(p. 121) Adaptation
- DOI:
- 10.1093/med:psych/9780195335804.003.0013
The first two sections of this chapter provide information on adapting the regular program for different ages and for patients with asthma. The rest of the chapter outlines the adaptation for the intensive treatment program.
Adapting for Different Ages
When implementing any psychological treatment, it is important to consider the developmental level of the child or adolescent when introducing skills and new materials. Although the chronological age of the child is significant, the child’s developmental age or maturity is most important. For example, much variability exists in the cognitive abilities, maturity, and levels of independence among 12-year-olds, A young, less mature adolescent (developmental age of 11 or 12) may need to have skills written out very clearly, in a “step-by-step” fashion, or may need to have the therapist give him many concrete examples of how to utilize the tools learned in therapy. For example, when teaching cognitive restructuring, younger adolescents still might benefit from and enjoy the idea of being a “detective” with their own thoughts, or might benefit highly from having the therapist work with them to restructure several maladaptive thoughts before doing one on their own. In addition, it is important that the therapist be sensitive about not using language or terms that might be unfamiliar to a younger adolescent. For that reason, when working with a younger adolescent, the therapist might use the term “worry thoughts” instead of “maladaptive thoughts,” whereas the language used with a 17-year-old might be more sophisticated.
(p. 122) The developmental level of the adolescent becomes even more important to keep in mind when conducting exposure exercises. Although the therapist should remove “safety behaviors,” she should keep in mind the overall safety of the young adolescent and think of exposures that do not jeopardize the patient. For example, the therapist should avoid exposures that require leaving a young adolescent alone in an unfamiliar neighborhood, or that require that a developmentally immature adolescent be able to read train or bus schedules alone and find the right transportation back to the office. Although this latter exposure may be within the ability level of most older adolescents, a younger adolescent might have difficulty with it, and it may not be safe or appropriate to have the adolescent travel alone. Thus, the therapist should brainstorm some possible exposures that are part of the adolescent’s hierarchy, but are places and activities that the parent and therapist agree would be acceptable and generally safe.
The treatment also may be adapted for patients as young as 9 years old with appropriate language adaptations and with therapist accompaniment on exposures (e.g., using public transportation, etc.).
Adaptations for Asthma
Adolescents with both asthma and panic disorder (PD) are often very in tune with interoceptive cues regarding breathing. In some cases, these adolescents might be hypersensitive to any changes in their breathing, even when they are not having an asthma attack. The elevated heart rate and rapid breathing that typically accompany a panic attack can trigger a cycle of worry regarding whether the adolescent can breathe, lead to overuse of an inhaler, and lead to worry and confusion regarding whether the adolescent is actually experiencing a panic attack, an asthma attack, or both.
When working with adolescents with asthma, the therapist should be sure to carefully delineate as part of the three-component model those “triggers” that often induce asthma (such as an allergy, temperature change, exercise, etc.) and encourage the adolescent to take the inhaler as prescribed during these situations. Use of the common asthma medication albuterol also naturally increases one’s heart rate, which can lead to further (p. 123) worry regarding whether or not a panic attack will occur. Therapists might outline a “cycle of asthma” that looks similar to the three-circle model “cycle of panic” and highlight some of the differences in the triggers for asthma and the triggers for panic. This might help the adolescent distinguish better between them. Also, when conducting exposures, adolescents with asthma might worry that a panic attack might induce an asthma attack. We recommend getting a doctor’s approval for asthmatic adolescents’ participation in treatment, along with formulating a clear plan for therapists and adolescents to follow if an asthma attack does occur during treatment. Some practitioners suggest using an inhaler prior to going out on exposures, so that the adolescent does not have to worry about the onset of asthma, but can focus solely on the panic attacks. In any case, the therapist can let the adolescent know that, in some ways, having asthma has helped him become very in tune with interoceptive cues. When having a panic attack, these adolescents might be very skilled at noticing even minute changes in their bodily state, which can help them learn more about the nature of their panic attacks.
Intensive Treatment
Pincus, et al. (2003) recently conducted a pilot study to determine the efficacy of an 8-day intensive treatment of panic disorder and agoraphobia that was developmentally adapted for use with adolescents. Intensive Panic Control Treatment for Adolescent Panic Disorder and Agoraphobia (APE) was modeled after a similar program for adults developed by David Spiegel and David Barlow (Spiegel & Barlow, 2000).
The intensive program is intended to treat patients with panic disorder with the full range of agoraphobic avoidance (PDA). It is conducted over 8 consecutive days and incorporates a self-study format combined with therapist guidance. Rather than following a hierarchically based exposure plan, interoceptive and situational exposures are conducted in an ungraded massed fashion. Furthermore, the exposure aspect of treatment is particularly unique in that it emphasizes the deliberate provocation and maximal intensification of anxious symptoms without teaching any arousal reduction procedures. Other aspects of Panic Control Treatment (PCT), particularly psychoeducation and cognitive restructuring, (p. 124) are also part of the treatment (Spiegel & Barlow, 2000; Heinrichs, Spiegel, & Hofmann, 2002).
The primary objective of the pilot study (Pincus et al., 2003) was to assess the impact of the 8-day APE on the clinical symptoms of PDA, and on the overall quality of life of adolescents. Eighteen adolescents (12 girls, six boys) between the ages of 12 and 17 (mean age, 14.5 years) were included. Thirteen out of the eighteen families were from states other than Massachusetts, and five were from the local Boston area. These five families specifically asked for a more “intensive” form of therapy. Families from outside the local Boston area traveled to Boston and stayed in lodgings in close proximity to the Center for Anxiety and Related Disorders (CARD) for the duration of the 8-day treatment program. Adolescents and their parents were all administered the Anxiety Disorders Interview Schedule for the DSM-IV, Child and Parent Versions (ADIS-IV-C/P) (Silverman & Albano, 1997) at pretreatment, posttreatment, and at 1 and 3 months’ follow-up. At pretreatment, 12 adolescents attended school regularly, whereas six refused to attend school due to fears of having panic attacks in the classroom. In addition, at pretreatment assessment, the adolescents reported having an average of 11.4 panic attacks per week, and reported experiencing distress and interference in several areas of their lives. At pretreatment, all adolescents were given clinician severity ratings on the ADIS-IV-C/P above the clinical level, ranging from 5–7. No significant differences were found at pretreatment between those from the local Boston area and those from out of town on any demographic variables or on pretreatment self-report or parent report measures.
APE was administered to patients over 8 consecutive days. Adolescents and parents were provided with self-study reading material each evening, and the therapist reviewed and clarified material during sessions. In the first 3 days of treatment, adolescents learned about the nature of anxiety and panic, including the physiology of anxiety, and were taught skills such as cognitive restructuring and hypothesis testing. They also learned how to create a personalized Fear and Avoidance Hierarchy (FAH) and were taught the concepts of exposure and habituation. These first three sessions lasted approximately 2–3 hours each. Adolescents met individually with the therapist, and parents were included in the last half hour of the session to teach them the skills the adolescents had learned. Adolescents (p. 125) and parents were taught skills such as acknowledging the “cycle of panic,” cognitive restructuring, recognizing avoidance and safety behaviors, and practicing interoceptive exercises. During days 4–7 of treatment, adolescents participated in situational exposures with integrated interoceptive exposure exercises for 5–7 hours per day (2 days with therapist accompaniment, 2 days with family accompaniment). The therapist taught the adolescents and parents how to conduct interoceptive and situational exposures, and then assisted them in entering situations listed on the adolescents’ FAH. During day 8 of treatment, adolescents met with the therapist for approximately 2 hours to learn skills to prevent relapse, discuss ways to maintain gains, and plan future self-directed exposure sessions. Parents were included in the last half of this session for an open discussion of these issues with their child with therapist mediation.
Results of this pilot study indicated that the clinical severity ratings (CSR) of PD (based on the ADIS-IV-C/P) significantly decreased from pre- to posttreatment, with 14 out of 18 adolescents displaying nonclinical levels of PD by posttreatment. Because of more substantial agoraphobia, this was a more severe group than in our ongoing 11-week study. Follow-up clinician severity ratings at 1 and 3 months posttreatment indicated that the adolescents’ gains were maintained at each follow-up point. At 1 month posttreatment, 17 out of 18 adolescents received nonclinical CSRs for PDA, and reported that panic was no longer significantly interfering in their lives.
At 1 month following treatment, adolescents reported a mean of 2.2 panic attacks per week, as compared to 11.4 at pretreatment (self-monitoring of weekly panic attacks obviously is not recorded at posttreatment, as that would include the week of treatment). At 3 months follow-up, the number of reported panic attacks was further decreased to an average of 1.5 per week. Adolescents’ anxiety sensitivity, as measured by the Childhood Anxiety Sensitivity Index (CASI), decreased from pre- to posttreatment, and was maintained at follow-up points.
Numerous collateral changes were also reported by families, including improved academic performance, improved social functioning, and improved family functioning. Adolescents reported decreased depression and avoidance of situations due to panic. Parents reported feeling more (p. 126) knowledgeable about the factors that cause and maintain panic and reported feeling more confident in their abilities to effectively deal with adolescents during a panic attack. They also reported improved interactions with their adolescents, as they utilized skills learned in therapy to positively encourage their children’s nonavoidance of previously avoided situations. Changes in parents’ perceptions of their adolescents’ overall adjustment also improved, as evidenced by decreased scores on the Child Behavior Checklist.
Based on the positive results of this pilot study, a randomized controlled trial of intensive treatment for PDA in adolescence is currently underway (NIMH: Pincus, PI). The aims of the study are to investigate the efficacy of an intensive treatment program for treating panic and agoraphobia in adolescents, to evaluate the relative advantages of involving parents in treatment, and to examine mechanisms of action in treatment. Thus far, approximately 30 adolescents have been treated with intensive treatment, and initial results are quite positive. Adolescents have shown decreases in their overall clinical severity of panic, decreases in the frequency of panic attacks, and numerous positive collateral changes.
Benefits
Although an 11-week version of PCT has been shown to be initially efficacious (Mattis, Pincus, Ehrenreich, & Barlow, under review), there are many reasons why an intensive treatment option may be very attractive to families of adolescents with PDA. First, many adolescents with PDA show significant interference in developmentally appropriate activities, and approximately half do not attend school regularly. Intensive treatment can help adolescents return to normal daily functioning rather quickly, which may make it especially appropriate for adolescents who are not attending school or for those who attend school but experience significant distress. Second, for those families who do not have access to appropriate forms of treatment near their hometowns, the option of on-site 1-week intensive treatment may be ideal. Third, intensive treatment might be especially useful for those adolescents with PDA who have tried other therapies without success. Some adolescents benefit greatly from the therapist-accompanied in vivo exposure time that an intensive form of therapy offers. In sum, many families of adolescents with PDA (p. 127) find it favorable to have treatment intensified into 8 days, rather than stretching therapy out over the course of several months.
Another benefit to conducting treatment intensively is that the therapist and patient have a short but “intense” period of time in which to build rapport and work on skills. Rather than losing ground over weeks and months of therapy (due to missed sessions, etc.), the intensive treatment format allows the therapist to keep the patient motivated to make changes. Often, the result is quite positive, and patients often leave the intensive program feeling as if their lives have been “changed in 8 days.” Parents also describe that they feel the intensive nature of the program is extremely helpful and that it gives adolescents “their lives back.”
One drawback to intensive format of treatment, however, is that less time is available to follow up with adolescents over time, especially if the patient is from out of town. It is important to be sure that the adolescent has a follow-up therapist in her home town, if necessary, to ensure adequate maintenance of skills. Also, because of the short time period of treatment, less time is available to deal with issues regarding adolescents who do not comply or who are not motivated to try.
Notes to Therapist
To conduct intensive treatment, the therapist must have solid training in PCT for adolescents, cognitive-behavioral principles, and treating adolescents. Furthermore, therapists need to prepare themselves for having to motivate an adolescent who has been avoiding developmentally appropriate activities for a long time. Often, parents have inadvertently developed maladaptive ways of helping their child, and this only further perpetuates the child’s dependence on his parents. The therapist should have an awareness of these family dynamics in order to effect lasting change on the adolescent and his family system.
Schedule
Treatment must be scheduled for a week when the patient can devote full time (at least 8 hours per day) to therapy for 8 consecutive days. That (p. 128) may require families to take time off work or school, arrange for childcare, and obtain the cooperation of family members. The therapist must emphasize the importance of this and ensure that the family has made adequate arrangements to protect the allotted time. In this regard, the treatment can be compared to an 8-day hospitalization.
Session Frequency and Duration
APE is administered over an 8-day period, as depicted in Table 13.1. These session numbers correspond to the sessions of this manual; however, during intensive treatment, more than one session may be covered per meeting. Generally, sessions 1 through 7 are conducted Monday through Friday, sessions 8 to 10 are completed by the patient over the weekend, and the final session is held on the following Monday. Every effort should be made to adhere to this schedule; however, if necessary to accommodate unavoidable interruptions, sessions may be delayed or rescheduled. It is recommended, however, that the entire treatment be completed within a maximum of 12 days.
Table 13.1 Outline of Sessions
Treatment Day(s) |
Corresponds to Sessions |
Treatment Component |
|---|---|---|
1–3 |
1–5 |
Cognitive-behavioral therapy and interoceptive exposure |
4, 5 |
6–7 |
Intensive situational exposure with initial therapist accompaniment |
6, 7 |
8–10 |
Continued exposure, patient working independently or with family members |
8 |
11 |
Skill consolidation and relapse prevention |
On treatment days 1–3 and 8, the therapist typically meets with the patient for 2 hours to cover the session material. The duration of sessions 6 and 7 on days 4 and 5 will depend upon the nature of the exposures to be done and the rapidity and practicality with which therapist accompaniment can be faded. In preliminary studies, therapist involvement in these two sessions combined averaged approximately 10 hours.
(p. 129) Scheduled Posttreatment Contacts
It is recommended that therapists contact patients at several points after the conclusion of treatment (e.g., once a week). These contacts will generally be made by telephone and should not exceed 30 minutes each. The purpose is to provide a transitional end to therapy, assess for possible deterioration that might require intervention, and provide a context for discontinuation of pharmacotherapy. After the intensely emotional experience of the 8-day treatment, it seems unnatural to abruptly terminate treatment and not have any further contact. It is also possible that a patient might be reluctant to report a lapse, so that leaving contacts to the patient’s initiative could result in deterioration going undetected until the follow-up assessment. The addition of regular contact will systematize posttreatment interactions and ensure closer monitoring of patient status.
Exposures
In the intensive treatment, exposure are conducted over four days (days 4–7), with the last 2 days usually occurring over a weekend in which the patient practices exposures on her own. At the end of the third day, the therapist explains to the patient that the next four days are the most important days of treatment, the days for which they have been preparing and during which the greatest gains will be made. During the next few days, the patient will face some of the most difficult situations that can be arranged and will need to do this for about 8 hours per day. It will be hard, but it will also be short, and the therapist will be there to guide and assist the patient. The following dialogue may be used:
Just as a surgeon does not scratch at the surface but goes quickly to the site of the problem, so we will go quickly to the most difficult of your situations. This is a much more powerful method than gradual exposure over weeks or months and will get the discomfort over much sooner. People literally can change their lives dramatically within a few days.
Also like surgery, exposure therapy requires informed consent. You can choose to keep a cancerous organ or live a life restricted by fear, or you (p. 130) can choose to courageously endure 4 days of pain and discomfort in order to break the back of panic disorder and recover your health and freedom. We are providing a unique opportunity, one you are not likely to have again, but you must decide for yourself whether the benefit is worth the cost.
See Chapter 9 on how to handle common patient objections to doing exposures. In addition, if the patient acknowledges the need to do exposure but gives excuses for not going ahead with it now (e.g., something has come up, under unusual stress at the moment, anxious because of coming off medication, dealing with withdrawal symptoms, not feeling well physically), the therapist can point out that it is now or never for this program. The therapist has set aside the next 2 days to work with the patient.
If the patient agrees to go forward at the end of the third day, the therapist should encourage her to start exposures on her own that night or the next morning, if she feels able to (e.g., taking public transportation home or to the clinic, taking an elevator, etc.).
Prior to day 4, the therapist should give some thought to the exposures to be done. From review of the patient’s pretreatment ADIS and the preceding CBT sessions, the therapist should by this point have a good idea of tasks that would be appropriate. Some of these may require advance planning (e.g., checking schedules, deciding on the need for a car, getting directions or a map). If so, that should be done before day 4, so as not to lose time in session. The plans will be refined, and possibly changed, when the therapist meets with the patient in the morning to go over her fear and avoidance hierarchy, so the therapist should allow for flexibility. Tasks that need firm schedules (e.g., appointments or reservations) are best done during the second day of exposures, after the therapist sees how well the patient does.
Day 4 (session 6) begins in the office, to discuss the rationale for exposure, deal with patient resistance, and complete the FAH form. After that, the therapist and patient go to wherever the exposures are to be done. No specific time limits need be set for this session, but the patient should spend most of the day (at least 6 hours) doing exposures. The therapist should fade her presence out as the day proceeds.
