علل و مدیریت مقاوم به درمان اختلال هراس و موقعیت هراسی: بررسی کارشناسی درمانگران

Cognitive behavior therapy (CBT) is recognized as an effective psychological treatment for panic disorder (PD). Despite its efficacy, some clients do not respond optimally to this treatment. Unfortunately, literatures on the prediction, prevention, and management of suboptimal response are not well developed. Considering this lack of empirical guidance, we decided that it would be useful to survey expert cognitive behavioral therapists about what they have found in their practices to contribute to a poor treatment response and what strategies they have found helpful in preventing or managing these problems. Ten factors associated with suboptimal responding emerged. Listed in order of reported frequency, they were as follows: lack of engagement in behavioral experiments, noncompliance, comorbidity, inadequate case formulation/misdiagnosis, secondary gain, problems with cognitive restructuring, presence of other negative life events, medication complications, poor delivery of treatment, and therapeutic relationship barriers. The current paper discusses these factors and details treatment suggestions to improve outcome provided by the survey participants.

Panic disorder (PD) is a distressing and disabling anxiety disorder characterized by an onset of recurrent unexpected panic attacks. Panic attacks involve a sudden rush of intense fear that is accompanied by a variety of physical (e.g., palpitations, dizziness, sweating) and cognitive (i.e., fear of dying, losing control, or going crazy) symptoms (American Psychiatric Association, 2000). Clients with PD fear subsequent attacks and become preoccupied with potential “catastrophic” consequences of panic attacks (e.g., the panic attack will cause a heart attack, stroke, fainting, loss of control). Many clients suffering from PD develop agoraphobia, which refers to fear and/or avoidance of activities or situations that they believe will provoke an attack, where escape may be difficult (e.g., airplanes, elevators, trains), or where help may be unavailable in the event of a panic attack (e.g., being at home alone, in an airplane, far from home). The severity of panic attacks and agoraphobia can range from multiple daily attacks and house-boundness to infrequent attacks and endurance of feared situations with discomfort, respectively. Cognitive behavior therapy (CBT) is well established as an effective psychological treatment for PD. It is a first-line treatment option according to guidelines of best practice (cf. American Psychiatric Association, 1998). Although there are several different CBT “packages” for PD (cf. Margraf, Barlow, Clark, & Telch, 1993), most CBT treatments include the following components: ▪ psychoeducation about PD and CBT; ▪ panic management strategies such as relaxation and breathing; ▪ cognitive restructuring of fear-based thought content and processes; ▪ exposure to feared bodily sensations (interoceptive exposure); ▪ exposure to feared situations (exteroceptive exposure) For most clients undergoing treatment, CBT has been shown to reduce panic attacks, generalized anxiety, agoraphobic avoidance, and depression (e.g., Barlow, Gorman, Shear, & Woods, 2000). Although results across studies vary slightly, most show that CBT results in a panic-free rate of approximately 75% to 90% (Barlow, Raffa, & Cohen, 2002). Despite the efficacy of CBT for PD, some clients show a suboptimal response to it in that they either do not respond or respond only partially (Rosenbaum, Pollack, & Pollack, 1996). The literatures on the prediction, prevention, and management of suboptimal treatment response are not advanced. Studies of factors associated with poor outcome were recently reviewed by McCabe and Antony (2005), who identified three factors with consistent support: symptom severity, comorbid depression, and a comorbid personality disorder. Although this information is useful to the practicing clinician in anticipating potential challenges in treatment, empirical guidance on the types of problems commonly encountered that lead to suboptimal response and how they might be prevented or managed is lacking. In the absence of this guidance, we decided that it would be useful to ask expert clinicians what they have found to contribute to poor treatment outcome and what strategies they have found to be useful in the prevention and management of the problems they see. A similar method was employed by Scott, Pollack, Otto, Simon, & Worthington (1999) to evaluate psychiatrists’ response to treatment-refractory PD when using pharmacological interventions.