Empiric al sup port for cogn itive-b eh a vior thera py

Prior to the introduction of social phobia into the diagnostic nomenclature, few studies examined the efficacy of psychotherapy treatments for th is condition. Since its introduction in to the DSMIII (APA, 1980), nu merous studies have been undertaken to determine the efficacy of psychotherapy treatments for SAD. A growing body of e vidence now suggests that cognitive-behavioral treatments are efficacious in treating SAD and have be en found to be superior to waiting-list conditions (see Hope et al., 1993; for a complete review, Taylor, 1996; Turk et al., 2002). Studies have also found that the effects of CBT are maintained in th e long run, even for per iods up to 5 ye ars following therapy discontinuation.

Beh avior the rap y

Exposure is considered to be the essential ingredient in all an xiety disorders, including SAD. Numerous studies demon strate that exposure alone is an effective treatment for SAD (Fava et al., 1989) and that its effects are superior to progressive muscle relaxation (PMR) trainin g (Alstroem, 1984; A l-Kubaisy et al., 1992), pill placebo (Turner et al., 1994), wait-list con trol (Butler et al., 1984; Newman et al., 1994), and a control therapy comprising of psychoeducation, se lf-exposure instructions, and unspecified anxiolytic mediation (Alstroem, 1984).

Cognit ive th er apy

Different forms of cogn itive therapy includin g Beck's cogn itive therapy, Ellis's rational emotive therapy, and Meichenbaum's se lfinstructional train ing have demonstrated efficacy in th e treatment of SAD (see Coles et al., 2002 for a review). It is n oted, however, that with fe w exception s, most cognitive therapies in clude behavioral techniques such as behavioral experiments and

exposure and hence are not a pure test of cogn itive r estructuring (Juster and He imberg, 1995). Further, it is unclear if cogn itive therapy adds efficacy beyond the effects of exposure alone (Hope et al., 1993; Turk et al., 2002). However, because the fear of negative evaluation, the hallmark of social ph obia, is essentially a cogn itive construct, several researchers believe that cognitive interventions may play a more important role in the treatment of SAD than in other anxiety disorders (Butler, 1989). Further, in light of studies that show that exposure alone has n o substantial impact on the fear of negative evaluation (Butler et al., 1984) and that fear of negative evaluation has a stron g relationsh ip to treatment outcome ( Mattick and Peters, 1988; Mattick et al., 1989), it suggests that altering distorted thoughts re lated to these fears may be sign ificantly related to treatment outcome. Finally, some research suggests that, although e xposure plus cogn itive restructuring does not increase efficacy of treatment above and beyond exposure alone, the combined treatment is associated with lower relapse rates once treatment is discontin ued, suggesting that the addition of cogn itive restructuring may be pr otective in the long run (Heimberg and Juster, 1995).

being critical and rejecting. Avoidance adds to difficulties in developin g coping strategie s. As with panic patients, in patients with social phobia, anger is threatening due to fears of rejection by important attachment figures. For social phobics, anger and disdain for others are typically denied and projected on to others in order to avoid acknowledging these fee lings (Gabbard, 1992; Zerbe, 1994). However, with this projection, the patient views others as critical and rejecting of h im, tr iggering social anxiety. Additionally, patients experience gu ilt about their anger at others for bein g critical or rejecting, and for their own aggressive yet denied wishes for attention. Social anxiety can serve as a pu nish ment for this guilt. In addition to conflicts with the experience of anger, social ph obic patients struggle with inte nse feelings of inadequacy. Alon gside their low se lf-esteem, they can deve lop a compensatory grandiosity, with fantasies of others being very responsive or adoring of their specialness (Kaplan, 1972). Th is is typically associated with a desire to exhibit onese lf sexually (Fenichel, 1945), which must be denied. This grandiosity adds to the recurrent disappointments that these patients exper ience in social situations, and may intensify the pain and anger they experience in response to rejection. As with other psychological symptoms, from a psychodynamic

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Psychodyn am ic m odel of soc ia l p ho bia

There are clin ical and psychodynamic similarities between panic disorder and social phobia. Clin ically, social phobia sh ares the symptoms of anticipatory anxiety, pan ic-like symptoms, or panic attacks in feared situations, and phobic avoidance of feared situations. In addition, the two disorders may share a similar neurophysiological vu lnerability, as behavioral inh ibition descr ibed by Kagan et al. (1990) is associated with social phobia as well as panic disorder. Parents of children with behavioral in hibition have been found to be at greater risk for the deve lopment of anxiety disorders, particu lar ly social phobia (Rosenbaum et al., 1991a,b). P.147

vie w, social phobia also re presents a compromise for mation. Social phobics are conflicted abou t the wish to exh ibit themselves sexually, and social anxiety is both an e xpression of the conflict, and a pun ish ment for the wish. Avoidance of social situations aids in avoidance of the conscious experience of these wishes. Similar ly, anxiety and avoidance punishes the individual for angry feelings an d fantasies. Efforts at idealization of self or others attempt to ward off painfu l feelings of low self-esteem but then add to the potential for disappointment.

Psychodyn am ic tre atment o f soc ia l p hobi a

The therapist mu st be particular ly alert to the patient's shame ful feelings in treatment of social phobia. The patient may anticipate that the therapist will be as critical and rejecting of h im as he expects others will be. This can be used as an opportunity to explore an early transference reaction to the therapist and to examine the patient's fantasies that he experiences as conflicted. In particu lar, angry fantasies and exh ibition istic wishes may emerge. The therapist explores the patient's fears upon entering a

Whether through physiological predisposition, developmental stressors, traumatic experiences, or a combination of these factors, these patients typically have internalized repr esentations of parents, caretakers, or siblings who shame, cr iticize, ridicu le, humiliate, abandon, and embarrass them. These perceptions are established ear ly in life an d then are repeatedly pr ojected on to persons in the environment who are avoided, for fear of the ir

social setting, and why the patient may have difficu lty confronting these fears. This inqu iry will often aid or encourage th e patient to confront h is social anxiety directly.

relapse rates (Feske an d C hambless, 1995; Taylor, 1996; Gou ld et al., 1997). Further, dismantling studies suggest that e xposure alone is at least as effective as exposure plus cogn itive restructuring (Hope et al., 1995).

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Cognit ive-be hav io r the rapy

An extensive body of research supports the efficacy of combin ing cogn itive restructuring and exposure. These studies show that CBT is more effective than waiting-list control groups (Kan ter and Goldfr ied, 1979; Butler et al., 1984; D iGiuseppe et al., 1990; Hope et al., 1995), an education al-supportive control therapy (Heimberg et al., 1990, 1993, 1998; Lucas and Te lch, 1993), an d pill placebo (Heimberg et al., 1998). T o date, Heimberg's Cognitive-behavioral Group Therapy (CBGT) for SAD has received the widest empir ical support and is included in a list of empirically suppor ted treatments by the Society of C linical Psychology's (D ivision 12 of the American Psych ological Association) Task Force on Promotion and Dissemination of Psych ological Pr ocedures (He imberg et al., 1990; Chambless et al., 1998). A nu mber of well-designed studies demonstrate that CBGT is e fficacious in the treatment of SAD (Gelernter et al., 1991; Heimberg et al., 1985, 1990, 1998; Heimberg et al., 1993). Th ese studies demonstrate that the CBGT is comparable with medications, such as phenelzine, and superior to other treatments such as an educational-supportive group psychotherapy and pill placebo (Lu cas and Telch, 1993; Heimberg et al., 1998). Group and in dividual version of treatment do not appear to var y with regard to efficacy (Lucas and Telch, 1993). Social effectiveness therapy, another combined treatment that combines social skills train ing an d exposure, has also received empirical support but has n ot yet met required criter ia for place ment on the list of empir ically supported treatme nts (Turner et al., 1994, 1996). Some studies show that combin ing exposure and cogn itive restructuring is more effective than e ither treatment alone (Butler et al., 1984; Mattick and Peters, 1988) wh ile others show that combin ing treatments does not add to the efficacy of exposure alone (Butler et al., 1984; Hope et al., 1995; Taylor, 1996). Further, a number of review articles and meta-analyses demonstrate that CBT is not more effective than exposure alone (Feske and Chambless, 1995; Taylor, 1996; Turner et al., 1996; Gould et al., 1997). Meta-analytic reviews suggest that exposure is associated with the largest effect sizes and that exposure alone and exposure combined with cogn itive restructurin g ar e not significantly different with regard to effect sizes, drop out or

T reatment pl an an d str ategi es

The goal of cogn itive-behavioral strategies is to alleviate the anxiety and avoidance beh aviors associated with the social or performance situations. When possible, group treatme nt is the format of choice for patients with social anxiety because it is costeffective, gives participants the opportunity to learn vicariously, see others with similar proble ms, and make a public commitment to change (Sank and Shaffer, 1984; Heimberg, 1991). Group treatment also provides th e opportun ity for mu ltiple r ole-play partners and a range of pe ople to provide e vidence to challenge distorted thoughts (Sank and Shaffer, 1984; Heimberg, 1991). Treatment is in itiated on ce the therapist has establish ed the diagn osis of social anxiety and assessed the extent to wh ich symptoms create distress and impair function ing. The therapist identifies key cogn itive, behavioral, and ph ysical symptoms of anxiety, lists all the social situations that patients endure with dread or avoid altogether along with the safety-seekin g behaviors they employ to cope with their anxiety in social situations.

Psychoed ucati on
During the psychoeducation phase, which typically takes one session to complete, the goal is to provide infor mation about SAD, correct myths, and foster optimism. Toward this end, the therapist discusses the nature and evolutionary function of social an xiety, educates the patient on symptoms, demograph ics, an d etiology of SAD and outlines the various treatments that have de monstrated efficacy in remediating symptoms. Finally, the therapist presents the cognitive-behavioral model of treatment and provides a br ief overview of the different components of treatment.

Relax ation tr ain in g

Relaxation train ing is e mployed when hyperarousal is a prominent feature in the patient's symptomatology. The goal of relaxation training is to decrease h yperarousal and regulate bre athing in individuals with social anxiety to he lp them stay calm and focused during social encounters. PMR is used to reduce the physiological components of anxiety and is based on the Jacobson ian technique of alternating muscle contr action and re laxation (Bernstein and Borkovec, 1973; Brown et al., 2001). Patients are trained to

discr iminate between muscle tension and relaxation an d the goal of discr imination train ing is to facilitate rapid re laxation to individual mu scle groups by enablin g patients to detect sources and early signs of muscle tension and substitute the learned relaxation response. Once the patient has mastered PMR using all muscle gr oups (typically over a span of 2 weeks), re laxation exercises are shortened to key muscle gr oups and strategies su ch as relaxation-by-recall and cue-controlled re laxation are used to generalize effects to proble matic social situation s (see McGinn and Sanderson, 1999, for a review). Like PMR, breathin g retrain ing is used to reduce the somatic component of anxiety. S pecifically, patients learn diaphragmatic breathing to counteract P.148 the shallow, irregu lar, and rapid breathing patterns often exhibited by individuals under anxiety or stress. The latter is ch aracterized by the use of chest mu scle s (thoracic breathing) and is associated with an increase in respiration rate (hyperventilation). By contrast, in abdominal or diaphragmatic breath ing, th e process of breathing is even and nonconstricting, as the inhaled air (oxygen) is drawn deep into the lungs and exhaled (carbon dioxide) as the diaphragm constr icts and e xpands. This type of breathing in volves move ment in and out of th e abdominal rather than the chest muscles, and allows for the most efficient exchange of oxygen and carbon dioxide with the least effort (see Sch wartz, 1987, for a complete description). Breathing retrain ing is be lieve d to reduce respiration rate and cause changes in autonomic function ing, thereby leading to overall relaxation (Clark et al., 1985).

Cognitive restructurin g may be particu lar ly usefu l for patients who do not exhibit behaviora l a voidance of feared situations. Such individuals may use cognitive maneuvers to avoid anxiety (e.g., distract themselves, withdr aw into the mselves) thus preventing the experience of fu ll-blown anxiety during social or performance tasks. Others may distort social or performance encou nters (e.g., see them as unsuccessful ) despite objective evidence to the contrary.

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Attentio n r efocus
As attention is often disrupted in individuals with social an xiety, attention strengthening an d refocusing exercises are also utilized to help patients refocus th eir attention on the task at hand instead of on the mental representation of how they appear to others, and away from the expected negative feedback they expect from others. The goal of these e xercises is to he lp patients refocus attention on the task at hand (e.g., a conversation with a stranger), wh ich is be lieve d to lead to better performance and an increased like lihood of positive feedback from others. Patients are taught to sustain the ir attention by practicing tasks requir ing concentration such as reading in creasingly complex materials over increasing lengths of time. Next, patients learn to practice the task with an increasing list of distractions. Finally, patients apply attention strengthening exercises to social or perfor mance situations and are encouraged to focus attention on the other person or the social task at hand. With in creasing awareness, patients learn how to refocus attention on the task even if attention habitually comes back to the se lf.

Socia l sk ill s tr ai ni ng
Social skills training is e mployed only if individuals demonstrate social skills deficits. Goals during th is phase include creating an awareness of the social envir onment, and enhancing interpersonal and/or presentation skills as needed. The process of skills train ing includes in itial instruction on the skill and subsequent demonstration of the skill by the therapist. After the therapist teaches and models the required behaviors, the client is typically asked to rehearse the behavior dur ing the session following wh ich corrective feedback and positive reinforcement are offered until the individual has mastered the required skill. Flexibility exercises are also used to address th e rigid behavioral style common to individuals with social anxiety.

Cognit ive restr uct urin g

Typically, cognitive restructuring is used in conjunction with exposure exercises in the treatment of SAD. Goals include modifying negative cogn itions about the self (e.g., defectiveness, undesirability), modifying unrealistic standards of pe rformance (e.g., perfectionism), and modifying view of others as extremely evaluative and cr itical. Automatic thoughts regarding feared and avoided situations are elicited, cogn itive distortions are identified, and rational responses are developed before in dividuals engage in simu lated or actual in vivo exercises. Then, individuals are instructed to use cogn itive restructuring techniques be fore, during, an d after each exposure exercises in or der to facilitate exposure tasks.

Systemat ic ex po su re

The goal of systematic exposure includes breaking th e association between social situations and fear and breaking the association between escape and avoidance of social situations and subsequent feelings of relief. Exposure may be conducted in imagination (imaginal exposure), directly dur ing social situation s (in vivo) or in 510-minute role-plays of anxiety-provoking situations dur ing treatment sessions (simu lated exposure). In a group format, other group members serve as r ole-play partners in addition to the therapist. Outside actor s may also be brought in to serve as roleplay partners in both individual and group formats. Pr ops may be used to make the simu lated exposures as realistic as possible. For example, a patient may be required to stand at a podium while giving a talk or food may be brought in if a patient has a fear of eating in pu blic. Anxiety-provoking situations using exposure exercises are based on fear and avoidance h ier archies that contain rank-ordered situations rated for fear, avoidance, and fear of negative evaluation by others. These can range from in itiating a conversation with a stranger to giving a presentation at a staff meeting. Nonperfectionistic, behavioral goals shou ld be set for exposure tasks wh ich may require some negotiation as pat ients with social anxiety tend to have unrealistic or unmeasurable goals (e.g., I should feel no anxiety, or I should be responsible for filling in all the pauses in a conversation) (He imberg, 1991). During exposure, anxiety levels and automatic though ts are mon itored per iodically and the exposure task is continued until the anxiety decreases or plateaus and the goal(s) have be en met. The patient's perfor mance and anxiety level, as we ll as th e automatic thoughts and rational responses used during exposure are then discussed, with the goal of identifying self-statements that increase their an xiety and those that decrease it to facilitate future performance. Individuals are not permitted to use escape or avoid behaviors during exposure in order to prevent the anxiety from reducin g prematurely. Subtle avoidance behavior s such as distraction or safety-seeking behaviors are also e liminated. Although in vivo exposure is descr ibed as the treatme nt of choice for anxiety disorders in ge neral (Bar low and Beck, 1984), simu lated exposure techniques form an important part of treatment for social anxiety for multiple reason s (He imberg, 1991). One reason is becau se in vivo exposure exercises are harder to design and imple ment in the treatment of social anxiety. Unlike simple exposure exe rcises such as driving over a bridge for

a panic disorder patient, patients with social anxiety must perform a complex sequence of inte rpersonal behaviors during the phobic situation, an d expose themselves to a var iety of feared interpersonal consequences. In vivo exposure are not only more complicated but are also le ss easily available to socially anxious patients who may have cut themselves off from most social contacts. Because social situations are intr insically u npredictable,

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it is also harder to design in vivo exercises in advance , and harder to ensure that patients repeat the same social situation or expose themselves to easier situations before difficult ones. Finally, the success of in vivo exposure usually comes from prolon ged exposure to the feared situation, wh ich leads to habituation of anxiety. Because several social or performance situations involve a brief exchange, patients with anxiety cannot remain in the situation until the anxiety peaks and then reduces. However, in order to facilitate transfer-of-train ing to real-life social or performance situations, in vivo e xposure exercises are generally assigned to patients dur ing each session. Specific homework assignments are negotiated with patients and are coordinated with simu lated exposure tasks conducted dur ing sessions. Typical exposure situations inclu de initiating or maintain ing a conversation with me mbers of the same or opposite sex, asking for a date, wr iting, eating, dr inking, working or playing while being observed, assertion and interaction with authority figu res, job interviews, participating in small or large groups, par ties, meetings, and public speaking. Other exposure situations include join ing ongoing con versations, giving and rece iving compliments, making mistakes in front of others, revealing personal in formation, expressin g opin ions, and drawing attention in front of a crowd. Acute treatment is discontinued when social anxiety is sign ificantly reduced and does not impair function ing. Strategies to maintain gains and prevent re lapse are implemented and treatment is slowly tapered over time.

Case i llu strat ion

James is a 32-year-old computer analyst who descr ibe d his social anxiety as a curse passed down from generations. He recalled that he was shy as a child P.149 and never spoke up in class. He remembers rejecting a var iety of career option s including his dream to become a musician. He feels that he was trapped beh ind what he called an in visible barrier

and feels that he never allowed people to see his true personality. A lthough he is attractive, James was afraid of dating and had never had a mean ingful relationsh ip until he was actively pursued by a woman wh om he ultimately married. He decided to begin treatment after he was promoted to the position of a manager. He in itially turned down the position but after he read an article on SAD in Time magazine, James decided to accept the new position and pursue treatment. Although James had begun the process of reading on S AD, the psychoedu cation phase re in forced h is growing understanding of his condition. Realizing that he had a disorder that cou ld be treated effectively qu ickly reduced the symptoms of depression he had been experiencing for the past 2 years. He began to fe el optimistic that he could be he lped an d expressed an eagerness to continue with treatment. James was assigned se lf-help books su ch as Ronald Rapee's Overcoming shyness and social ph obia (1998) and was encouraged to join the Anxiety D isorders Association of American (http://www.adaa.org). James reported that he had been experiencing increased physical tension as he had accepted the new position. To combat these symptoms, he was taught deep muscle re laxation and breathing retraining and was instructed to practice exercises daily. As he mastered the exercises over the next few weeks, James was encouraged to use them as and when he needed before he faced anxiety-provoking situation s. Although James had many social or perfor mance-base d situations that triggered anxiety, h is decision to accept the promotion at work necessitated a focus on interpersonal situations at work related to h is new position. Using a thought log, James learned to identify and mon itor automatic thoughts dur ing periods of social anxiety at work or in anticipation of social encounters in his new position. Representative au tomatic thou ghts were iden tified such as he will th ink I am stupid, I am goin g to mess up, they will be able to see that I am ne rvous, they will be waitin g for me t o fall on my face, they won' t listen to me, and I will not be able to cope with the stress of this ne w job. Once James was able to identify h is own automatic thoughts, he was encouraged through guided discovery and Socratic question ing to con sider the fact that he did not know for sure what others were thin kin g, and to he lp broaden his perceptions away from the most catastrophic prediction s (e.g., he may n ot notice that I am nervous, she may be thinking that I am better than the previous manager). His

perfection istic standards of performance (e.g., I cann ot expect belief that others were cr itical and evaluative (e.g., she will think I am a loser) were also modified. Within a fe w weeks, James grew skilled at identifyin g and challenging h is automatic thoughts using Socratic question ing. A s a result of daily practice, he began to

22

that I will be able to be an effective manager immediately) and h is

notice a reduction in anxiety, particu lar ly during moments when he anticipated social encounters at work. Using a fear and avoidan ce hierarchy, the therapist and James identified key interpersonal situations that he wou ld face in his new position. Key situation s such as interfacing with clients and his team at wor k in h is new position were transfor med into specific, behavioral tasks such as meeting clients face to face, calling clients on the te lephone, holdin g a meeting with his staff, asking h is staff to condu ct tasks, an d so on. Once these tasks were rated it became clear that even the smallest task (e.g., calling clients on the telephone) was creatin g more th an a moderate level of anxiety (e.g., over 50 on a scale of 1100). Consequently, imaginal exposure and anxiety provokin g tasks unrelated to h is place of e mployment were first used in in itial exposure sessions. For example, James practiced exposure with tasks such as asking stran gers for the time (30) for directions (35), asking acquaintances for simple favors (40), imagin ing talking to clients on the te lephone (45) before he con fronted more anxiety-provoking tasks at work. In addition, other exposure tasks such as mispronouncing a word in front of others (60) and slipping and falling in front of strangers (75) were used later on in the hierarchy to help James learn that he was capable of coping even if he did place h imself in a position where negative e valuation might occur. B y integrating cogn itive restructur ing into exposure, James was able to ackn owledge that he cou ld not expect to become a skilled manager r ightaway and consequently, was able to set nonperfection istic goals du ring exposure. S imulated exposure exercises were also used with the therapist and James role -playing key situations. For example, other individuals were bought in to the session to simu late wor k meetings during an exposure session. As James did not possess leadership skills, exposure sessions were often preceded by sessions where requisite skills were practiced during sessions through instruction, modeling, behavior rehearsal, corrective feedback, and positive rein forcement. James was also assigned to read books on leadership and effective commun ication strategies in the workplace . Finally, to refocus h is attention on

conversations with clients and staff instead of on how he appeared to them, James was taught attention refocusing exercises. He was required to read in creasing long and complex articles on computer programming, first under optimal conditions such as in his home after his wife went to bed, and then under increasingly distracting situations such as with mu sic on, in the subway and so on. Finally, James learned to become aware of situations in wh ich his attention wandered away from the task at hand (e.g., a conversation with a client) and learned to apply the new skills to refocus his attention away from the mental repr esentation of h imself and towards the task at hand. James was encouraged to u se cogn itive restructur ing before and after exposure situations to ensure that his fear of ne gative evaluation changed as a result of successfu l exposure . He was also encouraged to use exposur e situations as behavioral experiments in wh ich to test out irrational predictions. James was also encouraged to continue using daily re laxation exercises but was not permitted to use them during exposure sessions, in order to prevent his anxiety from reducing artificially. He practiced social and attention skills prior to exposure and soon began to feel less anxiou s, more confident about his ability to handle h is new job and his ability to cope with his symptoms. As his symptoms reduced and he was able to perfor m effectively at work, other social and performance situations were targeted in treatment. Acute treatment was discontinued once h is overall symptoms reduced to manageable leve ls, his social fu nction ing was no longer impaired, and he was able to gu ide h is own treatment. Strategies to maintain gain and prevent relapse now became the focus of treatment and session were tapered to monthly sessions until James was able to manage on his own.

is that the situation may e licit a pan ic attack. The lifetime prevalence of pan ic disorder is 1.53.8%, with female s twice as like ly to man ifest this disorder. Age of onset for pan ic disorder with agoraphobia is in the early twenties.

23

Evalu ation
Panic disorder is distingu ished from SAD in that in SA D the main fear is that others will see the individual's an xiety an d that this will be a humiliatin g exper ience. Panic disorder is distingu ished from OCD in that in OCD the main fear is of making mistakes or being contaminated or leaving something undonerather than the fear of the consequences of one's own anxiety, as is characteristic of pan ic disorder. A lthough in the general popu lation there are many individuals who man ifest agoraphobia without prior h istory P.150 of pan ic disorder, it is individuals with both pan ic disorder and agoraphobia who are more like ly seek treatment. People with pan ic disorder and agoraphobia are 18 times more like ly to tr y to commit su icide than people without any psych iatr ic disorder (Weissman et al., 1989) and are more like ly to have an increased r isk of cardiovascular disease, including an eurysm, congestive heart failure, and pu lmonary embolism (Coryell et al., 1982, 1986). These people eventually have a risk of stroke that is twice the rate for other psych iatric disorders (We issman et al., 1990; McNally, 1994).

T heoretic al mode l s
Many of the situations that are feared by the agoraph obic are situations that might con fer greater danger in an evolutionary adaptive environment (Leahy and Holland, 2000). For example, situations that might elicit panic attacks are open spaces (greater vulnerability to predators), closed spaces (vu lnerability to suffocation or bein g trappe d), bright sun light (more visible to predators), and heights (danger of falling). A lthough the fear in panic disorder is of the con sequences of one's own an xiety symptoms (that is, the fear of going insane, losing control, or a medical cr isis) it may be that this fear of fearelicited in these specific situations was adaptive to primitive ancestors. There is a reasonably h igh heritability component for pan ic disorder, suggestin g a genetic lin k of some importance. The cognitive-behavioral th eoretical mode l is der ived from the work of A. T. Beck et al. (1985), C lark (1986), and Barlow (1988).

Panic di sord er and ago rap hobi a Diag nostic fe ature s

Panic disorder is defined by the occurrence of pan ic attacks, wh ich are marked by intense physical sensations (heart palpitations, shakiness, sweating, shortness of breath, sensation of choking, chest pain, nausea, dizzine ss, feelings of detachment or unreality (depersonalization or derealization), fear of losing con trol or goin g insane, fear of a medical cr isis (e.g., heart attack), nu mbness or tingling, and hot or cold flashes (APA, DSM IV)). Agoraphobia is characterized by fear of open spaces, places where exit is blocked or other stimu li (such as h eights, bright sun light), wh ere the fear

The initial physiological ar ousalrapid breathing, dizziness, or sweatin gmay, in some cases, be due to greater exertion, fatigue, undiagnosed illness, life stressorsthat are often underestimated by the pan icker. This in itial pan ic attack is accompanied by a catastrophic interpretation I am going crazyleadin g to hypervigilance for other signs of anxiou s arousal. This increased self-focus on one's own arousal in creases the likelihood of arousal being detected or escalate dleading to false confirmations that another panic attack is imminent. Many pan ickers rely on safety behavior ssuch as be ing accompan ied by another per son, stiffenin g one's posture, taking deep breaths (that augment the hyperventilation syndrome). Situations that trigger increased arousalsuch as open spaces, heights, closed spaces, or behavior s that trigger arousal (exercise) are anticipated with dr ead or tolerated with increased discomfort.

We utilize the patient infor mation forms fr om the Leahy and Holland (2000) manual on treatment of depression and anxiety disorders. Man y patients find the schematic presented above to be especially usefu l in demystifying the nature of pan ic disorder. Behavioral anxiety manage ment techniques (such as r elaxation training, activity schedulin g, and rebreathing) are helpful in reducing overall level of ar ousal, but are not sufficient in themselves to e liminate panic disorder or anticipatory anxiety about having panic attacks. It is important to con vey to the patient that reducing anxious arousal is not the same thing as decastroph izing anxietyas some anxious arousal will be inevitable, it is important to deve lop a different interpretation and response to the anxiety. In deed, in explain ing the cognitivebehavioral treatment plan, the therapist shou ld be car eful to inform the patient that incr easing an xious ar ousalthrough exposureand even inducing pan ic attacks in session will be essential components of th erapy. The process of e xposure, and the role of safety behaviors, is explained to the patient as an opportunity to learn (with new tools

24

Empiric al sup port for tre atme nt

Gould et al. (1995) have pr ovided a meta-analysis of 48 controlled studies of cognitive-behavioral treatment of panic disorder with agoraphobia. The authors concluded from this analysis that CBT was h igh ly effective in yie lding pan ic-free outcomes, with an effect size of 0.88 (compared with an effect size of 0.47 for pharmacological treatment). The range of percent of patients who received CBT who were pan ic free after treatment was between 32% and 100%. In most of the studies reviewed, the percentage of panic free exceeded 80%. When CBT was compared with an emotion-focused approach, the former was sign ificantly more effective than the latter (Shear et al., 2001).

that are available) that panic attacks can be induced, experienced, and naturally come to a swift conclu sion. Th is will he lp disconfirm the belief that pan ic attacks will lead to something more adverse such as insan ity or medical emergencies. Furthermore , safety behavior s will need to be eliminated as they do n ot allow disconfir mation of the pan ic be liefs. Thus, as illu strated in the schematic, the patient utilizin g the superstitious safety behaviors (such as holding on to a chair in order to avoid falling) will not experience the liberating e xperience of learning that his dizziness does not lead to a collapse response even when he is not holding on to the chair. We utilize imaginal exposure early in treatment to afford the patient with the opportunity of exper iencing the feared stimu li within a more comfortable presentation. Durin g imaginal exposure to the situations and sensations of pan ic, the therapist engages in role-plays with the patient to either elicit the catastrophic prediction s (e.g., I am losing control and I will die) or to challenge these catastroph ic predictions (e.g., I have had numerous panic attacks and nothing terrible has happened). Many patients are assisted by using flash cards (e.g., index cards) on which catastrophic predictions are wr itten on one side wh ile rational or calming responses are listed on the other side. Subsequent to imaginal exposure the therapist an d patient will

Ration al e for tre at ment and inte rven tions Strateg ies a nd tec hniqu es
The plan of treatment involves a variety of interventions in cluding socialization to treatment (explain ing the CBT mode l of pan ic and agoraphobia and the use of bibliotherapy), anxiety management techniques (rebreathing, PMR, time-manage ment), construction of a fear hierarchy (including external stimu lifor example, open areas, heights, closed spaces, and interoceptive stimu lifeelings of dizziness or hyperventilation sensations), and gradual exposure to stimu li in the hierarchy. In addition, identifyin g catastrophic prediction s, e liminating safety behaviors, and setting up behavioral experiments to disconfir m negative predictions about anxiou s arousal are important cogn itive components of treatment.

move on to more threatening stimu li and will engage in exposure to these situations in vivo. Inducing pan ic attacks in session, with the explanation of th is technique and its rationale , can allow the patient to engage in experiencing the interoceptive stimu li (shortness of br eath, dizziness, sweating, or heart racing)and learn that these sensations are se lf-limiting. Induction of pan ic symptoms can be accomplished by practicing rapid breathin g or spinn ing in a chair with the therapist noting the patient's report of su bjective units of distress (an xiety leve l) at short periodic intervals. Some clin icians find it usefu l to pr ovide th e patient with pan ic-reversal behaviors such as breathing into a bag slowly, practicing diaphr agmatic breathing, or running in place (all of wh ich will establish a balance of car bon dioxide and reduce hyperventilation or dizziness). However, it is also effective to allow the patient the opportunity that riding out a panic attack without utilizing these anxiety management techniques can also be effective.

trying to take deep breaths (wh ich was based on the incorrect advice of another therapist). She was instructed in diaphragmatic breathingwh ich she practiced as an initial h ome work assignment. A fear hierarchy was constructed that consisted of be ing at the center of a mall (most feared), walking into a mall, walking into a crowded hotel lobby, walking along a wide avenue, fluorescent lights, and br ight sun light. The therapist indicated that these feared stimu li might be related to situations that conferred danger in a pr imitive envir onment (being trappedno exit availableand bright light making her more visible and vulnerable to predators). Initially, she was quite ske ptical of th is interpretation but she noted over the week following the first meeting that she felt considerably less anxious. Noting her safety behaviors was also valuable for her , as it helped explain why she still maintained her fears e ven after she had experienced some exposure . Specifically, the therapist indicated that she might be inclined to attribute a successfu l exposure experience to her safety be havior srather than to the safety of

25

Case ex am ple
The patient was a single woman in her mid-twenties who complained of fear ing pan ic attacks in sh opping malls. She indicated that her first pan ic attack occurred 2 months after her breakup in a re lationsh ip when she became intensely anxiou s while at an in door shopping mall where she had previously h ad a discussion about a breakup with her boyfr iend. Dur ing the in itial panic attack she exper ienced shortness of breath, dizziness, sweatin g, and a sense that she was about to collapse and feared that she wou ld not be able to get out of the mall with out being accompan ied by someone. Subsequent to the in itial panic attack she began to experience in tense anxiety wh ile walkin g along wide avenues in New York C ity. As a result of her pan ic disorder she avoided malls an d tr ied to walk close to bu ildings to which she could escape from the open space in the event of a panic attack. The first phase of treatmen t focu sed on socialization to the CBT mode l of panic. Th is involved providing her with an evolutionary rationale for P.151 innately predisposed fears of open spaces. In addition , further evaluation indicated that h er safety behavior s include d scann ing the street or building for quick exits or escape routes, tightening her body wh ile walking, narrowing her focus on specific signs of danger, sitting in a chair, exiting the street into a taxi, and

the situation. She was inst ructed to keep track of her use of safety behavior s, identify her predictions of what wou ld happen if she relinqu ished these behaviors (e.g., I will collapse or If I do not tighten my body when I am walking, I will lose control and run out). These predictions we re subsequently tested out by e ither deliberately relinqu ish ing the safety behavior s or actu ally doing the opposite of her safety behavior s (e.g., purposefu lly trying to make her body as loose as possible or avoiding lookin g at any exits and scanning the side walk rather than the bu ildings for safety places). Gradual exposure to avenues and crowded streets was followed by exposure to h otel lobbies. She was instructed to repeat these exposures for 30 minutes e ach dayand to view her experience of anxiety as a successfu l component of her exposure. This was considered important as sh e had perfection istic expectations about her anxietyI shou ldn't fe el any anxiety. Th is idealized vie w was challenged by You need to have some anxiety or fear during exposure for you to learn that your anxiety will dimin ish. At termination of treatmen t after 3 months the patien t was able to enter and walk through malls with mild anxiety and to cross wide avenues without anxiety. Her mood and confidence had improved substantially and she repor ted greater confidence in being able to handle any threat of panic in the future.

Psychodyn am ic m odel of p anic di sor der

The mode l for pan ic disorder described by Busch et al. (1991) and Shear et al. (1993) weaves neurophysiological factors with psychodynamic concepts and data to deve lop a psychodynamic formu lation for panic disor der. This mode l was e mployed for the development of treatment interventions and manualization (Milrod et al., 1997). The authors describe that an inherent tendency toward fearfulness in unfamiliar situations resu lts in a state of fearful dependency on sign ificant others in the ch ild's environ ment to provide a sense of safety. Th is an xious attach ment causes a narcissistic hu miliation for the child, as he cannot fee l safe without the help of others, and a propensity toward anger at others for being unable to provide su fficient comfort to relieve h is anxiou s state. Ch ildren may also deve lop a state of fe arful dependency in environments in which parents behave in a cr itical, threatening, or rejecting manner. Thus these children deve lop representations of others as abandoning, rejecting, and controlling. Anger at others is fueled by these perceptions, but the child is fearful of exper iencing or expressin g anger for fear of dr iving away or damaging the needed parent. Fearful dependency can be tr iggered again in adulthood by life events that represent danger or separation from a sign ificant other. Angry feelings, wh ich are often unconscious, ar e experienced as a danger to centrally important relationships, and signal anxiety is tr iggered. Defenses such as reaction formation, in which anger is con verted in to positive or he lping feelings, or undoing, in which any negative feelings that do emerge into consciousness are taken back, attempt to quell the danger experienced fr om fr ightening angry feelings. However, these defenses fail, and patients experience the onset of traumatic anxiety in the for m of a panic attack. The panic attack represents a compromise formation, in wh ich the patient can expr ess anger via demands for he lp from others, can desperately seek help in the setting of feared loss or separation, and can shut out angry feelings considered to be dangerous with a focus on intense, overwhelming an xiety. From the standpoint of the ple asure principle, patients experien ce a pan ic attack as less painfu l than the potential r isk of loss of an important attachment figure, or of a conscious awareness of other symbolic meanings that the panic attack carr ies.

Case reports and psychological assessments of patients with panic disorder formed the basis for the development of a systematic approach to the psychodyn amic treatment for pan ic disorder (Busch et al., 1991; Milr od et al., 1997). Milrod and S hear (1991) found 35 case reports of su ccessfu l treatment of panic with psychodynamic psychotherapy or psychoanalysis in th e psychoanalytic literature. A 15-session manualized psychodynamic psychotherapy for pan ic disorder, when combined with clomipramine treatment, was found to reduce the r isk of relapse

26

over an 18-month period following treatment termination compared with a gr oup treated with clomipramine alone (Wiborg and Dahl, 1996). Th is study did n ot match treatment groups for frequency of therapist contact. Milrod et al. (2000, 2001) conducted an open tr ial of panic-focused psychodynamic psychotherapy (PFPP) (Milr od et al., 1997), a manualized psychodynamic treatment that focuses on exploring the underlying unconscious me anings of pan ic symptoms and associated psychodynamic conflicts. This therapeutic approach was employed as a 24-session, twice weekly treatment intervention for 21 patients with DSM-IV panic disorder, u sing standardized pan ic disorder assessment measu res recommended by the National Institute of Mental Health Collaborative Report (Shear and Maser, 1994). At study entry, patients had sign ificant pan ic disorder and agoraphobia, along with fu nctional impair ment. Of 17 treatment completers (four patients were dropouts), 16 experie nced remission of panic disorder and agoraph obia, and also experienced statistically significant, clinically mean ingfu l improve ments in phobic symptoms and psychosocial function, both at treatment termination and at 6-month follow-up following a 6-month notreatment interval. The results of the open tr ial suggested that PFPP is a pr omisin g treatment for pan ic disorder. A randomized controlled trial of PFPP in comparison with applied re laxation training (A RT) is in pr ogress.

Psychodyn am ic tre atment o f p anic di sorde r

In treatment of pan ic disor der, therapists focus on th e conflicts surrounding separation and anger as they e merge in precipitating events, interpersonal relationships, and in the transfe rence. Examin ing the use of defenses is of value in br inging frightening feelings an d fantasies to consciousness (Busch et al., 1995; Milrod et al., 1997). For example, the therapist treatin g a panic patient can identify the use of reaction for mation when a patient is avoiding the experience of anger by be ing over ly helpful to those

Empiric al sup port for ps ychody nam ic treatme nt of pa nic diso rde r

with wh om they are actually angry. For instance, a patient may refer to loving to death a boyfr iend whom she actually experiences as depr iving and hurtful. Undoing, in wh ich angry feelings are expressed and then taken back, provides an important opportunity to identify and explore the threat the patient experiences fr om angry feelings. By examin ing these defenses the therapist can help the patient with the core conflicts in pan ic, and with the fear of disrupting attachment to others who are considered essential to safety.

demands. When she was 7 years old, con flicts between her parents

27

intensified, with her father ultimately leaving the hou se for a year. Her father's drinking incre ased when Sarah was an adolescent, and she struggled with rage an d her hurt feelings about h is behavior. She feared that her father wou ld injure h imself in a fall or car accident. At times dur ing h er adolescence, she was re cruited to bring him h ome from the bar or take h im to a rehabilitation program. She was extremely embarrassed by her father's behavior and worr ied about what her fr iends thought of both of them. In her vie w, he was a car ing and interested father during h is sober periods who disappeared emotionally and sometimes physically when he was dr inking. In part related to her father's alcoholism, the family was in constant financial turmoil. Sarah recalled feeling frightened about whether the family would be able to meet monthly payments. Sarah entered into a 24-session psych odynamic psych otherapeutic treatment that was part of a research protocol. In the first few sessions it became evident that her panic attacks were precipitated by her separations from Dan. The panic attacks began after their return from their trip and wou ld intensify when he left after they spent the weeke nd together. In addition, the panic became more severe when he wou ld cancel a visit with her. Exploration of her relation ship with her father provide d clues about the difficu lty she had with separations. When the therapist was questioning her about her father's disappearances when drinking, she became tearful when expressing anger at her father. Then she suddenly became disparaging of the psychotherapy: I dealt with my anger a long time ago. There's no point in dredging it all u p again. It's just going to make me feel worse. The therapist replied that tryin g to sweep her anger under the rug wou ld n ot be he lpfu l to her , and her ongoin g struggle s with her anger like ly emerged in he r panic. Sarah then reveale d that she was fearful that her anger at Dan, when she was disappointed with him, wou ld cause h im to re ject her. Similar ly, she felt that any expression of her own and her mother's and siblings frustration with her father set off h is drinking bouts, and tr iggered his extended disappearances. Sarah viewed her needs as potentially dr iving away her boyfriend and father. After separations from Dan she struggled with her wishes to call h im, presuming she wou ld come across as too needy. She feared that Dan wou ld see her as h igh maintenance and abandon her. She fe lt that expressions of need we re another

Case ex am ple
Sarah was a 29-year-old single admin istrative assistant who presented with the onset of panic disorder 4 months prior to evaluation. In addition to P.152 typical symptoms of pan ic disorder she described clen ching her teeth and stomach pain. Th e symptoms recurred after she returned from a tr ip abroad with her boyfr iend, Dan, that had lasted several months. When they returned they moved to the ir usual h omes in separate towns, wh ich wer e about a 3 -hour dr ive apart. Although Sarah hoped to marry Dan she became aware of the limitations in his availability to her. They planned to get together every weekend, but he often missed coming to visit her because his job kept him very busy. She became frustrated because she did not feel he was making the effort to set the necessar y limits at his job to make sure he cou ld see her. She became in creasingly anxious during her discussions with Dan about these issues, le ading ultimate ly to pan ic attacks. When they were together she described h im as very n ice to her, and said that they got along quite well. Thus she struggled with whether she was r ight to see him as putting her secondary to h is work, and whether he cou ld be trusted. Sarah was also struggling with other stresses. She had been laid off pr ior to the trip and began to feel financial pressu re. She also felt lonely, as most of her friends were in the city she had left 2 years previously. Even mor e so than with her boyfr iend, she complained that fr iends in her new location did not follow up with plans and were not responsive when she needed them. Sarah described a difficu lt and tumu ltuous upbringing. The youngest of four siblings, h er father was an alcoholic who withdrew from the family when drunk. Her mother was temperamental, and easily overwhelmed by her childre n's

factor that tr iggered her father's drinking. Panic occur ring at these times included a feeling of desperate aloneness and wishes to contact her mother and others for comfort. However, she attempted to avoid bein g n eedy by acting more se lf-sufficient, leaving her feeling even more isolated. Examin ing the patient's catastrophic fears of her anger and dependency when separated helped to detoxify these feelings, renderin g them less likely to trigger pan ic. Discu ssion about termination, wh ich began in session 16, indicated that she viewed the therapist as another source of support wh o wou ld sudden ly disappear. She reacted to the approaching termination in itially with feelings of anger, hurt, rejection, and anxiety. She eventually was able to see the similar ities between her feelings about the treatment ending and those sh e experienced toward her father and boyfriend. She was particu lar ly worr ied that she wou ld have a recurrence of her pan ic with n o one to help her. Her ability to safely work through these feelings with her therapist added to a reduction in her fears, the resolution of he r panic, and an increased ability to man age separation s.

Generalized Anxiety D isorder Questionnaire (GAD-Q; Newman et al., 2002).

28

T heoretic al mode l s
The behavioral model of GA D stresses both individual differences in arousal and experiences that are coupled with negative consequences. According to this mode l, specific events or stimu li become associated through condition ing with anxiety or fear. Treatment implications of the strict behavioral mode l include emphasis on decreasing an xious arousal through relaxation, coupling th is relaxation with the feared stimu li (reciprocal inh ibition; Wolpe, 1958), increasing exposure without escape, and enhancing assertion. The cognitive-behavioral model, deve loped over the past 15 years, emphasizes the central role of worry in GAD (Borkove c, 1994; Wells, 1997). Worry primar ily involves thoughts (rath er than images) that are experienced as ego-syntonic, but wh ich are associated with predictions of negative outcomes. In particu lar, worriers with GAD are more like ly to perceive threats that are either not there or are ambiguous (MacLeod et al., 1986; Borkovec, 1994; Matthews and We lls, 1999, 2000), th ey underestimate their ability to cope with negative outcomes, and their negative predictions are often extreme. Borkove c noted that worriers with GAD often believe that the worry itself will cause negative consequences for them (such as sickness or insanity) and that their worry is out of control. However, worr iers also be lieve that worry protects and prepares them and, therefore, cannot be easily abandoned. A recent mode l of worry as intolerance of uncertainty has gained significant empirical support. Dugas, Ladouceur, Free ston and colleagues have indicated that worr iers are often so in tolerant of uncertainty that they continue to worry (or seek solutions to hypothetical proble ms) until the uncertainty can be reduced (Freeston, 1994; Dugas and Ladacoeur, 1998; Dugas et al., 2004). Ironically, th ough, given the intolerance of uncertainty, th is search for a perfect solution above the threshold of ce rtainty will lead to failure, thereby leading to further worry and further search for perfect solutions. P.153

Gene ra liz ed anx i et y di sorde r Diag nostic fe ature s

Generalized anxiety disorder (GAD) is characterized by physiological arousal (restlessness, fatigue, difficu lty concentrating, irr itability, muscle tension, in somnia) and apprehensive worry. Un like other anxiety disorders wh ere the fear or anxiety is about a specific event or stimu lus, GAD is characterized by worry about several events (e.g., relationsh ips, illness, finances, wor k). Lifetime prevalence of GAD is about 5% and 1-year prevalence is 4% reflecting the fact that GAD is widespread and chron ic (B lazer et al., 1991; Wittchen et al., 1994; Kessler et al., 1999; Ne wman et al., 2003).

E valu ation
GAD is characterized by worry about a number of diffe rent things, the sense that worry is dangerous or out of control and physical arousal and tension. Measu res assess the degree of worry in GAD (Penn State Worry Questionnaire), examination of be liefs about worry (Metacogn itions Questionnaire), areas or topics of worry (Worry Domains Questionn aire), and the Intolerance of Uncertainty Scale (IUS). GAD status may also be evaluated using the Anxiety Disor ders Interview Schedule (Brown et al., 1994) and the

Borkovec and others have proposed that worry is an attempt to avoid negative e motions by relying on abstract, lingu istic

processing rather than direct emotional processing (B orkovec and Hu, 1990; Borkovec, 1994; Heimberg et al., 2003). When GAD patients engage in worr y, they are actually less anxious or aroused, resulting in the inhibition of emotion durin g the worry phase. This inhibition of e motion regarding unpleasant content prevents exposure or emotional processing, resulting in a later rebound of anxiety after the worry abates. Wells and his colleagues have descr ibed this as the in cubation of anxiety that results from relying on wor ry. Developmental histor ies of GAD patients reveal an interesting pattern of exper iences that may give rise to later vuln erabilities related to uncertainty, negative outcome, and concern over the feelings of others. For example, GAD adults report th at during childhood that they had more disruption s in attach ment relationships, experienced reversed parenting (such that they attended to the emotional needs of a parent who often neglected the patient's needs), unpre dictability of outcomes (or noncontingency), and had parents who combined both overcontrol and coldness. Presumably, these socialization e xperie nces would sensitize worriers to the needs of othersfor example, GAD patients rank high on empathy and their most common worr ies relate to interpersonal issu es. Moreover, the ch ild growing up in this kind of family wou ld learn to inhibit emotional experience and expression and re ly on anticipatory problem solvinge ither to soothe the emotional needs of the parent or to solve proble ms that others cou ld n ot solve or that the child cou ld not re ly on to solve. Most intriguin g, in support of the emotional avoidance model, is that worr iers as ch ildren were the most like ly of all anxiety disorder patients to have e xperienced a physical trau ma or threat of ph ysical trauma. Yet, th ey are the least likely of adult an xiety patients to worry or fear such trauma. Th is may reflect that worr iers engage in focusin g on re lative ly irre levant concerns as a way of avoidin g the more troublesome ph ysical vu lnerability.

Strateg ies a nd tec hniqu es

Cognitive-behavioral treatments for worry have incor porated a variety of interventions aimed, alternately, at autonomic arou sal, stimu lus control of worry, uncertainty train ing, distin guish ing between productive and unproductive worry, time management, activity scheduling, problem solving, identifying and challenging automatic thoughts, evaluating estimates of probabilities, mindfu lness train ing, and interpersonal interventions.

29

Brie f p lan of t re atment

Treatment will in clude a variety of techn iques and evaluations, not necessarily used in a particular sequence. A brief plan might include the following: in itial assessment (see above), identifying meta-cogn itive beliefs and distingu ish ing between Type 1 and Type 2 worry (i.e., Type 1 worry that in volves negative pre dictions about the future and Type 2 worry that involves concern that worry may go out of control or cause har m to the self). Worr y time is assigned, that requires that the patient de lay all worry to a specific time and place, th ereby conferring a sense of control and fin iteness to the worry. Worries that occur outside of worry time are written on cards and th en become the focus of attention dur ing the latter worry time. Prediction s of negative outcomes are gathered and tested against actual outcomes. Cognitive therapy techniqu es are helpfu l in addressin g specific worr ies. The therapist can ask the patient to identify the specific worry, identify the e motion s associated with the worry, examine the costs and benefits of the worry, consider the outcomes of past worr ies, weigh the evidence for and against the worry, ask what advice the patient would give to a fr iend with the wor ry, and collect evidence about specific prediction s. The patient can be trained in uncertainty tolerance: first, a distinction is made between present and future possible problems. Second, the present proble ms are reframed as proble ms to be solved, activating problem-solving strategies and behaviors. Th ird, possible problems become the focus of uncertainty tr ain ing, with the patient practicing flooding h imse lf with the though t or image that the bad thin g cou ld h appen, with instruction s to eliminate reassurance. The patient is encouraged to practice living in the presentincluding mindfu lness train ing, focusing on the present circu mstance, and using activities to immerse h imse lf in present experience.

Empiric al sup port for tre atme nts

There is considerable support that cogn itive-behavior al treatments are effective in the treatment of GAD (Gou ld et al., 2003), with some evidence that treatment gains are maintained 6 months after CBT is completed. Moreover, combin ing cogn itive and behavioral treatment is more effective than behavior therapy alone (Butler et al., 1991).

Ration al e for tre at ment and inte rven tions

Relaxation and other meditative train ing may be utilized as anxiety management techniques th at may assist in reducing generally higher autonomic arousal. These anxiety management techniques not on ly reduce the arousal that may exacerbate the worry, but they may also provide the patient with evidence that he or she does have some control over the worry.

encouraged to increase the frequency of aerobic exercise, wh ich he did to a moderate degree. In regard to his insomn ia, he was instructed to avoid naps and to use the bed on ly for sleep and sex. Thus, he refrained from reading in bed, given this guide line. Like man y insomniacs, h is sleeplessness was due to mental activity. He was instr ucted to write out h is worr ies and h is action to do list at least 3 hours before bedtime. If he had difficu lty falling asleep, he was instructed to practice repe ating I will never fall asle ep. The rationale for this instruction is that h is in somn ia was based on a worryI might never get to sleepthat he tried to n eutralize by trying to sleep. This gene rally failed. Over the course of n ine biweekly sessions his worry dimin ished substantially and h is sleep improved. He was urged to continue with the worry time, to do lists, uncertainty train ing, and practicin g feared thoughts at the termination of treatment.

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Case ex am ple
The patient was a 53-year-old manager who complain ed of worrying all his life. Always someone concerned with being conscientious, he noted that his worry had become more pronounced in the past 15 years, as he had taken on more responsibilities at work that in volved deadlines and un certainty of outcome. He relied on sedatives for sleep, had found antidepressant medication to be unhelpfu l and had se veral short experiences in tradit ional psychotherapy that were not productive. The general GAD model was explained to h im, distinguish ing between productive and unproductive worry, and e mphasizing the importance of uncertainty tolerance. A distinction was made between worr ies that can rapidly (almost immediate ly) be turned into a to do list of specific action versus worr ies about possible events over which he had almost no control. Specific to do lists were utilized daily, along with trackin g actual accomplish ments and behaviors on a daily basis. Worry time was set aside for flooding himse lf with worries and listing these worr ies. Th is resulted in a recogn ition th at his worries pr imar ily focused on a few areaswork to be done , meetings he wou ld have, and the concern about be ing on time. The worry time was immen sely helpfu l to him and ran against h is in itial prediction that he would not be able to set aside worr ies until later. This gave h im more of a sense of control. Specific prediction s were elicited th at characterized these worr iesI won't get the report in and People will be hostile toward meand these were tested weekly. Un certainty train ing was imple mentedwith the therapist telling him that much of worry is the intolerance of uncertainty. He was urged to practice both in session and as se lfhelp homework repeatin g, It's possible that I can make mistakes and people will be angr y with me. In addition, he practiced visualizing (as e xposure) images of negative outcome s until these outcomes became boring. On a daily basis the patien t was instructed to practice PMR, forming visual images of relaxing settin gs. In addition , he was

Psychodyn am ic m odel of ge ner al iz e d anx iety disor der

From a dynamic perspective, anxiety is lin ked to the potential emergence of threatening u nconscious wishes into con sciousness, and to early interpersonal relationships that for m an internal psychological template in which P.154 attachments are experienced as easily disrupted. In GAD, defenses have been ineffective at ne utralizing or disguising unconscious wishes, leading to persiste nt anxiety, or somatization may be operating as a primary defense. Crits-Christoph et al. (1995, 1996) suggest that early re lationsh ips in GAD patients trigger feelings of rejection, poten tial loss, anger, and a sense of needing to protect the caregiver to maintain the re lationsh ip. Ongoing anxiety derives from these conflicted feelings and the sense of unstable re lationsh ips. In addition, they h ypothesize that past traumas can set off a pattern of generalized worry.

Psychody nam ic tre atment of g ener al i z ed anx iety di sord er

As in other psychodynamic approaches with anxiety disorders, the therapist explores the content of the patient's specific worr ies with the goal of determin ing the particular threatening unconscious wishes that the patient is attempting to manage or displace, in an

effort to make the patient's emotional reactions more understandable to him. In addition, early life relation ships and traumatic experiences are investigated to determine why the patient vie ws attach ments as easily disrupted and the wor ld as unsafe. Further clues can be obtained from experience s of anxiety in the transference. The therapy provides a safe atmosphere in which fr ighten ing uncon scious wishes and conflicts can emerge and be rendered less threatening, wh ich functions to diminish conscious worrying about the self, relationsh ips, and the wor ld.

Future encounters or memories of the event activate the traumatic experience, resulting in increased anxiety. Avoidance or even numbing following the even t results in decreased anxiety, thereby reinforcing avoidan ce or escape and consequently maintaining the traumatic association. Foa and her colleagues have expanded on the behavioral model by pr oposing that PTSD is characterized by a combination of the associations descr ibed above and by the meanings given to the expe rience. This mode l stresses the importance of the fear str ucture, which in clu des the problematic interpretations given to the event, such as I am never safe, I can be killed at any time, The world is n ot fair, or I am all alone. Foa's mode l stresse s the importance of both information and emotional processing and places the cogn itive-affective fear structure at the heart of PTSD. According to th is model, attempts

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Posttrau matic str e ss d iso rder Diag nostic fe ature s

PTSD is defined by exposur e to a life-threatening or injurythreatening experience in which the individual experienced intense fear, helplessness or h orror and after which the individual experienced one of the following: intrusive recollections of images of the event, recurrent distressing dreams, exper iencing the event as if it is recurr ing, psychological distress with exposure to the event, or physiological reactivity to stimuli similar to the event. In addition, there are attempts to avoid the stimu lus and increased and recurrent arousal (in somnia, irritability, hypervigilance, etc.) (APA, DSM IV ). The lifetime prevalence of PTSD in th e National Comorbidity Study was 7.8% (males 10.4% and females 5.0%, with 60% of males and 51% of females exposed lifetime to traumatic events). Younger individuals are at greater risk for PT SD than older individuals.

to assimilate the feared experiencein order to proce ss it and give it meaningoccur dur ing th e intrusive re-experiencin g, but are so overwhelming that complete processing is not obtaine d. This results in further attempts to avoid and, consequently, emerging interpretations that one is helpless and always vu lnerable. S imilar to shattered assumption s, the traumatic event may h ave more generalized implications for the individual about the n ature of physical and interpersonal security and meaning. Specific cogn itive processe s involved in PTSD include dissociative experiences (derealization and depersonalization), increased recall of vivid imagery associated with the trauma, but also a tendency in some cases to have vagu e or overgeneral recall (Loftus and Burns, 1982; Brewin and H olmes, 2003). McNally provides an extensive review of the literature related to me mory processes, repressed memory, and so-called traumatic amnesia. His revie w casts considerable dou bt on sensational claims of recovered memory related to abuse and trauma. Rather, it appe ars that traumatic events generally are more me morable and account for the intrusive nature of subsequent PTSD. There is mixed evidence for attentional biasesbut some evidence suggests th at individuals with PTSD man ifest the Stroop effect of interference with subliminal stimu li (Harvey et al., 1996). Shame and anger are also often associated with the traumatic exper ience, mental defeat (a combination of helplessness and dissolution of person al identity, Elhers et al., 2000), negative beliefs associated with depression and PTSD (Foa et al., 1999). Brewin and colleagues h ave proposed a dual representation mode l of trauma, suggesting that information is encoded and experienced as verbally accessible

E valu ation
PTSD differs from pan ic disorder in that the individual with PTSD has had these symptoms for lon ger than 1 month following the trauma (versus acute stress disorder) and re-experien ces the traumatic event through in trusions, dreams, and a se nse of the recurrence of the event (ve rsus pan ic disorder). Evalu ation instruments for PTSD in clu de the Clinician-Administered PTSD Scale (CAPS), the PTSD Symptom Scale, an d the Impact of Events Scale-Revised (We iss and Marmar, 1997).

T heoretic al mode l s
The behavioral model of PT SD entails both classical and operant condition ing, following Mowrer's two-factor theory. S pecifically, it has been proposed that the original traumatic event results in a learned association of the emotional trauma that has occurred with the stimuli (visual images, sensations, sounds, etc.) of th is event.

memor y (VAM) or situationally accessible me mory (SA M), with sights, sounds, and sensations exper ienced at the mor e primitive leve l of SAM (Brewin, 1996; Brewin and Holmes, 2003). Thus, effective treatment of PTS D wou ld entail both the ver bal or narrative mean ings associated with trauma (VAM) an d the more concrete stimu li and sensations entailed in SAM. Interpersonal factors are also associated with PTSD, with lack of social support predicting continuation of symptoms (see Brewin et al., 2000). Finally, eye movement desensitization and reprocessing (EMDR) was developed by Shapiro and has been utilized for tr eatment of PTSD by associating the elicited images of trauma with rapid eye move ments produced by th e patient followin g the therapist's hand. Although some studies have found th is to be as effective as exposure and anxiety management interventions, the findings are mixed.

Strateg ies a nd tec hniqu es

The approach to treatment involves several components, including psychoedu cation of the nature of PTSD (see Leahy an d Holland, 2000 for handouts for patie nts on PTSD), anxiety man agement techniques (re laxation, rebreathing, stress manage ment), developin g a detailed descr iption of the initial trau matic event, identifying specific hot spots associated with increased anxiety (or numbin g), repeated exposure to the narrative of the trauma, construction of a fear h ierarchy, imaginal or in vivo exposure to the elements in the fear h ierarchy, identifying the automatic thoughts and shattered assumptions that are associated with the trauma, and cogn itive restr ucturing. Other interventions that are utilized are reducing or e liminating use of alcohol or drugs, reducing avoidant behavior in general, and the use of activity scheduling and longer-term goal setting. In cases of trauma associated with rape or abuse, rescripting of the traumatic experience through imagery and active role-plays can be utilized (see Smucker and Dancu, 1999).

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Empiric al sup port for tre atme nts

There is considerable support for cogn itive-behavioral treatments of PTSD, with some protocols utilizing a combination of var ious interventions and other utilizin g other CBT interventions. It is not unusual for CBT outcome studies to utilize extended or double sessions (60120 minutes) so as to allow for sufficient exposure and habituation to the fear ed stimu lus. Empir ical support for the efficacy of these treatments can be found in numerou s reports (Foa et al., 1991, 1995; Tarrier et al., 1999).

Case ex am ple
The patient was a 31-year-old married female who had been exposed to the destruction of the Wor ld Trade Center and who pursued treatment 5 months after the event. During the traumatic event, she had been near the buildings and had been caught by the falling debris. She witnessed bodies falling and fe ared during the experience that she would be killed. She returned to her apartmentnot far from th e trauma siteand was unable to get in touch with her husband. When she presented for treatment she was depressed, anxious, had recurring images of the explosion, feared watch ing airplanes in the sky, and was avoiding going near Ground Zero. She had incre ased drinking since the event, suffered from insomnia, and felt hopeless about the future. The therapist provided her with infor mation about PTS D (see Leahy and Holland, 2000) and explained to her that she was suffer ing from PTSD and that the treatment wou ld con sist of learning how to understand why she still had the fears and intrusive experiences that she had and to utilize exposure techniques and cognitive therapy techniques to modify her fee lings an d be liefs. Her automatic thoughts about the event and life at present was that she was really all alone, she could be killed at any moment, life is not safe, and you always have to keep your guard u p. The therapist explained to her that the reason that she was re-

Ration al e fo r tr eat ment and inte rven tions

The cognitive-behavioral approach to treatment proposes that the patient must re-exper ience the traumatic images and stimu li, activate the fear structure associated with the traumatic experience, and learn that the images and stimu li are no longer dangerous. This is based on the mode l of exposure with response prevention, where exposur e entails re-exper iencin g the images long enough that the patie nt habituates a fear respon se and by preventing escape or avoidance during this exposure by prolonging the experience. Thus, the two-factor model of conditioning stressing both classical condition ing through exposure and operant condition ing (by preventing escape) is the basic ration ale. In addition, cogn itive restructuring assists the patient in modifying the dysfunctional beliefs th at have arisen during th is experience. P.155

experiencing these intrusive images was that her min d was trying to assimilate this information but was being overwhelmed with the intensity of the content. Gradual and repeated exposu refirst utilizing imaginal and then in vivo techniqueswou ld be expected to have an effect on the emotional evocativeness of these images. Her drinking behavior was an in itial focus of treatment, as increased su bstance abuse has a negative impact on treatment efficacy. She examined the costs and benefits of dr inking, how drinking impeded her proce ssing of th is experience, and how drinking added to her sense of inability to handle the trauma. Initially, she kept a log of the drinking, including noticing her emotions and situational tr iggers. After 2 weeks her drinking had been reduced by 80%. Until the dr inking had subsided, the exposure and cogn itive restructuring was de layed. In addition, like many individuals who are traumatized and who hope to use avoidance as a coping mechanism, her resistance to treatment was also addressed. Th is included examination of her be lie fs that therapy wou ld open up these memories and make th in gs worse. The therapist acknowledge d that exposure and examination of her thoughts and feelings would increase anxiety temporarily, but that her current situation of an xiety, depression, n ightmar es, avoidance, and intrusive imagery was to be we ighed against the in itial costs of treatment. The patient was asked to describe in great detail the events of 9 11 and to revie w with the therapist the particu lar hot spots that were most difficu lt. As the patient recalled the events, the therapist noticed a bland and distant style that the patient used in describin g events. On further inqu iry the patient indicated that these events (falling bodie s, debr is collapsin g around her) were especially troublesome and that the blan d style was simply a manner of avoiding the emotional content. The patient was asked to wr ite out a detailed description of the event and read it over and over each day until it became less anxiety pr ovoking. During the therapy session, the particu lar hot spots were explored, indicating that the patient interpreted these images as indicating that her life was always in danger and that anyth ing can happen to anyoneand that it probably wou ld happen. These feelings of helplessness an d danger were then explored using standard cogn itive therapy techn iqu es. For example, the be lief that she was helpless was examined by defin ing helplessness (unable to do anyth ing), examining the costs and benefits of this belief, reviewing the evidence and

keeping an activity schedule in wh ich pleasure and mastery were recorded. Furthermore, she examined the singu lar ity of th is event and considered how her increased awareness of her own mortality might resu lt in greater insight, matur ity and wisdom. Exposure to the images of planes flying and endangering her was conducted by having her practice modifying the image by th inking of a plane flying very slowly out to se a, turning back, and then flying again out to sea. This gave her more of a sense of control over the image and reduced her anxiety substantially. Finally, she was encouraged to visit the site of the Wor ld Trade Center and to go

33

there every day for 1 week. In itially, th is provoked in tense anxiety that gave way to sadness and finally to acceptance.

Psychodyn am ic m odel of postt rau m atic stres s disor der

In Freud's conceptualization (1920), trauma pierces the ego's stimu lus barrier, overwhelming the ego. In an attempt to cope with resulting traumatic an xiety, the ego e mploys dissociation, minimizin g painfu l feelings through denial, or separating the feelings from thoughts and memories surrounding the trauma. Any intense affect state can create fears of a recurrence of the trauma (Krystal, 1988). In addition, the individual is dr iven to repeat the trauma in an attempt to assuage feelings of overwhelming helplessness an d lack of control. As with other anxiety disorders, the vicissitudes of an ger play an important role in the psychodynamic underpinning of PTSD symptoms. Patients with PT SD experience intense rage at those they view to be responsible for the ir trauma (Brom et al., 1989). This rage is pr ojected on to others not connected to the event, who are consequently vie wed as dangerous, intensifying anxiety. Patients may employ the defense of identification with the aggressor, in wh ich they ally themse lves with the individual or group responsible for the trauma (Lindy et al., 1983). This mental operation can help to allay feelings of helplessness an d may provide a sense of empowe rment. However, identification with the aggressor often triggers gu ilt, and fears of becoming like the abuser. Survivor gu ilt, a core feature of one type of posttrau matic reaction, can occur when an individual survives a traumatic experience in which others have died or have been severely injured. The individual who survives unconsciously identifies with the victims of trauma, but may also develop an uncon scious

identification with the perpetrators of the trauma, as described above, tr igger ing guilt. Developmental experiences can affect the risk of deve lopin g PTSD in response to a trauma. Traumatic deve lopmental experiences can disrupt the early sense of autonomy and cau se a regression from the developmental level th at has been attained. Traumatic experiences in adu lthood also cause regression, and often reawaken past experiences of disillusion ment and anger at parents for failures to protect ch ildren from ear lier traumas.

event traumatic to th is par ticu lar patient, and what factors in the patient's background, including pr ior traumas, rendered them susceptible to PTSD. The therapist sh ould identify un conscious fantasies of identification with the aggressor related to the trauma. In therapy of all anxiety disor ders, but particularly in PTSD, exploration of the patient's need to be punished by the symptoms themselves as a result of intense gu ilt is essential.

34

Conclu sion s
In this chapter we have attempted to outline both cognitivebehavioral and psychodynamic models of treatment. T he cogn itivebehavioral model has been more extensive ly validated empir ically, although there is now an attempt to provide more e mpir ical validation of the psychodyn amic model. The rapid expansion of specific cogn itive -behavior al models for specific an xiety disorders suggests that th is mode l will likely undergo further expansion and soph istication in coming ye ars. Although the focus here has been on the Axis I nature of these disorders, most individuals with anxiety disorders, especially those with long-standing pr oblems, will also present with personality disorders that may complicate the clin ical picture. Perhaps for this reason most practicing clin icians utilize an eclectic or integrative orientationone that may gain from the var ious mode ls presented in th is chapter. Finally, as most therapists adhere to an eclectic appr oach, the different issues addressed by the cogn itive and psych odynamic approaches may allow the therapists to provide a more comprehensive approach to treatment. Indeed, it has been our experience that few patients in the real world of clin ical practice actually present with only a single Axis II anxiety disorder. This comorbidity may challenge the clin ician to incorporate not on ly more than one empirically validated treatment module , but also more than one theoretical approach.

E mpiric al sup port for ps ychody nam ic treatme nt of postt raum atic stre ss di sorde r
Lindy et al. (1983) studied 30 survivors of a fire usin g a br ief (six to 12 sessions) manualized psychodynamic therapy. Nineteen of the survivors met DSM III criteria for PTSD. The patients demonstrated sign ificant improvement and were less symptomatic than a control group of untreated survivors at follow-up. Brom et al. (1989) found improve ment in patients P.156 with PTSD in three treatment groups (psychodynamic psychotherapy, hypn otherapy, and systematic desensitization) compared with a control gr oup. The psychodynamic tr eatment was more effective with avoidance symptoms compared with the other treatments, wh ich were more effective with intrusive symptoms. A manualized psychodynamically or iented group psychotherapy for Vietnam veterans with PTS D has also been deve loped (We iss and Marmar, 1993), but has not been systematically tested.

Psychodyn am ic tre atment o f po sttra umatic stres s d isord er

In the psychodynamic treatment of PTSD, efforts are made to explore the precipitating traumatic event to give the patient an opportunity to discharge fe elings of rage and terror and to investigate the uncon sciou s sign ificance of the event. Un like other exposure-based treatments of PTSD (Resick and Schnike, 1993; Foa et al., 1999; Jaycox et al., 2002), therapeutic focus is not on reexperiencing the trauma. Exploration and reexperie ncing of a traumatic experience may be harmfu l or disruptive to some patients, and therapists ne ed to be careful to modulate their exploration to what the patient can tolerate (Krystal, 1988; Gabbard, 2000). It is important to in vestigate what made this

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