ادراکات درمانگر و ارائه مواجهه با انگیزش و تحریک درونی برای اختلال پانیک

Interoceptive exposure (IE) is widely regarded as an essential procedure in the cognitive-behavioral treatment of panic disorder (PD). However, treatment manuals differ substantially in their prescribed delivery of IE, and little research exists to inform the optimal manner of its implementation. The present study examined therapists’ perceptions and delivery of IE for PD. Results revealed substantial variability in how clinicians provide IE. In contrast to the prolonged and intense manner in which exposure techniques are traditionally applied, many therapists reported delivering a low dose of IE accompanied by controlled breathing strategies. Concerns about the potential adverse effects of IE were common despite the fact that participants reported the actual occurrence of negative outcomes of IE in their own practice to be extremely infrequent. It is possible that some therapists deliver IE in a cautious manner in an attempt to minimize the perceived risks associated with this treatment.

Methodologically rigorous clinical trials have demonstrated the efficacy of numerous cognitive behavioral therapy (CBT) approaches to the treatment of panic disorder (PD) with or without agoraphobia (e.g., Barlow et al., 2000, Clark et al., 1994 and Gloster et al., 2011). These treatments target the fear of panic itself by providing corrective information intended to disconfirm maladaptive beliefs regarding the dangerousness of panic-related internal and external cues. In particular, direct exposure to feared arousal-related body sensations, also known as interoceptive exposure (IE), is considered an essential component of effective CBT for PD (Craske & Barlow, 2007). By engaging in sensation-induction tasks such as hyperventilation or spinning in a chair, clients with PD learn that panic-related bodily sensations such as heart palpitations and dizziness are harmless and tolerable (Antony et al., 2006 and Schmidt and Trakowski, 2004). Indeed, reduction in the fear of fear appears to mediate improvement in CBT (Smits, Powers, Cho, & Telch, 2004). Whereas most evidence-based CBT approaches for anxiety disorders such as obsessive–compulsive disorder, post-traumatic stress disorder, and specific phobias primarily emphasize exposure-based techniques (e.g., Foa et al., 1999, Foa et al., 2005 and Ollendick et al., 2009), CBT treatments for PD often utilize a variety of therapeutic procedures. For example, Barlow and Craske's (2007) empirically supported panic control treatment includes cognitive reappraisal techniques and diaphragmatic breathing skills in addition to in vivo exposure and IE, and symptom-induction exercises are not introduced until the final stages of treatment. Clients following this approach complete a pre-specified number of IE trials (e.g., 3 min-long trials of hyperventilation), each of which is followed by the use of cognitive and controlled breathing strategies and a rest period of sufficient length to allow anxiety symptoms to subside. This method of delivering of IE differs markedly from the typical implementation of exposure therapy for other anxiety disorders in which trials are conducted in a prolonged manner without concurrent arousal-reduction strategies and continue until the client's anxiety has habituated (e.g., Abramowitz, Deacon, & Whiteside, 2010). In contrast to panic control treatment, other effective CBT treatment packages for PD minimize or omit cognitive and controlled breathing techniques and emphasize the prolonged and intense delivery of IE (e.g., Arntz, 2002, Otto et al., 2009 and Telch et al., 1993). Although a large body of research supports the overall efficacy of CBT treatment packages for PD that include IE (McHugh, Smits, & Otto, 2009), little empirical guidance exists to clarify the optimal delivery of IE. Few dismantling studies have examined CBT for PD; one exception was reported by Schmidt et al. (2000) who found that removal of controlled breathing did not detract from overall treatment outcomes. Investigations of variations in the delivery of IE itself have yielded inconsistent findings, with one study demonstrating an advantage of concurrent cognitive reappraisal (Carter, Marin, & Murrell, 1999) and two others failing to do so (Deacon et al., 2012 and Smits et al., 2008). Deacon et al. (2012) also found that the efficacy of IE was not enhanced by the addition of controlled breathing strategies. In summary, there is scientific consensus that IE is an important ingredient in effective CBT for PD (American Psychiatric Association, 2009) but existing research provides little empirical guidance to inform the manner in which IE is best delivered. As a result, there may be substantial variation among therapists in the application of this procedure, and this variation is likely influenced by factors other than research evidence. Exposure therapy is associated with a host of negative beliefs among therapists including the perception that it is unethical, harmful, intolerable, and poses a risk management problem (Deacon et al., in press and Olatunji et al., 2009). Deacon and Farrell (in press) hypothesized that negative beliefs about exposure therapy affect the manner in which therapists deliver this treatment to anxious clients. Concerns about safety and tolerability might prompt well-meaning clinicians to provide exposure in a less-than-intense manner (e.g., with concurrent use of arousal-reduction strategies) in order to minimize its perceived risks (Farrell, Deacon, Kemp, Dixon, & Sy, in press). Prolonged and intense IE may be seen by some therapists as unacceptably aversive and unsafe owing to the perceived dangers of high anxiety itself (e.g., decompensation, loss of consciousness). Relative to the use of in vivo and imaginal exposure techniques for other anxiety disorders, the implementation of IE for PD may be particularly susceptible to therapist reservations about exposure. IE is the least used exposure-based technique (Freiheit et al., 2004 and Hipol and Deacon, in press) and was rated as the least ethical, acceptable, and helpful form of exposure in a survey of university students and psychotherapy outpatients (Richard & Gloster, 2007). Despite its established efficacy, exposure-based CBT for PD does not work for all clients and many individuals experience a fluctuating course of residual panic symptoms following treatment (Brown & Barlow, 1995). It is possible that variations in the implementation of this treatment are associated with differential client outcomes. In particular, the delivery of IE in a cautious manner by therapists concerned with its potential adverse effects may produce less beneficial outcomes than the confident delivery of IE in a prolonged and intense manner. As a first step in investigating this possibility it is necessary to understand how therapists deliver IE and the factors associated with their style of delivery. Accordingly, the present study examined perceptions and style of delivery of IE among therapists who use this procedure in the treatment of clients with PD. Given the inconsistency with which CBT treatment packages implement IE and the lack of clear scientific guidance for its optimal delivery, it was hypothesized that therapists would vary considerably in their style of delivering IE as well as the extent to which they endorse various risks associated with this treatment.