تجربیات بالینی در استفاده از رفتاردرمانی شناختی در درمان اختلال هراس

Although there is a growing body of research to support the use of psychological treatments for specific disorders, there has been no way for practitioners to provide feedback to researchers on the barriers they encounter in implementing these treatments in their day-to-day clinical work. In order to provide practitioners a means to give researchers information about their clinical experience, the Society of Clinical Psychology and the Division of Psychotherapy of the American Psychological Association collaborated on an initiative to build a two-way bridge between practice and research. A questionnaire was developed on the therapist, patient, and contextual variables that undermine the effective use of CBT in reducing the symptoms of panic disorder, a clinical problem that occurs frequently in clinical practice and has an extensive research base. An Internet-based survey was advertised internationally in listservs and professional newsletters, asking clinicians to indicate all aspects of CBT that they used in treating panic disorder, and to respond to a series of questions with variables that presumably limited successful symptom reduction in clinical work using CBT to treat panic disorder. The final database included responses from 338 participants who varied in experience in applying CBT to the treatment of panic disorders. Participants identified a wide range of patient factors that were barriers to symptom reduction, including symptoms related to panic, motivation, social system, and the psychotherapy relationship, in addition to specific problems with implementing CBT for the treatment of panic disorder.

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Results Techniques typically used in conducting cbt for panic disorder Table 2 lists the proportion of CBT techniques respondents endorsed to treat panic disorder. Most (84%–99%) indicated using patient education and cognitive restructuring or labeling of affect. A majority (54%–75%) indicated using behaviorally oriented techniques such as in vivo exposure, simulation of panic sensations, and relaxation, in addition to resolution of conflict situations and an understanding of developmental roots of panic. Finally, from 10% to 31% used specific forms of training to treat panic (e.g., assertiveness training, communication training). Table 2. Techniques Typically Used in Conducting CBT for Panic Disorder % n Psychoeducation about nature of panic 99% 333 Cognitive restructuring of general beliefs associated with panic 92% 312 Cognitive restructuring of feared outcomes associated with panic attacks 88% 339 Identification of emotional reactions to situations associated with panic 85% 228 Cognitive relabeling of sensations triggering panic 84% 285 In vivo exposure to travel, open spaces and other agoraphobic situations 75% 255 Breathing retraining 68% 228 Simulation of panic sensations within the session 65% 220 Resolution of stressful conflicts leading to panic e.g., relationships, work 57% 192 Relaxation training 54% 182 Helping patient understand developmental roots of fears 53% 178 Mindfulness 48% 161 Motivational enhancement 31% 103 Assertiveness training 25% 86 Communication training 18% 60 Independence training 10% 32 Table options Barriers to treatment progress due to symptoms related to panic disorder Table 3 reports the frequencies of responses to patient symptoms that limited symptom reduction. The majority of respondents indicated the chronicity of the panic symptoms (57%), but also the severity of the symptoms (36%), and how the symptoms impaired the patient’s ability to function at home or work (39%). Comorbid disorders such as posttraumatic stress disorder (39%), and symptoms such as the tendency to dissociate (39%) and a history of fainting (16%) were barriers to successful treatment. Table 3. Barriers to Treatment Progress Due to Symptoms Related to Panic Disorder % n Chronicity 57% 194 Tendency to dissociate 39% 132 Functional impairment travel, work, social 39% 130 Post-traumatic stress disorder 39% 133 Severity 36% 121 Fainting history 16% 55 Table options Barriers to treatment progress due to other patient characteristics Table 4 reports responses to a list of patient characteristics that limit symptom reduction. Patients’ lack of adherence to treatment in the form of inability to work between sessions (70%), unwillingness to give up safety behaviors (for example, objects or people believed to prevent panic attacks; 63%), a reliance on psychotropic medication (52%), fear of exposure and associated emotional reactions (46%), and resistance to directedness of treatment (37%) were all reported to have interfered with the implementation of CBT. Comorbid disorders such as personality disorders (55%), substance abuse (49%), intellectual limitations (34%), and depressed mood and mood disorders (32%) similarly complicated treatment. Finally, patients’ chaotic lifestyle (55%), limited premorbid functioning (46%), and personality characteristics such as dependency and endorsements of lack of assertiveness (33%) and a perfectionistic or obsessive style (30%) were identified as problematic. Table 4. Barriers to Treatment Progress Due to Other Patient Characteristics % n Inability to work independently between sessions 70% 235 Unwillingness to give up safety behaviors e.g., objects/people believed to prevent panic 63% 214 Personality disorders 55% 186 Chaotic life style 55% 186 Reliance on psychotropic medication 52% 175 Substance abuse 49% 165 Premorbid functioning is limited 46% 157 Fear of exposure and associated emotional reactions 46% 156 Resistance to directiveness of treatment 37% 124 Intellectual/cognitive/introspective ability is limited 34% 116 Dependency/unassertiveness 33% 112 Depressed mood/mood disorder 32% 108 Perfectionistic/obsessive style 30% 100 Low self-esteem/self-efficacy 22% 73 Negative emotions not recognized 21% 71 Poor interpersonal skills 19% 64 Physical problems 16% 55 Low socioeconomic status 7% 23 Diversity issues associated with ethnicity/race/sexual orientation 3% 9 Table options Barriers to treatment progress due to patient expectations Patients' unrealistic expectations about the process and outcome of treatment mitigated the successful implementation of CBT. Frequencies of participants’ endorsements as reported in Table 5 indicate that patients expected that they would be free of all anxiety following treatment (54%), successful exposure would mean not having any panic or anxiety (41%), and that more than reduction of panic symptoms was needed in treatment (20%). In addition, patients’ beliefs that therapists would do all the work to make things better (53%), disappointments with past therapists (33%), and expecting that treatment would be brief and easy (28%) were problems. Patients’ beliefs that they need medication to reduce panic (49%) also interfered with CBT. Finally, 20% of respondents indicated that their patients believed that reduction of panic symptoms was not enough. Table 5. Barriers to Treatment Progress Due to Patient Expectations % n They will be free of all anxiety 54% 184 Therapist will do all the work to make things better 53% 179 They need medication to reduce panic 49% 164 Successful exposure means not having panic/anxiety 41% 139 Pessimism due to disappointment with past therapy 33% 110 Treatment will be brief and easy 28% 94 Symptom reduction is not enough 20% 67 Table options Barriers to treatment progress due to patient beliefs Patients’ beliefs about their panic symptoms also interfered with CBT’s ability to reduce symptoms. Table 6 reports that many respondents indicated that their patients believed their fears were realistic, for example, that they may really have a heart attack (57%), that their problems were due to external factors (40%), and that being anxious was abnormal and dangerous (38%). Problematic patient beliefs also included the notion that panic was biologically based (26%) and that symptom reduction could have a negative impact on their relationships (12%). Table 6. Barriers to Treatment Progress Due to Patient Beliefs % n Belief that their fears are realistic (e.g., they may have a heart attack) 57% 193 Their problems are due to external factors (e.g., situation, other people) 40% 135 Being anxious is abnormal/dangerous 38% 128 Panic is biologically based 26% 88 Belief that symptom reduction will have negative impact on relationships 12% 39 Table options Barriers to treatment progress due to patient motivation Frequencies of responses associated with problems due to patient motivation are reported in Table 7, and indicate that premature termination (60%), minimal motivation at the beginning of treatment (60%), and decreased motivation with some symptom reduction (31%) all interfered with treatment. Table 7. Barriers to Treatment Progress Due to Patient Motivation % n Premature termination 60% 203 Minimal motivation at outset 60% 202 Motivation decreased as some improvement occurs 31% 105 Motivation decreased when patient learns reasons for having panic 10% 33 Table options Barriers to treatment progress due to patient’s social system Table 8 reports elements in patients’ social system that respondents identified as interfering with the effectiveness of CBT. Most respondents identified that patients' symptoms were reinforced and supported by their social network (61%) and that their patients were trapped in a dysfunctional environment (57%). Other mitigating factors included high levels of stress at home or work (48%), lack of family support for treatment (43%), social isolation (39%), and family members who were controlling or critical (34%) or themselves very anxious (32%). Table 8. Barriers to Treatment Progress Due to Patient’s Social System % n Symptoms/dependency is reinforced/supported 61% 205 Trapped in a dysfunctional home, work, or social situation 57% 194 Stress very high at home, work, or socially 48% 162 Family does not support treatment 43% 144 Social isolation of patient 39% 132 Family is controlling and critical 34% 116 Family members are very anxious 32% 107 Loss of family member, partner, employment 18% 62 Table options Barriers to treatment progress due to problems/limitations associated with the cbt intervention Table 9 lists problems and limitations associated with CBT that respondents endorsed as limiting symptom reduction. These include patients’ reluctance to eliminate safety behaviors (56%), logistical problems with in vivo exposure (44%), the fact that CBT does not offer guidelines for dealing with comorbid problems and symptoms (34%), and difficulty in simulating panic symptoms in session (33%). Respondents also identified how triggers to panic were not evident (27%), overly strict adherence to CBT protocols (26%), and how relaxation either does not work or causes anxiety (25%) as limiting CBT. Table 9. Barriers to Treatment Progress Due to Problems/Limitations Associated With CBT Intervention % n Patient’s reluctance to eliminate safety behaviors e.g. carrying meds, being with others 56% 189 Exposure in vivo has logistical problems 44% 150 Doesn’t deal with comorbid problems/symptoms 34% 116 Simulating panic in session is difficult 33% 113 Triggers to panic not evident 27% 92 Strict adherence to CBT protocol 26% 87 Relaxation doesn’t work or causes anxiety 25% 85 Absence of guidelines for dealing with resistance/noncompliance 17% 58 Doesn’t deal with patient’s anger 16% 55 Doesn’t deal with fear of interpersonal loss 14% 46 Triggers for panic are not linked to client's past history 10% 33 Doesn't deal with comprehensive or lasting change 9% 29 Current coping skills are not linked to past 7% 25 Table options Barriers to treatment progress due to therapy relationship issues Respondents were asked about factors in the therapy relationship that were barriers in implementing CBT, and their responses are summarized in Table 10. A little over one third of the respondents (36%) indicated that the therapy alliance was not strong enough, 33% reported that the patient did not feel that his/her distress was sufficiently understood or validated, 17% confessed that their own negative feelings toward the patient were problematic and that their frustration with progress interfered with symptom reduction. Table 10. Barriers to Treatment Progress Due to Therapy Relationship Issues % n Therapy alliance not strong enough 36% 121 Patient doesn’t feel his/her distress is sufficiently understood/validated 33% 111 Therapist’s negative feelings toward patient 17% 57 Therapist’s frustration with progress 17% 56 Table options Other survey findings Survey respondents reported an average success rate of 78% in reducing panic symptoms using CBT. Respondents also indicated that 55% of their patients were prescribed some form of psychotropic medication.