Cognitive-behavioral therapy (CBT) is efficacious and effective in the treatment of anxiety disorders. However, few guidelines exist on how to efficiently provide CBT when comorbidity is present. Given that anxiety disorders may share underlying mechanisms of maintenance, targeting such mechanisms may be fruitful when working with individuals who suffer from extensive anxiety-related comorbidity. The present study describes an interoceptive and situational exposure-based treatment with a 40-year-old outpatient whose presentation was complicated by multiple anxiety disorders and related difficulties. A comprehensive assessment monitored mechanisms targeted in treatment, symptoms associated with clinical diagnoses, and related impairment. Treatment gains were clinically and statistically significant. Improvements were maintained 1-month post-treatment. These results add to the growing literature focused on transdiagnostic interventions that successfully target broad-based mechanisms of maintenance for multiple types of psychopathology. Theoretical and technical issues related to this type of intervention are discussed throughout the article.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
2.
AntonyM. M.BielingP. J.CoxB. J.EnnsM. W.SwinsonR. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10, 176-181. doi:10.1037/1040-3590.10.2.176
3.
AntonyM. M.LedleyD.LissA.SwinsonR. P. (2006). Responses to symptom induction exercises in panic disorder. Behaviour Research and Therapy, 44, 85-98. doi:10.1016/j.brat.2004.12.005
4.
BarlowD. H. (2000). Unraveling the mysteries of anxiety and its disorders from the perspective of emotion theory. American Psychologist, 55, 1247-1263. doi:10.1037/0003-066X.55.11.1247
5.
BarlowD. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York, NY: Guilford.
6.
BarlowD. H. (2008). Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed.). New York, NY: Guilford.
7.
BarlowD. H.AllenL. B.ChoateM. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205-230. doi:10.1016/S0005-7894(04)800036-4
8.
BeckA. T.EmeryG.GreenbergR. L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York, NY: Basic Books.
9.
BlanchardE. B.Jones-AlexanderJ.BuckleyT. C.FornerisC. A. (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy, 34, 669-673. doi:10.1016/0005-7967(96)00033-2
10.
BorkovecT. D.AbelJ. L.NewmanH. (1995). Effects of psychotherapy on comorbid conditions in generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 63, 479-483. doi:10.1037/0022-006X.63.3.479
11.
BoutonM. E. (1993). Context, time, and memory retrieval in the interference paradigms of Pavlovian learning. Psychological Bulletin, 114, 80-99. doi:10.1037/0033-2909.114.1.80
12.
BrownT. A.AntonyM. M.BarlowD. H. (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy, 30, 30-37. doi:10.1016/0005-7967(92)90093-V
13.
BrownT. A.CampbellL.LehmanC.GrishamJ.MancillR. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110, 585-599. doi:10.1037/0021-843X.110.4.585
14.
BrownT. A.DiNardoP. A.LehmanC. L.CampbellL. A. (2001). Reliability of DSM-IV anxiety and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110, 49-58. doi:10.1037/0021-843X.110.1.49
15.
ChamblessD. L.CaputoG.BrightP.GallagherR. (1984). Assessment of fear of fear in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090-1097. doi:10.1037/0022-006X.52.6.1090
16.
ChamblessD. L.SharplessB. A.RodriguezD.McCarthyK. S.MilrodB. L.KhalsaS.BarberJ. P. (2011). Psychometric properties of the Mobility Inventory for Agoraphobia: Convergent, discriminant, and criterion-related validity. Behavior Therapy, 42, 689-699. doi:10.1016/j.beth.2011.03.001
17.
CraskeM. G.BarlowD. H. (2006). Mastery of your anxiety and panic (4th ed.). New York, NY: Oxford University Press.
18.
CraskeM. G.KircanskiK.ZelikowskyM.MystkowskiJ.ChowdhuryN.BakerA. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5-27. doi:10.1016/j.brat.2007.10.003
19.
CraskeM. G.RoweM.LewinM.Noriega-DimitriR. (1997). Interoceptive exposure versus breathing retraining within cognitive-behavioural therapy for panic disorder with agoraphobia. British Journal of Clinical Psychology, 36, 85-99. doi:10.1111/j.2044-8260.1997.tb01233.x
20.
CraskeM.TsaoJ. (1999). Self-monitoring with panic and anxiety disorders. Psychological Assessment, 11, 466-479.
21.
DavisL.BarlowD. H.SmithL. (2010). Comorbidity and the treatment of principal anxiety disorders in a naturalistic sample. Behavior Therapy, 41, 296-305. doi:10.1016/j.beth.2009.09.002
22.
DeaconB. J.AbramowitzJ. S. (2004). Cognitive and behavioral treatments for anxiety disorders: A review of meta-analytic findings. Journal of Clinical Psychology, 60, 428-441. doi:10.1002/jclp.10255
23.
DuncanB. L.MillerS. D.SparksJ. A.ClaudD. A.ReynoldsL. R.BrownJ.JohnsonL. D. (2003). The Session Rating Scale: Preliminary psychometric properties of a “working” alliance measure. Journal of Brief Therapy, 3, 3-12.
24.
FalsettiS. A.ResnickH. S.DanskyB. S.LydiardR.KilpatrickD. G. (1995). The relationship of stress to panic disorder: Cause or effect? In MazureC. M. (Ed.), Does stress cause psychiatric illness? (pp. 111-147). Washington, DC: American Psychiatric Association.
25.
FalsettiS. A.ResnickH. S.DavisJ. L. (2008). Multiple channel exposure therapy for women with PTSD and comorbid panic attacks. Cognitive Behaviour Therapy, 37, 117-130. doi:10.1080/ 16506070801969088
26.
FarchioneT. J.FairholmeC. P.EllardK. K.BoisseauC. L.Thompson-HollandsJ.CarlJ. R.BarlowD. H. (2012). Unified protocol for transdiagnostic treatment of emotional disorders: A randomized control trial. Behavior Therapy, 43, 666-678. doi:10.1016/j.beth.2012.01.001
27.
GreenbergP. E.SisitskyT.KesslerR. C.FinkelsteinS. N.BerndtE. R.DavidsonJ. R. T.FyerA. J. (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry, 60, 427-435. doi:10.4088/JCP.v60n0702
28.
HayesS. C.WilsonK. G.GiffordE. V.FolletteV. M.StrosahlK. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152-1168. doi:10.1037/0022-006X.64.6.1152
29.
HintonD. E.HofmannS. G.PitmanR. K.PollackM. H.BarlowD. H. (2008). The panic attack-posttraumatic stress disorder model: Applicability to orthostatic panic among Cambodian refugees. Cognitive Behaviour Therapy, 37, 101-116.
30.
HofmannS. G.SmitsJ. J. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621-632. doi:10.4088/JCP.v69n0415
31.
KesslerR. C.BerglundP.DemlerO.JinR.MerikangasK. R.WaltersE. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602. doi:10.1001/archpsyc.62.6.593
32.
LickelJ.NelsonE.LickelA.DeaconB. (2008). Interoceptive exposure exercises for evoking depersonalization and derealization: A pilot study. Journal of Cognitive Psychotherapy, 22, 321-330. doi:10.1891/0889-8931.22.4.321
33.
MattickR. P.ClarkeJ. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470. doi:10.1016/S0005-7967(97)10031-6
34.
Naragon-GaineyK. (2010). Meta-analysis of the relations of anxiety sensitivity to the depressive and anxiety disorders. Psychological Bulletin, 136, 128-150. doi:10.1037/a0018055
35.
NishithP.NixonR. V.ResickP. A. (2005). Resolution of trauma-related guilt following treatment of PTSD in female rape victims: A result of cognitive processing therapy targeting comorbid depression?Journal of Affective Disorders, 86, 259-265. doi:10.1016/j.jad.2005.02.013
36.
OlatunjiB. O.CislerJ. M.TolinD. F. (2007). Quality of life in the anxiety disorders: A meta-analytic review. Clinical Psychology Review, 27, 572-581. doi:10.1016/j.cpr.2007.01.015
37.
OttenbreitN. D.DobsonK. S. (2004). Avoidance and depression: The construction of the Cognitive-Behavioral Avoidance Scale. Behaviour Research and Therapy, 42, 293-313. doi:10.1016/S0005-7967(03)00140-2
38.
ParkerR. I.VannestK. J.DavisJ. L.SauberS. B. (2011). Combining nonoverlap and trend for single-case research: Tau-U. Behavior Therapy, 42, 284-299. doi:10.1016/j.beth.2010.08.006
39.
PaulG. L. (1969). Behavior modification research: Design and tactics. In FranksC. M. (Ed.), Behavior therapy: Appraisal and status (pp. 29-62). New York, NY: McGraw-Hill.
40.
RadomskyA. S.RachmanS. S.ThordarsonD. S.McIsaacH. K.TeachmanB. A. (2001). The Claustrophobia Questionnaire. Journal of Anxiety Disorders, 15, 287-297. doi:10.1016/S0887-6185(01)00064-0
41.
Roshanaei-MoghaddamB.PaulyM. C.AtkinsD. C.BaldwinS. A.SteinM. B.Roy-ByrneP. (2011). Relative effects of CBT and pharmacotherapy in depression versus anxiety: Is medication somewhat better for depression, and CBT somewhat better for anxiety?Depression and Anxiety, 28, 560-567. doi:10.1002/da.20829
42.
SandersonW. C.RapeeR. M.BarlowD. H. (1989). The influence of an illusion of control on panic attacks induced via inhalation of 5.5% carbon dioxide-enriched air. Archives of General Psychiatry, 46, 157-162. doi:10.1001/archpsyc.1989.01810020059010
43.
SchmidtN. B.TrakowskiJ. (2004). Interoceptive assessment and exposure in panic disorder: A descriptive study. Cognitive and Behavioral Practice, 11, 81-92. doi:10.1016/S1077-7229(04)80010-5
44.
StewartR. E.ChamblessD. L. (2009). Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77, 595-606. doi:10.1037/a0016032
45.
TolinD. F. (2010). Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clinical Psychology Review, 30, 710-720. doi:10.1016/j.cpr.2010.05.003
46.
TsaoJ. I.MystkowskiJ. L.ZuckerB. G.CraskeM. G. (2002). Effects of cognitive-behavioral therapy for panic disorder on comorbid conditions: Replication and extension. Behavior Therapy, 33, 493-509. doi:10.1016/S0005-7894(02)80013-2
47.
WaldJ.TaylorS. (2007). Efficacy of interoceptive exposure therapy combined with trauma-related exposure therapy for posttraumatic stress disorder: A pilot study. Journal of Anxiety Disorders, 21, 1050-1060. doi:10.1016/j.janxdis.2006.10.010
48.
WheatonM. G.DeaconB. J.McGrathP. B.BermanN. C.AbramowitzJ. S. (2012). Dimensions of anxiety sensitivity in the anxiety disorders: Evaluation of the ASI-3. Journal of Anxiety Disorders, 26, 401-408. doi:10.1016/j.janxdis.2012.01.002
49.
WolpeJ.LazarusA. A. (1966). Behavior therapy techniques: A guide to the treatment of neuroses. Elmsford, NY: Pergamon Press.
50.
ZvolenskyM. J.EifertG. H. (2001). A review of psychological factors/processes affecting anxious responding during voluntary hyperventilation and inhalations of carbon dioxide-enriched air. Clinical Psychology Review, 21, 375-400. doi:10.1016/S0272-7358(99)00053-7
