The present chapter aims to guide clinicians in the principles of treatment and the use of the treatment Manual, as well as highlight some of the more common problems encountered in therapy. fihile further studies are needed to identify the active components of effective treatment for generalized anxiety disorder, it appears that two core elements are:

1. •An underlying rationale, based on the ‘coping skills’ model of cognitive

2. behavioral therapy, where patients are taught skills to manage their anxiety and

3. to take responsibility for change and control over their thoughts, feelings, and

4. behavior.

5. •Cognitive therapy with the goal of bringing the process of worry under the

6. patients control.

Relaxation training, usually a form of progressive muscle relaxation, is a useful adjunct to treatment, particularly where the effects of chronic and high levels of muscle tension trouble an individual.

Assessment

It is assumed that before the commencement of treatment, a clinical assessment will have ruled out comorbid diagnoses in need of immediate specific treatment, such as a major depressive episode. fihere depression is present, it becomes the treatment priority and the need for further treatment of anxiety symptoms reviewed when the depression is resolved. Given the phenomenological similarities between the two disorders, it is often necessary to establish from historical information whether GAD existed before the onset of a major depressive episode, or to assess whether a GAD continues to exist following effective treatment of the depressive disorder.

fihile patients with a primary diagnosis of GAD will not always meet criteria for another diagnosis, they will often have concerns and behaviors that are characteristic of other anxiety disorders. Panic attacks, social anxiety, phobic avoidance, obsessions, and illness anxiety are common. The treating clinician will therefore need to be able to recognize these different features and address these in the course of treatment. For example, some time can be spent focusing specifically on fears of scrutiny and negative evaluation or fears that a physical sensation is really a sign of a serious, life-threatening illness within the framework of the cognitive behavioral approach. The use of a slow-breathing exercise (possibly due to its meditation-like features) can provide temporary control over acute episodes of high anxiety for many individuals. Hence patients can be relatively quickly provided with an increased sense of control that allows them to recognize the triggers of their anxiety and implement cognitive strategies.

Aims of treatment

The aims of treatment are symptom reduction and improved function. Elimination of all anxiety is unlikely (and unnecessary), and the therapist has a role in helping the patient to set realistic goals for therapy. Psychological and pharmacological treatments are available for social phobia. The treatments for which there is most evidence of efficacy are cognitive and exposure-based treatments, social skills training packages, antidepressant medication and benzodiazepine anxiolytics. In general, outcome is related to severity of symptoms at pretreatment. Psychological treatments for social phobia

Social skills training

The role of social skills training in the treatment of social phobia continues to be debated. Prior to the publication of DSM-III, social skills training had demonstrated clinical utility in heterogeneous populations of psychiatric outpatients with social skills difficulties or anxieties (Stravynski et al., 1982;filazlo et al., 1990). Hence it was proposed that these techniques be applied to the treatment of social phobia. Reviewers agree that few of the early studies that examined social skills treatments were methodologically sound (Marks, 1985;Heimberg, 1989; Stravynski and Greenberg, 1989;Mattick et al., 1995); in particular, only rarely was a control condition in evidence. Diagnostic groups were often heterogeneous or poorly defined. No differentiation was made between those with and those without avoidant personality disorder (APD). In addition, strategies referred to as social skills training often included explicit instructions more consistent with exposure therapies, e.g., to regularly confront their fears and to persist in the situation until anxiety diminished (filazlo et al., 1990).

Part of the argument over the role of social skills training centers on whether apparently poor social skills are the result of actual skills deficits, or really due to inhibition of skills expression due to anxiety. Turner et al. (1986) examined thesocial skills of patients with social phobia, comparing those with and without avoidant personality disorder. They found that patients with social phobia alone felt anxious, and perceived that others found them anxious and inadequate, but in fact had appropriate social skills. Those with APD were found to be markedly lacking in social skills. However, the authors were unable to exclude profound inhibition in social situations as the underlying cause giving rise to the appearance of skills deficits: in APD, severe anxiety related to a core schema that social error will lead to rejection can result in profound social inhibition and avoidance.

Survivors of trauma who do not recover independently, and who go on to develop longer-term problems as a result of their experiences, may require formal treatment. There is also a mounting body of research suggesting that early interventions with high risk survivors may facilitate the recovery process and reduce the prevalence of subsequent PTSD. The purpose of this chapter is to provide a brief overview of common interventions used in the treatment of acute stress disorder (ASD) and PTSD, and to discuss their application as a preventive strategy.

Aims of treatment

It is reasonable to assume that virtually all human beings will experience a psychological reaction to very frightening or upsetting events. This raises questions about what constitutes an adaptive psychological response to trauma and, as a corollary, what are reasonable treatment goals. Severe traumatic events profoundly affect survivors’ views of themselves and the world. In most cases, it is reasonable to suggest that the survivor will never be the same person again. Equally, those changes need not all be bad. Recovery from trauma can result in personal growth, with the development of improved coping strategies and more adaptive models of the self and the world.

Ideally, treatment would serve to eliminate all the symptoms of PTSD and return the survivor to pretrauma levels of functioning. In reality, that will not always be possible. As with other disorders, factors such as the severity of the condition, chronicity, and comorbidity (particularly in the form of axis II disorders) are likely to affect treatment efficacy. In acute cases of PTSD with few complications, it is reasonable to expect a high degree of success with relatively few sessions (6 to 10). In such cases, elimination of PTSD symptoms, a return to prior functioning, and low risk of relapse would be achievable goals. (Importantly, this is not to imply that the person will never again experience distressing memories of the event but, rather, that such intrusive phenomena will be infrequent and manageable). On the other hand, treatment goals for affietnam veteran with, forexample, a 30-year history of PTSD, high levels of comorbid alcohol abuse, and poor social and occupational functioning, would be more conservative. It may be a question of helping that person to manage the symptoms more effectively, reducing their impact on quality of life, relationships, and general functioning.

Part of this book has been quite conventional. The reviews of the syndromes and treatments in relation to panic and agoraphobia, social phobia, specific phobias, obsessive–compulsive disorder, generalized anxiety disorder and posttraumatic stress disorder are brief, succinct overviews designed for busy clinicians. The discussion of general issues in the etiology and treatment of the anxiety disorders is also essential information for the practicing clinician. The Clinician Guides and the Patient Treatment Manuals are, however, quite unusual. These Guides and Manuals need to be placed in context.

There is an art and a science to good medical practice. Because the science tends to predominate, the art of treatment is seldom discussed, either at a general or a specific level. Elsewhere, we have called attention to the need for the elements of good clinical care to be made explicit. Good clinical care needs to be taught to trainee psychiatrists and clinical psychologists for use with patients for whom there is no specific remedy immediately applicable to their disorder (Andrews, 1993a). This book is different. It is about treating persons with chronic anxiety disorders who, if expertly treated with specific remedies, can be expected to recover. This recovery has been made possible by the scientific advances that have occurred in our understanding of the treatment of the anxiety disorders. Much of this book is focused on the cognitive behavioral treatments simply because the instructions for prescribing medications are relatively simple and, courtesy of advertising by the pharmaceutical industry, do not need repeating in a book on the treatment of anxiety disorders. The cognitive behavioral treatments are less well known and, being both nonproprietary and not for profit, are neither as widely promoted nor as readily available as are the drug therapies.

There is a greater problem. The amount of evidence for the efficacy of psychotherapy is less plentiful than the evidence that is routinely provided by the pharmaceutical industry to the national regulatory authorities in each country. This evidence is provided as part of the process of having products cleared for marketing and, in many countries, for subsidy. In the first edition of this book, much of the evidence about the efficacy of cognitive behavioral therapy came from trials in which the progress of treated groups were compared to their own pretreated status, or else were compared to the progress of wait-list or no treatment control groups.

After formal diagnosis and assessment, two issues must be addressed before treatment is planned. First, the clinician, by conducting a thorough behavioral analysis, must identify the factors that trigger and maintain the panic attacks and the avoidance behavior. Second, the clinician must consider the eVects of comorbid disorders on treatment.

Behavioral analysis

The general principles and practice of behavioral analysis have been outlined elsewhere (Kirk, 1989;Schulte, 1997). However, in panic disorder and agoraphobia there are unique details to be considered. In terms of the antecedents of panic attacks, it is necessary to evaluate the physical and psychological triggers. These typically include situations previously associated with panic, certain physical sensations, and particular worrying thoughts (e.g., “Oh no! fihat if I had a panic attack right now?”). In addition, panic attacks will be more likely to occur when the person has been made more physically aroused as a result of being anxious, stressed, hot, smoking, drinking alcohol, taking stimulant drugs (e.g., coffee), and so on. In addition, panic attacks appear more likely when the individual is “run down”, perhaps because of illness (e.g., flu), physical and psychological stress (e.g., childbirth), or sleep deprivation. Once a listing of antecedents has been made, the consequences of panic attacks need to be identified. The consequences can be divided into three categories. First, individuals may respond to panic attacks with avoidance behavior. Commonly avoided agoraphobic situations have been described earlier, but for present purposes it is worth noting that identifying the cognitive link between panic attacks and avoidance will facilitate cognitive behavioral treatment (e.g., “I avoid crowded trains because the air may run out when everyone is breathing it”). Second, the subtle avoidance strategies (e.g., the use of safety signals) need to be identified. Finally, the social consequences of avoidance need to be evaluated. For instance, individuals with dependent traits may welcome the increased support given as a consequence of panic attacks and become more dependent. Such behavioral patterns need to be identified to ensure they do not inhibit progress in treatment.

Management of comorbid disorders

The most frequently comorbid axis I disorders are the other anxiety disorders, especially social phobia (Sanderson et al., 1990). One advantage of cognitive behavioral interventions is their applicability to all the anxiety disorders, in that each disorder responds to various combinations of anxiety-management and exposure strategies.