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Flexible Application of Interoceptive and Situational Exposure-Based Treatment for an


Outpatient With Multiple Anxiety and Mood Disorders: A Comprehensive Case Study
Liviu Bunaciu and Matthew T. Feldner
Clinical Case Studies 2013 12: 179 originally published online 29 January 2013
DOI: 10.1177/1534650112473518

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473518 CCS12310.1177/1534650112473518Clinical Case StudiesBunaciu and Feldner

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Clinical Case Studies

Flexible Application of 12(3) 179­–198


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DOI: 10.1177/1534650112473518
Exposure-Based Treatment for ccs.sagepub.com

an Outpatient With Multiple


Anxiety and Mood Disorders:  A
Comprehensive Case Study

Liviu Bunaciu1 and Matthew T. Feldner1,2

Abstract
Cognitive-behavioral therapy (CBT) is efficacious and effective in the treatment of anxiety dis-
orders. However, few guidelines exist on how to efficiently provide CBT when comorbidity is
present. Given that anxiety disorders may share underlying mechanisms of maintenance, target-
ing such mechanisms may be fruitful when working with individuals who suffer from exten-
sive 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.

Keywords
exposure, avoidance, anxiety, depression, comorbidity

1 Theoretical and Research Basis for Treatment


Anxiety disorders represent the most prevalent class of psychological disorders, with approxi-
mately 29% of the U.S. population meeting diagnostic criteria for an anxiety disorder in their
lifetime (Kessler et al., 2005). Moreover, anxiety disorders result in high levels of impairment and
societal cost. The quality of life of individuals with anxiety disorders is notably poorer compared
with that of psychologically healthy comparison groups (Olatunji, Cisler, & Tolin, 2007), and
estimates suggest these conditions accounted for US$42.3 billion in costs in 1990 in the United
States (Greenberg et al., 1999). Fortunately, anxiety disorders are treatable conditions.
1
University of Arkansas, Fayetteville, USA
2
Laureate Institute for Brain Research, Tulsa, OK

Corresponding Author:
Liviu Bunaciu, University of Arkansas, 216 Memorial Hall, Fayetteville, AR 72701, USA.
Email: liviubunaciu@gmail.com

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180 Clinical Case Studies 12(3)

Our field has long attempted to address Paul’s (1969) elemental questions regarding psycho-
social interventions: “What treatment, by whom, is most effective for this individual with what
specific problem under which set of circumstances, and how does it come about?” (p. 44).
Although these questions have yet to be comprehensively answered, treatment outcome research
has identified many successful interventions over the past four decades. Cognitive-behavioral
therapy (CBT) is an efficacious and effective intervention that outperforms other forms of psy-
chotherapy (Hofmann & Smits, 2008; Stewart & Chambless, 2009; Tolin, 2010) and rivals phar-
macotherapeutic approaches in the treatment of anxiety disorders (Roshanaei-Moghaddam et al.,
2011). In spite of the evidence base in support of CBT, several obstacles prevent the consistent
dissemination and implementation of this well-established intervention. One such obstacle stems
directly from our field’s commitment to empirically evaluate psychological treatments. More
specifically, in an attempt to address Paul’s (1969) questions, researchers have carefully devel-
oped, tested, and ultimately marketed many detailed manualized protocols that target problem
behaviors associated with distinct anxiety disorders. This approach has proven successful in
identifying efficacious interventions for Diagnostic and Statistical Manual of Mental Disorders
(4th ed.; DSM-IV; American Psychiatric Association, 1994)-defined anxiety disorders. However,
evidence-minded clinicians are now faced with the daunting challenge of receiving training in,
and ultimately choosing from, a plethora of evidence-based CBT manuals that are available for
each individual anxiety disorder. This task is further complicated by the issue of comorbidity. A
large majority of individuals meeting primary diagnostic criteria for an anxiety disorder receive
at least one additional anxiety or mood disorder diagnosis (Brown, Campbell, Lehman, Grisham,
& Mancill, 2001). Treatments for individuals with comorbid diagnoses can be a costly and time-
consuming endeavor for patients as the duration of manualized CBT for just one anxiety disorder
typically lasts between 12 and 20 weeks (Barlow, 2008). Providers are also faced with challenges
given they must learn multiple manualized treatments, often with few guidelines regarding
sequencing treatments to be delivered. In sum, CBT protocols are efficacious for individual anxi-
ety disorders, but they often adopt a relatively narrow focus and can be difficult to implement
with common highly comorbid treatment cases. These limitations must be addressed to enhance
dissemination efforts and reduce the economic burden placed on patients and providers.
Empirically supported CBT protocols typically consist of several theoretically derived tech-
niques that target mechanisms presumed to maintain anxiety psychopathology. Interestingly,
these techniques lead to improvement in not only principal anxiety disorders but also comorbid
conditions that are not directly targeted (Borkovec, Abel, & Newman, 1995; Davis, Barlow, &
Smith, 2010; Tsao, Mystkowski, Zucker, & Craske, 2002). These findings are noteworthy as they
suggest that anxiety disorders may share the same underlying mechanisms of maintenance and
that treatments that address such mechanisms may improve upon the noted limitations associated
with existing CBT protocols. Indeed, recent evidence suggests that transdiagnostic interventions
targeting broad-based mechanisms involved in the maintenance of multiple types of psychopa-
thology reduce the severity of principal anxiety disorders as well as comorbid conditions in a
timely and cost-effective manner (Farchione et al., 2012). Accordingly, continued empirical
examination of interventions targeting such mechanisms is needed.
Avoidance of negative affect, in all of its forms (e.g., behavioral, cognitive, experiential),
represents a hallmark maintaining variable for all anxiety disorders (Barlow, Allen, & Choate,
2004; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), and contemporary CBT approaches
regard avoidance behaviors as prime targets in treatment. Exposure techniques address entrenched
avoidance patterns by asking patients to gradually face feared stimuli and situations until extinc-
tion learning occurs, and a marked decrease in anxiety is observed in the absence of safety
behaviors or avoidance-based coping (Barlow, 2002). Such techniques constitute a primary com-
ponent of the aforementioned transdiagnostic treatment (Farchione et al., 2012), and evidence

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Bunaciu and Feldner 181

suggests that they may be the necessary and sufficient components of CBT for several, if not all,
anxiety disorders (Deacon & Abramowitz, 2004). However, these procedures are not often used
in isolation from other CBT components (i.e., cognitive restructuring; Beck, Emery, & Greenberg,
1985) despite the fact that doing so may prove to be an equally efficacious and more cost-
effective approach. This case study provides one such example of an exposure-based treatment
with an outpatient suffering from multiple difficulties.

2 Case Introduction
General details about this case have been altered to protect the patient’s confidentiality.
Information regarding symptomatology and the course of treatment remains intact. “Betty” was
a 40-year-old, single Caucasian female who was self-referred to the psychological clinic of a
large, south-central university for anxiety-related difficulties. Betty had worked as an educator,
but had been unemployed for 1 year, and was receiving disability compensation due to ongoing
psychological and medical difficulties. The first author was a 4th-year graduate student complet-
ing his doctoral training in clinical psychology under the supervision of the second author, a
licensed clinical psychologist.

3 Presenting Complaints
Betty reported multiple ongoing concerns. Her presenting complaint involved clinically signifi-
cant anxiety and avoidance related to social situations for fear of being negatively evaluated
(e.g., offending others). Feared and avoided situations included speaking with strangers or per-
sons in authority, dating, eating in public, giving presentations, attending parties and meetings,
and behaving assertively. These difficulties had persisted for several years since experiencing
unexpected panic attacks at work and were notably interfering with Betty’s functioning. For
example, in spite of limited social support and financial difficulties, she was reluctant to spend
time with people, go back into the workforce or continue with her education.
Betty reported clinically significant symptoms of depression that had persisted without dis-
cernible remission for 11 years, since the passing of several family members. Symptoms included
anhedonia, low positive affect, hopelessness, fatigue, sleep-onset difficulties, and overeating.
These difficulties were distressing and interfered with Betty’s life. Indeed, as a result of overeat-
ing, Betty was overweight and unable to perform chores around her home.
Betty reported clinically significant avoidance related to small, enclosed places for fear of
getting stuck or having a panic attack. These distressing difficulties had persisted without remis-
sion for 13 years since experiencing a panic attack in a magnetic resonance imaging (MRI)
scanner.
Betty endorsed being sexually assaulted by a close family friend. She reported experiencing a
number of distressing symptoms such as flashbacks and avoidance of internal and external
reminders of her index trauma. These difficulties were also preventing her from engaging in
multiple valued activities. For example, Betty had ceased hiking and playing with certain ani-
mals because of her emotional reactivity associated with these behaviors.
Betty reported a history of unexpected panic attacks that started in a local grocery store shortly
after the aforementioned sexual assault. She was highly aware of the stimuli and situations that
elicited her panic attacks and was experiencing only cued attacks when she presented to treat-
ment. Nevertheless, she reported significant worry about having additional attacks and the con-
sequences of these attacks (e.g., blacking out, falling, experiencing a heart attack). She was
highly apprehensive of leaving her home and avoided numerous situations for fear that she would
experience a panic attack or panic-like symptoms (e.g., diarrhea, nausea, dizziness, sweating).

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182 Clinical Case Studies 12(3)

She avoided public transportation, open spaces, movie theatres, and only went to grocery stores
for brief periods after first consulting detailed store maps.
Betty also reported excessive and uncontrollable nonspecific worries about minor matters,
finances, and her health. These worries and associated physiological symptoms (e.g., restless-
ness, fatigue) were distressing and further interfered with her daily life.

4 History
Betty’s mother was deceased, while her father resided locally. Family history of psychological
difficulties included mood and substance use disorders. Betty described her mother and sibling
as verbally aggressive, critical of her, and unpleasant to be around. The patient’s medical history
revealed that she suffered from sleep apnea, seasonal allergies, migraine headaches, and she was
overweight. She lived alone and engaged in few enjoyable activities. She reported no social
contacts other than her father and another family member. Substance use history was unremark-
able. She denied smoking tobacco products or using any illicit substances. She rarely consumed
alcohol. Betty had previously met with a psychologist for nearly 4 years to address some of her
ongoing concerns (e.g., depression). This intervention produced little improvement in terms of
the patient’s symptoms. Trials of psychotropic medications (including, but not limited to,
Trazodone, Celexa, Xanax, Prozac, Wellbutrin, and Zoloft) were unsuccessful and Betty was
dissatisfied with her psychiatric care.

5 Assessment
Betty’s psychosocial history was evaluated during an intake session. The Anxiety Disorders
Interview Schedule for DSM-IV (ADIS-IV) was administered to aid with assessment, diagnosis,
and treatment. This is a well-validated semistructured interview designed for the assessment and
diagnosis of anxiety and mood disorders (Brown, DiNardo, Lehman, & Campbell, 2001).
Results of this evaluation, described in greater detail above, indicated that Betty met diagnostic
criteria for the following disorders: panic disorder with agoraphobia (PDA), posttraumatic stress
disorder (PTSD), dysthymic disorder (DD), social anxiety disorder (SAD), generalized anxiety
disorder (GAD), and claustrophobia (CL).

6 Case Conceptualization
In line with contemporary etiological models of emotional disorders (Barlow, 2000), the devel-
opment of Betty’s conditions was likely affected by a host of biopsychosocial vulnerabilities and
life stressors. Her family history of mood difficulties may have marked a general biological
predisposition to experience negative affect, and ultimately develop anxiety and mood disorders.
This vulnerability, coupled with adverse life circumstances (e.g., death in the family) that limited
contact with positive reinforcement, likely amplified the experience of negative affect and
affected the onset of depression. Similarly, her early life experiences with her critical mother
may have contributed to perceiving socially evaluative situations as threatening, a psychological
vulnerability that likely imparted risk for the development of SAD after the patient experienced
embarrassing panic attacks in the presence of her coworkers. Other stressful life events may
have directly or indirectly contributed to Betty’s difficulties. After experiencing a severe panic
attack in an MRI scanner, she developed CL by acquiring a classically conditioned fear of
stimuli associated with this distressing experience (e.g., enclosed places). The fear experienced
by Betty during her salient sexual assault likely also became associated via classical condition-
ing with many previously neutral stimuli (e.g., somatic or sensory cues, cognitions, environmen-
tal cues). As a result, these and other related stimuli may have elicited emotional reactivity

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Bunaciu and Feldner 183

similar to that experienced during the assault, thereby contributing to PTSD symptomatology
(e.g., exaggerated startle response, flashbacks). Fearful reactivity to trauma-related stimuli
likely also contributed to Betty experiencing apparently unexpected panic attacks that influ-
enced the development of PDA. This conceptualization is consistent with contemporary models
of PTSD–PDA comorbidity (Falsetti, Resnick, Dansky, Lydiard, & Kilpatrick, 1995; Hinton,
Hofmann, Pitman, Pollack, & Barlow, 2008) as well as Betty’s report of experiencing an unex-
pected panic attack in a grocery store in close proximity to trauma-related reminders (i.e., olfac-
tory cues) that were initially unbeknownst to her.
Avoidance-oriented behaviors were widely implicated in the maintenance of Betty’s difficul-
ties. At the time of treatment, Betty was hypervigilant for various possible threats (e.g., negative
evaluation, trauma-related cues, somatic sensations) and was engaging in behaviors that reduced
the likelihood of experiencing aversive emotional states (e.g., fear, anxiety). These negatively
reinforced avoidance behaviors provided short-term relief from ongoing distress, but also served
to maintain Betty’s anxieties by preventing her from learning that she was able to tolerate feared
internal and external stimuli. These actions also prevented Betty from engaging in many value-
driven behaviors that were conceptualized as essential to elevating her mood and promoting
physical and psychological well-being.
Faulty beliefs likely also contributed to the maintenance of Betty’s symptoms (e.g., bodily
arousal was catastrophically misinterpreted as a sign of serious impending problems). However,
cognitive restructuring was excluded from treatment to provide a time and cost-efficient inter-
vention that consisted of the most necessary and sufficient components of CBT for anxiety
disorders (Deacon & Abramowitz, 2004). Instead, an exposure-based treatment was proposed
as a way to address the presenting difficulties. By encouraging her to experience somatic sensa-
tions and approach feared situations via exposure exercises, extinction learning would be pro-
moted. She would learn that the consequences she feared (e.g., serious physical problems
resulting from bodily arousal) were relatively unlikely and uncomfortable bodily sensations and
symptoms of anxiety typically decrease across time, or at the very least can be tolerated.
Moreover, behavioral activation involved in the situational exposure (SE) exercises would be
fostered as Betty would come in contact with positively reinforcing activities.
Treatment consisted of three phases: psychoeducation, interoceptive exposure (IE), and SE.
Psychoeducation was conducted to provide Betty with a rationale for treatment and to facilitate
adherence to exposure exercises. Fears of somatic sensations were targeted via IE, after which
SE was implemented to address the patient’s fears of external stimuli. This sequence of exposure
exercises was chosen for two reasons. First, PDA was conceptualized as the principal diagnosis
as she was nearly homebound due to concerns about experiencing elevated bodily arousal and
panic attacks outside of her home. Therefore, reducing avoidance and fear of somatic sensations
via IE was expected to significantly affect her immediate functioning. Second, IE was expected
to facilitate SE. Fears of somatic sensations are prominent among patients with PD and also those
with other emotional disorders (Naragon-Gainey, 2010). Accordingly, by first conducting IE,
Betty was expected to better tolerate somatic sensations that would likely be elicited later during
the course of SE. This approach is supported by evidence that IE enhances the efficacy of
exposure-based interventions for PD (Craske, Rowe, Lewin, & Noriega-Dimitri, 1997) and that
it may also facilitate such treatments for other anxiety disorders (i.e., PTSD; Falsetti, Resnick, &
Davis, 2008; Wald & Taylor, 2007).

7 Course of Treatment and Assessment of Progress


After undergoing the aforementioned diagnostic evaluation, Betty came to the clinic for one
session to complete a comprehensive assessment that was administered repeatedly throughout
the course of treatment. The formal intervention consisted of 27 weekly 1- to 2-hr individual

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184 Clinical Case Studies 12(3)

psychotherapy sessions that occurred over a period of approximately 9 months. A thorough


description of each phase of the intervention is provided below. This is followed by a detailed
description of the assessment that was used to monitor treatment outcome, a description of the
data analytic approach, and finally a detailed summary of results.

Phase 1: Psychoeducation
The psychoeducation phase consisted of three sessions. In the first session, the case conceptual-
ization and treatment rationale were presented, and the patient was introduced to the biopsycho-
social vulnerabilities hypothesized to have contributed to her difficulties (e.g., depressed mood).
Classical conditioning was thoroughly discussed as the process via which Betty likely acquired
a conditioned fear of previously neutral somatic sensations and environmental stimuli after
experiencing stressful life events and panic attacks. Escape and avoidance behaviors were
emphasized as being negatively reinforced by the short-term diminution in negative affect that
they engendered. In doing so, these behaviors were presented as being central to limiting extinc-
tion learning, and maintaining conditioned fears. Accordingly, repeatedly confronting (cf. avoid-
ing) a range of feared internal and external stimuli via exposure exercises was described as the
ideal means to evaluate feared consequences while also learning that symptoms of anxiety often
decrease or at the very least are tolerable. The second session was spent reviewing psychoeduca-
tion materials from a prominent treatment for PDA (Craske & Barlow, 2006). Emphasis was
placed on common myths associated with panic attacks (e.g., experiencing cardiopulmonary
failure during panic attacks), differentiating between fear and anxiety, while also highlighting
the function of the fight-or-flight response and its unintended side effects (i.e., uncomfortable
bodily arousal). The final psychoeducation session was devoted to discussing the structure and
parameters of IE exercises and introducing the Subjective Units of Discomfort Scale (SUDS;
Wolpe & Lazarus, 1966). Homework assignments during this phase of treatment consisted of
reading psychoeducation materials and self-monitoring daily symptoms (e.g., panic attacks,
anxiety). Broadly, Betty evidenced a clear understanding of the treatment rationale and psycho-
education materials, and completed all assigned homework.

Phase 2: Exposure
Exposure exercises targeted Betty’s widespread pattern of avoidance. The primary guidelines for
these exercises emphasized the importance of repeatedly confronting and fully attending to
feared stimuli and situations while refraining from engaging in safety behaviors or distraction
strategies. In contrast to contemporary CBT approaches, within-session fear reduction was not
the principal target of treatment. Although fearful subjective and physiological responding typi-
cally decrease over the course of exposure trials, within-session fear reduction and low end-state
fear levels are not always observed and do not appear to be necessary for long-term positive
outcomes (Craske et al., 2008). These observations are consistent with extinction research sug-
gesting that originally conditioned associations are not erased during exposure therapy and can
in fact be easily retrieved by altering various contextual cues in one’s environment (Bouton,
1993). Accordingly, although fearful responding was monitored and targeted, the primary goals
of exposure exercises were not necessarily to decrease fear and anxiety but rather to foster new
inhibitory associations between conditioned stimuli and emotional reactivity.
IE. As part of the ongoing assessment battery that was first administered before commencing the
intervention, Betty engaged in a voluntary hyperventilation (VH) exercise. The primary function
of the VH was to identify the somatic sensations that had become conditioned cues for panic
attacks and therefore needed to be targeted via IE during treatment. Although during CBT it is

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Bunaciu and Feldner 185

customary to use a series of panic-relevant exercises in anticipation of exposure (Craske &


Barlow, 2006), in this case, a VH was the sole symptom induction procedure during the preex-
posure assessment phase. This occurred for three primary reasons. First, the VH is a well-estab-
lished biological challenge that can be easily and safely implemented to reliably elicit abrupt
increases in panic-relevant bodily arousal (Zvolensky & Eifert, 2001). Second, using a single
symptom induction exercise was considered to be a time and cost-efficient approach. Finally, in
contrast to other such exercises (e.g., chair spinning, dot staring, head lifting), VH is typically
characterized by elevated anxiety and a range of bodily sensations (e.g., dizziness, dyspnea,
tachycardia, depersonalization) that resemble those experienced during naturally occurring panic
attacks (Antony, Ledley, Liss, & Swinson, 2006; Lickel, Nelson, Lickel, & Deacon, 2008;
Schmidt & Trakowski, 2004). Consistent with expectations, Betty prematurely terminated the
VH after 102 s (a standard 180-s maximum duration was used). Moreover, she reported extreme
anxiety (SUDS = 8/8) in response to this exercise, which produced 10 panic symptoms of at least
moderate intensity.
The IE phase consisted of seven sessions. IE exercises were chosen based on their likelihood
of evoking the most intense sensations endorsed by Betty following the initial VH (e.g., tachy-
cardia, dizziness, dyspnea, nausea, suffocation). Two sessions consisted of walking up and down
stairs while wearing a sweater. One session involved spinning in place while standing and keep-
ing eyes open. Three sessions were dedicated to keeping nostrils pinched and breathing as long
as possible through a coffee straw. Betty practiced wearing a continuous positive airway pressure
(C-PAP) mask during the last IE session. The goal of this exposure exercise was to not only elicit
sensations of difficulty breathing and breathlessness but also to address her recurring noncompli-
ance for medical treatment of sleep apnea by reducing anxiety she was experiencing when
attempting to wear the mask. To this end, some time was also spent providing Betty with sleep
hygiene recommendations to assist with ongoing sleep-onset and sleep-maintenance difficulties.
Sessions generally involved multiple exposure trials (2-7) each lasting between 30 s and 15 min.
Betty evidenced notably reduced SUDS ratings over the course of all IE exercises, with the
exception of breathing through a straw. Her anxiety remained greatly elevated (SUDS = 8)
throughout the duration of this exercise. Most importantly, as a result of these exercises, Betty
refuted her feared consequences (e.g., “symptoms will last forever,” “I will vomit”) and acknowl-
edged her ability to generally tolerate a range of uncomfortable bodily sensations (e.g., faintness,
tachycardia, muscle tension, perspiration, choking). Homework assignments consisted of prac-
ticing IE exercises 2 to 4 times per day while at home. Homework adherence was excellent.
SE. A behavioral approach test (BAT) that lasted approximately 1 hr was conducted in the pres-
ence of the clinician at the end of the last IE session. The primary function of the BAT was to
evaluate Betty’s functioning in a variety of situations that were relevant to her existing fears (e.g.,
negative evaluation, being trapped, trauma reminders) and to identify situations to be targeted via
SE during treatment. This BAT included the following in vivo components: (a) a walk through
the university campus, (b) multiple conversations with strangers, (c) going on an elevator, (d)
standing in crowded locations, and (e) confronting situational reminders of her sexual assault.
Betty was distressed by each of these situations, which elicited extreme anxiety (SUDS = 8/8)
and multiple panic symptoms.
The SE phase consisted of 17 sessions. Given that the patient had evidenced a clear under-
standing of the rationale and pragmatics of exposure therapy, most of the SE sessions aimed to
foster independence in exposure implementation to better prepare the patient for termination,
and ultimately assist with relapse prevention. Accordingly, Betty engaged in SE exercises during
only three of these sessions, whereas the remaining 14 sessions focused mostly on reviewing
between-session exposures and tailoring additional homework assignments. To increase the eco-
logical validity of these exercises and proceed in a timely fashion, SE exercises were designed to

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186 Clinical Case Studies 12(3)

target multiple fears of external situations concomitantly and to foster additional inhibitory asso-
ciations between bodily arousal and intense emotional experiences. For example, a SE exercise
that simultaneously addressed Betty’s fear of anxiety-related sensations, crowded places, and
negative evaluation involved walking through a busy Farmer’s Market on a hot day while engag-
ing in conversations with strangers. Similarly, a task that targeted agoraphobic fears and remind-
ers of the index trauma involved Betty shopping at a grocery store in her assailant’s old
neighborhood while exposing herself to olfactory cues of the trauma. SE exercises also aimed to
promote value-driven activation and physical health. For example, homework assignments
included attending a variety of events (e.g., support group meetings, movies, dog training,
church, concerts). While such exercises specifically targeted Betty’s fears (e.g., negative evalua-
tion, enclosed places), they also fostered an improvement in mood by helping her engage in
long-avoided behaviors that were consistent with multiple valued domains (e.g., spirituality,
recreation). Similarly, hiking on local trails was proposed as a way to not only further reduce fear
of bodily arousal but also increase physical exercise that was deemed essential in the treatment
of obesity. Homework adherence was excellent throughout the SE phase. In addition, by the end
of treatment, Betty evidenced the ability to independently design and engage in new exposure
exercises that were considered necessary for relapse prevention.

Assessment Strategy
A comprehensive assessment strategy was used to monitor proximal treatment targets and treat-
ment outcomes. Well-established self-report instruments (described below) were administered
to measure targeted mechanisms of maintenance (e.g., avoidance), symptoms associated with
Betty’s diagnoses, and related impairment. In an effort to reduce Betty’s burden, this battery was
divided in half, allowing for each questionnaire to be completed biweekly. Weight and anxious
reactivity to bodily arousal were also measured biweekly. Betty completed a measure of thera-
peutic alliance at the end of every session. The ADIS-IV was readministered at a 1-month
follow-up to evaluate posttreatment diagnostic status.
Proximal Treatment Targets and Process. Several mechanisms conceptualized as maintaining
Betty’s psychopathology, as well as therapeutic alliance thought of as critical for treatment prog-
ress, were measured as follows.
Anxiety Sensitivity Index–3 (ASI-3). The ASI-3 is an 18-item questionnaire that measures fear of
anxiety-related sensations due to perceived physical, cognitive, and social negative consequences
on a 0 (very little) to 4 (very much) Likert-type scale. The ASI-3 includes three subscales, includ-
ing Physical, Mental Incapacitation, and Social Concerns. Scores range from 0 to 24 on each
scale, with higher scores indicating greater anxiety sensitivity. The ASI-3 possesses excellent
psychometric properties (Wheaton, Deacon, McGrath, Berman, & Abramowitz, 2012).
Agoraphobic Cognitions Questionnaire (ACQ). The ACQ is a 15-item questionnaire that measures
maladaptive cognitions that can occur while anxious. The frequency of such thoughts is rated on
a 1 (thought never occurs) to 5 (thought always occurs) Likert-type scale. Total scores are
obtained by calculating the means of all items. Reliability and validity indices for the ACQ are
adequate (Chambless, Caputo, Bright, & Gallagher, 1984).
Cognitive-Behavioral Avoidance Scale (CBAS). The CBAS is a 31-item questionnaire that mea-
sures the degree to which individuals engage in cognitive and behavioral avoidance across social
and nonsocial domains. Total scale scores range from 31 to 155. Preliminary reports have sup-
ported the psychometric properties of this scale (Ottenbreit & Dobson, 2004).
VH. Fearful reactivity to bodily arousal was evaluated with a biweekly VH challenge. Although
the maximum duration of this exercise was 180 s, Betty was instructed to continue with each VH
challenge for as long as she felt comfortable (up to 180 s). Multiple indices of fearful reactivity

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Bunaciu and Feldner 187

were obtained. First, the duration that she engaged in the VH before discontinuing the exercise
was monitored as an index of behavioral avoidance of bodily arousal. Shorter durations were
deemed indicative of less willingness to tolerate uncomfortable somatic sensations. Second,
SUDS ratings were used to monitor levels of anxiety before and following the VH. Finally, Betty
completed the Diagnostic Symptoms Questionnaire (DSQ; Sanderson, Rapee, & Barlow, 1989)
following each VH procedure to indicate the degree to which she experienced any 1 of 15 panic
symptoms during the VH. Each panic symptom was rated on a 9-point scale from 0 (not at all)
to 8 (very strongly felt). A total DSQ score was derived by adding the number of panic symptoms
of at least moderate intensity (i.e., SUDS ≥ 4) that were reported following the VH.
Session Rating Scale (SRS). Therapeutic alliance was measured via the SRS (Duncan et al.,
2003), which includes four visual analogue rating scales. Scores on each scale (e.g., relationship)
range from 0 to 40, with higher numbers indicating a stronger working alliance. Psychometric
properties of the SRS are adequate and comparable with other alliance measures.
Primary Treatment Outcomes. In addition to measuring mechanisms maintaining Betty’s psy-
chopathology, each of the primary treatment outcomes was measured with well-established
instruments as described below. This assessment strategy was developed to measure the primary
anxiety-related outcomes as well as the primary nonanxiety outcomes.
Depression Anxiety Stress Scales (DASS). The DASS (Antony, Bieling, Cox, Enns, & Swinson,
1998) is a 21-item questionnaire that includes three scales measuring symptoms of depression,
anxiety, and stress. Scores range from 0 to 42 on each scale, with higher scores indicating more
severe levels of depression, anxiety, and stress. The DASS-21 has sound psychometric properties
(Antony et al., 1998).
Social Phobia Scale (SPS) and Social Interaction Anxiety Scale (SIAS). The SPS is a 20-item ques-
tionnaire that measures fears of being scrutinized during routine activities (e.g., eating in public).
The SIAS consists of 19 items that evaluate fears of interpersonal interactions (e.g., talking at
parties). Items on the SPS and SIAS are rated on a 0 (not at all characteristic or true of me) to 4
(extremely characteristic or true of me) Likert-type scale. Scores range from 0 to 76 on the SIAS
and 0 to 80 on the SPS, with higher scores suggesting more severe levels of social anxiety. The
SPS and SIAS evidence adequate levels of reliability and validity as measures of social anxiety,
and are sensitive to treatment effects (Mattick & Clarke, 1998).
PTSD Checklist–Civilian Version (PCL-C). The PCL-C consists of 17 items that measure PTSD
symptom severity. Each item is scored on a 5-point Likert-type scale, with scores ranging from
17 to 85. The psychometric properties of the PCL-C are well established among civilian popula-
tions (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996).
Mobility Inventory for Agoraphobia (MIA). The MIA is a questionnaire primarily used to index
severity of agoraphobic avoidance. The MIA lists 26 situations that are commonly avoided by
patients with PDA (e.g., supermarkets, auditoriums) when alone and when accompanied by oth-
ers. Each item is rated on a 1 (never avoid) to 5 (always avoid) scale, and a total score is obtained
by averaging all of the items on each scale. Higher scores are indicative of greater agoraphobic
avoidance. The MIA has excellent psychometric properties (Chambless et al., 2011). At the onset
of treatment, Betty had few social contacts and only endorsed avoidance when alone. Accord-
ingly, only scores from this scale are reported.
Penn State Worry Questionnaire (PSWQ). The PSWQ is a 16-item questionnaire that measures
trait-like tendencies to worry excessively about nonspecific topics. Scores range from 16 to 80,
with greater scores reflecting higher levels of nonspecific worry. The PSWQ has excellent psy-
chometric properties and is widely used to assess pathological worry characteristic of GAD
(Brown, Antony, & Barlow, 1992).
Claustrophobia Questionnaire (CLQ). The CLQ is a well-established 26-item questionnaire that
measures fears of suffocation and restriction characteristic of individuals with CL (Radomsky,

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188 Clinical Case Studies 12(3)

Rachman, Thordarson, McIsaac, & Teachman, 2001). Respondents are asked to rate how anx-
ious they would feel in a variety of situations using a 5-point scale ranging from 0 (not at all
anxious) to 4 (extremely anxious). Scores range from 0 to 104.
Weight. Betty’s weight was measured using a digital scale available in the clinic.
Disruption of Functioning Index (DFI). The DFI is a 7-item questionnaire that measures impair-
ment stemming from medical or psychological problems. Impairment across multiple life
domains (e.g., recreation, occupation) is rated on a 10-point scale ranging from 0 (no disruption)
to 10 (total disruption). A total score is obtained by averaging all of the items on the DFI.

Data Analytic Approach


Data from the psychoeducation, exposure, and follow-up phases are graphically displayed in
Figures 1 through 3. Tau-U analyses were used to gauge change in levels of each proximal target
and treatment outcome. This analytic approach is derived from Kendall’s Rank Correlation and
the Mann–Whitney U test and has recently been recommended for single-case research for mul-
tiple reasons (Parker, Vannest, Davis, & Sauber, 2011). First, similar to nonoverlap techniques,
it compares individual data points (cf., central tendency of data) across two treatment phases,
giving equal consideration to all data points. This is particularly important as nonoverlap or
dominance of one phase over another can be determined even when the possibility of outlier
scores is high, as is often the case with client-based research. In doing so, Tau-U allows for
indexing improvement via the percent of comparisons that document decreases, relative to
increases or worsening, in an outcome measure from one data point to the next. Importantly, in
contrast to other nonoverlap techniques or regression-based approaches, Tau-U is sensitive to
phase length, better manages assumptions regarding stability of trends in the data, and controls
for undesirable baseline trend. Ultimately, Tau-U’s ability to document nonoverlap in the data
while also control for trend within and across treatment phases results in a statistically powerful
technique that allows for more accurate conclusions regarding change during an intervention.
For the purposes of this study, Tau-U analyses focused on examining change within and across
the IE and SE phases of treatment. This approach, as opposed to analyzing such changes in
regard to the psychoeducation versus intervention phases, for example, was deemed most eluci-
dative in terms of understanding change in proximal targets and outcomes during treatment.

Summary of Results
Therapeutic alliance was strong throughout treatment. Scores on each scale of the SRS routinely
ranged between 38 and 40.
Graphic display of data from each proximal target measure is presented in Figure 1. Results
from Tau-U analyses of proximal target data are summarized in Table 1. As can be seen, steep
declines were observed across all proximal treatment targets. Also of note, Betty prematurely
discontinued the VH procedure in each of the first two administrations, thereafter completing
the maximum 180-s duration for the final 13 administrations, suggesting reductions in behav-
ioral avoidance of bodily arousal. Tau-U analyses further suggest that all proximal targets
(except for the physical concerns facet of the ASI-3) significantly decreased during the latter
half of treatment (i.e., SE phase), even after accounting for the slope of change during the IE
phase of treatment. With regard to the ASI–Physical Concerns subscale, a relatively dramatic
reduction (>70%) was observed during the psychoeducation phase. The resulting low level of
ASI–Physical Concerns appeared stable, and as a result, no significant change was observed
between the exposure phases of treatment.

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Bunaciu and Feldner 189

ASI-3-Physical 5 ACQ
20 4.5
4
15 3.5
3
10
2.5
5 2
1.5
0 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
CBAS 8 SUDS - Post
151
7
131
6
111 5
91 4
3
71
2
51 1
31 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

14 DSQ
12
10
8
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Figure 1. Proximal treatment target data across psychoeducation (), interoceptive exposure (),
situational exposure (▲), and follow-up phases (x).
Note: Dotted horizontal lines represent the mean scores of nonclinical/nonanxious controls. Solid horizontal lines
represent the mean scores of patients suffering from psychopathology (i.e., ASI-3 Physical–PDA; ACQ–PDA; CBAS–
Major Depressive Disorder [MDD] and SAD; SUDS–PDA; DSQ–PDA).

Data from each anxiety-related treatment outcome measure is presented in Figure 2 and
details regarding the associated Tau-U analyses are provided in Table 2. Figure 2 and Table
2 suggest significant reductions in all primary anxiety-related outcomes during SE after
controlling for trends during the IE phase of treatment.
Data from measures of non-anxiety-related outcomes are graphically presented in Figure
3. The associated Tau-U analyses are included in Table 1. Figure 3 and Table 1 indicate
significant reductions occurred in terms of DASS-Depression as well as DFI-measured
impairment. Contrary to expectations, the intervention did not appear to significantly affect
Betty’s weight. An observation that may explain this finding was that she was eating to
suppress bodily sensations that were elevated as a result of IE exercises. This eating pattern
corresponded to an increase in weight until, on identifying this pattern approximately mid-
way through treatment, eating as a means to suppress bodily arousal was directly targeted
in therapy as an avoidance strategy. Subsequently, Betty’s weight decreased, but not sig-
nificantly when considering change across the entire IE and SE phases.

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190 Clinical Case Studies 12(3)

Table 1. Tau-U Analyses of Proximal Treatment Targets and Non-Anxiety-Related Outcomes Within
and Across Interoceptive Exposure (IE) and Situational Exposure (SE) Phases of Treatment.
Decreases/
increases S Tau SD VAR z

Proximal treatment targets


Anxiety sensitivity concerns 3–Physical concerns
  Trend during IE 1/1 0 0.00 1.63 2.66 0.00
  Trend during SE 11/6 5 0.18 6.90 47.61 0.72
  IE vs. SE + trend SE − trend IE 32/11 21 0.38 12.10 146.41 1.74
Agoraphobic Cognitions Questionnaire
  Trend during IE 2/0 2 0.67 1.63 2.66 1.23
  Trend during SE 33/3 30 0.83 9.59 91.97 3.13**
  IE vs. SE + trend SE − trend IE 50/14 36 0.55 14.51 210.54 2.48*
Cognitive-Behavioral Avoidance Scale
  Trend during IE 1/2 −1 0.33 1.91 3.65 −0.52
  Trend during SE 29/6 23 0.64 9.54 91.01 2.41*
  IE vs. SE + trend SE − trend IE 58/7 51 0.77 14.55 211.70 3.51**
Self-reported post-voluntary hyperventilation anxiety
  Trend during IE 2/1 1 0.33 1.91 3.65 0.52
  Trend during SE 29/3 26 0.72 9.35 87.42 2.78**
  IE vs. SE + trend SE − trend IE 48/9 39 0.59 14.15 200.22 2.76**
Diagnostic Symptoms Questionnaire
  Trend during IE 1/2 −1 −0.33 1.91 3.65 −0.52
  Trend during SE 30/3 27 0.75 9.43 88.92 2.86
  IE vs. SE + trend SE − trend IE 53/9 44 0.67 14.45 208.80 3.04**

Non-anxiety-related outcomes
Depression Anxiety Stress Scales−Depression
  Trend during IE 1/2 −1 −0.33 1.91 3.65 −0.52
  Trend during SE 20/4 16 0.57 7.79 60.68 2.05*
  IE vs. SE + trend SE − trend IE 43/7 36 0.65 12.62 159.26 2.85**
Weight
  Trend during IE 1/2 −1 −0.33 1.91 3.65 −0.52
  Trend during SE 21/13 8 0.22 9.49 90.06 0.84
  IE vs. SE + trend SE − trend IE 26/37 −11 −0.17 14.48 209.67 −0.76
Disruption of Functioning Index
  Trend during IE 2/1 1 0.33 1.91 3.65 0.52
  Trend during SE 35/1 34 0.94 9.59 91.97 3.55**
  IE vs. SE + trend SE − trend IE 62/3 59 0.89 14.55 211.70 4.05**
Note: Decreases = count decreases in score from one measurement to the next; increases = count increases in score from one mea-
surement to the next; S = difference between the count decreases and the count increases.
*p < .05, two-sided exact. **p < .01, two-sided exact.

Despite the documented gains, the absence of a baseline phase and a true experimental design
should warrant caution when drawing inferences regarding the effects of this treatment. It is pos-
sible, although unlikely, that a host of factors other than those related to the intervention (e.g.,
time, regression to the mean) were responsible for the demonstrated improvements. Similarly,
the assessment itself may have reduced levels of certain factors. The self-monitoring (Craske &
Tsao, 1999) and the VH procedures (Schmidt & Trakowski, 2004) can result in anxiety reduc-
tions. This may have systematically resulted in decreases in related factors during the psycho-
education period (e.g., ASI–Physical Concerns, ACQ). Moreover, aspects of the IE and SE

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Bunaciu and Feldner 191

40 DASS-Anxiety 40 DASS-Stress
35 35
30 30
25 25
20 20
15 15
10 10
5 5
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

ASI-3-Mental ASI-3-Social
20 20

15 15

10 10

5 5

0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

80
70 SPS 70 SIAS
60 60
50 50
40 40
30 30
20 20
10 10
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

PCL-C 5 MIA
77 4.5
67 4
57 3.5
3
47
2.5
37 2
27 1.5
17 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

76 PSWQ 100 CLQ


66 80
56
60
46
40
36
26 20
16 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Figure 2. Anxiety-related treatment outcome data across psychoeducation (), interoceptive exposure
(), situational exposure (▲), and follow-up phases (x).
Note: Dotted horizontal lines represent the mean scores of nonclinical/nonanxious controls. Solid horizontal lines
represent the mean scores of patients suffering from psychopathology (i.e., DASS-Anxiety–PD; DASS-Stress–PD; ASI-3
Mental–GAD; ASI-3 Social–SAD; SPS–SAD; SIAS–SAD; PCL-C–PTSD; MIA–PDA; PSWQ–GAD; CLQ–CL).

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192 Clinical Case Studies 12(3)

Table 2. Tau-U Analyses of Primary Anxiety-Related Outcomes Within and Across Interoceptive
Exposure (IE) and Situational Exposure (SE) Phases of Treatment.
Decreases/
increases S Tau SD VAR z
Depression Anxiety Stress Scales–Anxiety
  Trend during IE 0/2 −2 −0.67 1.63 2.66 −1.23
  Trend during SE 26/1 25 0.89 8.02 64.32 3.12**
  IE vs. SE + trend SE − trend IE 40/9 31 0.56 12.50 156.25 2.48*
Depression Anxiety Stress Scales−Stress
  Trend during IE 2/0 2 0.67 1.63 2.66 1.23
  Trend during SE 20/4 16 0.57 7.79 60.68 2.05*
  IE vs. SE + trend SE − trend IE 41/9 32 0.58 12.62 159.26 2.54*
Anxiety sensitivity concerns 3–Mental incapacitation concerns
  Trend during IE 1/1 0 0.00 1.63 2.66 0.00
  Trend during SE 18/3 15 0.54 7.46 55.65 2.01
  IE vs. SE + trend SE − trend IE 42/4 38 0.69 12.38 153.26 3.07**
Anxiety sensitivity concerns 3–Social concerns
  Trend during IE 1/2 −1 −0.33 1.91 3.65 −0.52
  Trend during SE 24/3 21 0.75 8.02 64.32 2.62*
  IE vs. SE + trend SE − trend IE 45/7 38 0.69 12.70 161.29 2.99**
Social Phobia Scale
  Trend during IE 0/2 −2 −0.67 1.63 2.66 −1.23
  Trend during SE 25/3 22 0.79 8.08 65.29 2.72**
  IE vs. SE + trend SE − trend IE 47/5 42 0.76 12.70 161.29 3.31**
Social Interaction Anxiety Scale
  Trend during IE 0/3 −3 −1.00 1.91 3.65 −1.57
  Trend during SE 26/2 24 0.86 8.02 64.32 2.99**
  IE vs. SE + trend SE − trend IE 50/4 46 0.84 12.81 164.10 3.59**
PTSD Checklist
  Trend during IE 2/1 1 0.33 1.91 3.65 0.52
  Trend during SE 22/4 18 0.64 7.96 63.36 2.26*
  IE vs. SE + trend SE − trend IE 45/8 37 0.67 12.77 163.07 2.90**
Mobility Inventory for Agoraphobia
  Trend during IE 0/3 0 0.00 1.91 3.65 0.00
  Trend during SE 25/3 22 0.79 8.08 65.29 2.72**
  IE vs. SE + trend SE − trend IE 49/6 43 0.78 12.85 165.12 3.35**
Penn State Worry Questionnaire
  Trend during IE 1/2 −1 −0.33 1.91 3.65 −0.52
  Trend during SE 28/0 28 1.00 8.08 65.29 3.47**
  IE vs. SE + trend SE − trend IE 54/1 53 0.96 12.85 165.12 4.12**
Claustrophobia Questionnaire
  Trend during IE 2/0 2 0.67 1.63 2.66 1.23
  Trend during SE 28/0 28 1.00 8.08 65.29 3.47**
  IE vs. SE + trend SE − trend IE 49/5 44 0.80 12.81 164.10 3.43**
Note: Decreases = count decreases in score from one measurement to the next; increases = count increases in
score from one measurement to the next.
*p < .05, two-sided exact. **p < .01, two-sided exact.

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Bunaciu and Feldner 193

DASS-Depression Weight
40 300
35 295
30 290
25
20 285
15 280
10
5 275
0 270
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
DFI
10
9
8
7
6
5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Figure 3. Graphic representation of non-anxiety-related treatment outcome data across


psychoeducation (), interoceptive exposure (), situational exposure (▲), and follow-up phases (x).
Note: Dotted horizontal line represents the mean scores of nonclinical controls. Solid horizontal line represents the
mean scores of patients suffering from psychopathology (i.e., DASS-Depression–MDD).

phases were likely cumulative. Indeed, IE informally continued during the SE phase in various
forms, as Betty faced feared external situations that likely also elicited feared internal sensations.
For all of these reasons, fully isolating the unique effects of either phase of treatment is not pos-
sible in the current design.

8 Complicating Factors
Treatment was not notably affected by any particular factors. Betty had a long history of experiencing
unintended side effects as a result of the pharmacological treatments that she had undergone. Upon
presenting to treatment, she was being prescribed an anticonvulsant (i.e., Lamictal) for what were
presumed to be symptoms of bipolar disorder. The conducted diagnostic evaluation ruled out this pos-
sibility and prompted Betty to cease this regimen after consulting with the prescribing physician.
Betty’s physical health was relatively poor due to being overweight and a host of previous physical
injuries. As a result, treatment was at times tailored to minimize unnecessary discomfort that would
likely be elicited by IE exercises. For example, rather than engaging in stair-stepping exercises that
caused pain in her previously broken ankles, Betty was instructed to practice speed-walking during
homework assignments. Such modifications did not interfere with, but rather evidence the flexibility
of, the treatment approach. In spite of her multiple difficulties (e.g., extensive pattern of avoidance)
and ongoing life stressors (e.g., legal proceedings related to bankruptcy), Betty’s attendance was good.
Indeed, she only cancelled six scheduled appointments. She presented as highly motivated throughout
the entire course of treatment, and her homework adherence was excellent.

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194 Clinical Case Studies 12(3)

9 Access and Barriers to Care


There were no concerns regarding access or barriers to care. Betty had a reliable means of trans-
portation that allowed her to attend sessions consistently. The intervention was conducted at a
university-based clinic that did not accept third-party payers and charged for services using an
income-based sliding fee scale. Although Betty’s financial resources were limited, the course of
treatment was not influenced by managed care organizations.

10 Follow-Up
Betty underwent a thorough assessment 1 month after completing treatment, which included all
of the measures described above. Readministration of the ADIS-IV indicated that she no longer
met full diagnostic criteria for any disorder. As can be seen in Figures 1 through 3, all proximal
and treatment outcome measures suggested each of these (except for weight) remained well
below levels observed during the initial assessment. Betty’s weight initially increased during
treatment as discussed above. Although there appeared to be a trend toward weight reduction
during the second half of treatment, her weight increased by 6 lbs in the month after treatment
was completed. Accordingly, despite the fact that Betty routinely left her home and was much
more physically active by the end of treatment, engaging in regular outdoor activities (e.g., brisk
walks), additional treatment elements focused specifically on weight reduction (e.g., diet modi-
fication) may have been warranted.

11 Treatment Implications of the Case


Taken together, Betty responded very well to a challenging intervention that targeted extensive
anxiety-related comorbidity by first emphasizing psychoeducation and exposure to feared intero-
ceptive stimuli, and later primarily on exposure exercises to feared situational stimuli. As depicted
in Figures 1 through 3 and Tables 1 and 2, treatment gains were statistically and clinically signifi-
cant for a wide range of anxiety- and mood-related difficulties associated with clinical diagnoses.
Noteworthy improvements were also observed in terms of Betty’s quality of life. For example, at
follow-up, Betty was leaving her home at will and regularly engaging in an array of value-driven
activities along with a network of acquaintances and friends that she developed during the course
of treatment. Importantly, despite the documented improvements in Betty’s functioning, it should
be noted that the absence of rigorous experimental control precludes causal inferences about the
unique effects of the treatment phases used in this intervention. This limitation notwithstanding,
possible implications of the present case study should be considered. First, this case study provides
further evidence in support of CBT for emotional difficulties (Tolin, 2010). Second, results docu-
mented herein add to a burgeoning literature focused on the use of transdiagnostic interventions
that target mechanisms responsible for maintaining multiple types of psychopathology. Indeed,
although this study outlines one such approach that targets avoidance of negative affect, it should
be noted that other cost-effective exposure- and non-exposure-based interventions can be imple-
mented in the treatment of comorbid conditions (Falsetti et al., 2008; Farchione et al., 2012;
Nishith, Nixon, & Resick, 2005). Third, this case study contributes to the limited intervention lit-
erature focused on the efficacy of exposure procedures when used in isolation from other typical
CBT components (i.e., cognitive restructuring). Indeed, results support the notion that exposure
techniques may be a necessary and sufficient component of CBT for anxiety disorders (Deacon &
Abramowitz, 2004). Accordingly, research should continue examining the efficacy of such inter-
ventions, as they may represent timely and cost-effective alternatives to customary CBT treatments
when treating cases involving multiple comorbid anxiety and mood disorders. Finally, the role of

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Bunaciu and Feldner 195

strong therapeutic alliance in the outcomes observed here should not be underestimated. This alli-
ance likely was instrumental in assisting Betty during this intervention.

12 Recommendations to Clinicians and Students


This case study outlines a flexible approach to exposure-based treatment for an individual suf-
fering from multiple emotional difficulties. Although such unified interventions require addi-
tional empirical examination, this study illustrates one example of how to develop an
evidence-based case conceptualization when extensive comorbidity is present, and how to use
this conceptualization to provide a timely and effective intervention that targets broad-based
maintenance mechanisms. Importantly, this approach is very amenable to dissemination and
application by experienced clinicians as well as students who work with anxiety disorders.

Declaration of Conflicting Interests


The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies
Liviu Bunaciu, MA, is a doctoral student at the University of Arkansas. His research interests concern the
etiology, maintenance, and treatment of anxiety disorders broadly, and panic disorder specifically.

Matthew T. Feldner, PhD, is a licensed clinical psychologist, associate professor in the Department of
Psychological Science at the University of Arkansas, adjunct associate professor at the Laureate Institute
for Brain Research, and director of the Intervention Sciences Laboratory. His research interests focus on
understanding the development, prevention, and treatment of panic disorder, posttraumatic stress disorder,
and the overlap between drug use behavior and these conditions.

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