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2014 13: 231 originally published online 16 October 2013Clinical Case StudiesCristina L. Magalhães, Doil D. Montgomery, Ellen S. Magalhães and Julie Ngin

Disorder in a Case of Complex Developmental TraumaPhysiological Monitoring and Biofeedback-Assisted Relaxation Training for Panic

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Article

Physiological Monitoring and Biofeedback-Assisted Relaxation Training for Panic Disorder in a Case of Complex Developmental Trauma

Cristina L. Magalhães1, Doil D. Montgomery2, Ellen S. Magalhães1,3, and Julie Ngin1

AbstractThis article describes the effective use of physiological monitoring and biofeedback-assisted relaxation training as primary interventions for the treatment of panic disorder in a 31-year-old woman with a history of complex developmental trauma. A biopsychosocial perspective of panic disorder grounded in learning theory and informed by trauma practice was used to examine the role of multiple causational factors in the development of panic disorder and to discuss intervention strategies addressing the interconnected nature of the biological and psychosocial realms of the human experience. The client participated in 2 pretreatment (intake interview and formal testing) and 14 outpatient therapy sessions at a biofeedback clinic over a period of 6 months. Treatment-outcome data indicated a marked decrease in acute symptoms as measured by the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and the Minnesota Multiphasic Personality Inventory–Second Edition (MMPI-2).

Keywordspanic disorder, complex developmental trauma, physiological monitoring, relaxation training, applied biofeedback, cognitive-behavioral treatments

1 Theoretical and Research Basis for Treatment

Behavioral and cognitive interventions have a well-documented history in the treatment of panic and other anxiety disorders, and are considered empirically supported for these condi-tions (Barlow, 2004; Clark & Beck, 2010). Some of the most commonly used interventions include psychoeducation, cognitive restructuring, exposure-based techniques, and various forms of relaxation training, which are implemented to help clients understand the psychologi-cal and physiological processes involved in anxiety, achieve increased awareness of

1Alliant International University, Los Angeles, CA, USA2Fort Pierce, Florida, USA3Nova Southeastern University, FL, USA

Corresponding Author:Cristina L. Magalhães, Alliant International University, 1000 S Fremont Avenue, Unit 5, Alhambra, CA 91803, USA. Email: [email protected]

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232 Clinical Case Studies 13(3)

anxiety-provoking thoughts, promote attitudinal changes regarding the unpredictability and uncontrollability of future life events, and increase ability to engage in self-regulating behav-iors that induce states of calmness. Physiological monitoring, coupled with other cognitive-behavioral interventions, can be especially useful because it helps clients understand, with undeniable clarity, the reciprocal relationship between anxious thoughts and physiological arousal that characterizes anxious states and reinforces their successful attempts to self-regu-late (Goodwin & Montgomery, 2006).

Applied biofeedback is a type of treatment that uses sensors and computer technology to monitor physiological processes and help people learn how to control these processes to improve certain medical and mental health conditions (e.g., hypertension, headaches, attention-deficit, anxiety). The field originated in 1950s with the convergence of several areas of study, including psychophysiology, stress research, biomedical engineering, and others (Schwartz & Olson, 2003). In the context of mental health practice, applied biofeedback is often used as an adjunct treatment to psychotherapy, typically combined with other cognitive-behavioral interventions. While considered experimental for the treatment of depression and substance use, there is good empirical support for its effectiveness in the treatment of attention/deficit hyperactivity and anxi-ety disorders (Gevirtz & Schwartz, 2003; Schwartz, 2003; Yucha & Montgomery, 2008).

2 Case Introduction

The following case illustrates the effective use of physiological monitoring and biofeedback-assisted relaxation training as primary interventions for the treatment of panic disorder in a 31-year-old American-born White woman with a history of complex developmental trauma (i.e., repeated or prolonged interpersonal trauma in childhood). She was seen for individual therapy at a biofeedback clinic housed in a community mental health center. All identifying information has been altered so as to protect her confidentiality.

3 Presenting Complaints

Laura sought treatment due to feelings of anxiousness and frequent unexpected panic attacks that began after the sudden death of her 35-year-old brother who committed suicide with a gun approximately 4 months prior to the intake. Laura recalled that she began experiencing feelings of discomfort when driving (e.g., sweaty palms and afraid of accidents) soon after her brother’s death, and the symptoms quickly progressed to include other situations in which she had never felt anxious before. She reported, for example, feeling dizzy and noticing her pulse “way out of control” when standing in line at the deli and when getting up to make din-ner at home. At the time of intake, she was not driving on highways and during certain times of the day because she was afraid of not being able to manage the car in case she had another anxiety attack.

Her first full-blown panic attack occurred approximately 2 months after the onset of her symp-toms and included rapid heartbeat, difficulty breathing, tingling sensations, dizziness, legs shak-ing, feeling hot, sweating, fear of losing control, and an intense fear of dying. Since her first attack, Laura began experiencing unexpected panic-like episodes of varied intensity about two to four times weekly and became increasingly preoccupied with having heart problems and dying. Some of these attacks were minor, involving just a few symptoms, while others were clearly above the clinical threshold for panic (both in terms of number of symptoms and severity).

Laura sought medical treatment after her first panic episode and was prescribed Xanax .025 mg three times daily to reduce anxiety. She was diagnosed with Mitral Valve Prolapse (MVP) but was assured by her cardiologist that her heart condition was not what caused her panic attacks. In addition, Laura reported that she began grinding her teeth at night after she had her wisdom tooth



Magalhães et al. 233

taken out about 1 month prior to the intake and was diagnosed with Temporo Mandibular Joint Syndrome by her dentist. There was no history of previous mental health treatment.

4 History

Laura was the youngest of four children in a family with a history of interpersonal violence. Her father struggled with alcohol problems and was verbally and physically abusive toward her mother and the children when she was growing up. She ran away from home a few times between the ages of 12 and 15 but always returned after a couple of days out on her own because she had no other place to go. At the time of intake, Laura’s parents had been separated for about 6 years. Her mother lived nearby but her father had moved to another state after the separation. Laura expressed feelings of resentment toward her parents—her father for being abusive to his family, and her mother “for putting up with him all those years.”

Laura’s three brothers had problems with alcohol since adolescence. She said that she knew that her 35-year-old brother was unhappy with his life but never thought he would kill himself. He was unemployed and living with her father before he died, and his girlfriend had just left him. Laura’s 39-year-old brother was in jail due to a DUI charge (i.e., driving under the influence). He was involved in a serious car accident several months prior to her intake, left the country to avoid dealing with criminal charges, and was arrested when he returned to the United States for his brother’s funeral. Her 38-year-old brother was also living with her father but was about to be thrown out of the house because they did not get along and argued constantly. Laura reported that she also drank heavily when she was younger. She began drinking when she was 15 and, by the age of 21, alcohol had become a “serious problem” for her. She stopped drinking at the age of 28 when the place she used to work at as a bar tender closed.

Laura had an associate’s degree with a major in psychology and had plans to continue her education but reportedly stopped going to school a few years prior to the intake due to financial and family problems. She lived with her boyfriend and spent most of her time at home taking care of him and the house. They had been together for 3.5 years, and her boyfriend was the sole pro-vider in their household, which was an ongoing stressor in their relationship. According to Laura, they had been arguing over trivial things lately and she was feeling pressured to go back to work, which led to much of her anxiety, as she did not think she that could handle taking care of the house and work at the same time, even if just part-time. The stress in the relationship was also triggering feelings of sadness and low self-esteem for her. When probed about other symptoms of depression, Laura reported no sleeping or eating problems but had difficulty concentrating and felt she no longer enjoyed taking care of the house and gardening like she did before. She stated, “I don’t feel like I have anything to look forward to.” Regarding her social life, Laura visited her mother frequently, and occasionally went out with her boyfriend, but spent most of her time at home. She had about four or five close friends and described herself as “shy” and “reluctant to meet new people.” She reportedly did not avoid social situations and did not feel socially iso-lated. There was no other known family history of mental health problems aside from depression and substance abuse.

5 Assessment

Pretreatment evaluation was based on information obtained during a comprehensive clinical interview and analysis of assessment data. The client was asked to complete two self-report measures—the Beck Anxiety Inventory (BAI; Beck & Steer, 1992a) and the Beck Depression Inventory (BDI; Beck & Steer, 1992b), which provided information regarding the severity of her symptoms. She also completed the Minnesota Multiphasic Personality Inventory (MMPI-2; Butcher & Williams, 1996).




Behavioral Observations and Mental-Status Examination

Laura’s overall mood was moderately anxious and depressed during the initial clinical inter-view. She cried when talking about the recent loss of her brother and expressed feeling a sense of shame regarding her family history and current life situation. Her affect was mood-congru-ent and consistent with the subject of discussion. Laura’s level of intelligence was estimated to be at least in the average range of functioning as inferred by her vocabulary and level of educa-tion. Her flow of thought was appropriate from the perspective of content, productivity, and coherence. No history of hallucinations, delusions, suicidal or homicidal ideation, and sexual abuse was reported.

Initial Assessment Data

Laura was asked to answer the BAI twice—once to represent how anxious she was feeling and another time to indicate how she felt prior to the onset of her symptoms. Her score on the first test administration was 35, which suggests that she was experiencing severe levels of anxiety at the time of the intake. Her score of 8 on the second administration suggests that she was experiencing normal anxiety prior to experiencing her first panic attack (Beck & Steer, 1992a). On the BDI, the client obtained a score of 27, which falls within the moderate to severe range of depression (Beck & Steer, 1992b).

Analysis of the MMPI-II validity scales suggested that Laura’s profile was valid but some symptom exaggeration was possible due to an elevation on the F scale (75; Butcher & Williams, 1996). Six elevations were found among the clinical scales. Her highest score was on the Psychasthenia (81) scale, which is suggestive of a great deal of emotional discomfort, excessive worry, and concentration difficulties. A high score on this scale (combined with low scores on scales 6, 8, and 9) is typically interpreted as indicative of acute distress rather than more severe psychopathology (Greene, 1991).

A 3-point code type was used to interpret the elevations in the Hypochondriasis (78), Depression (75), and Conversion Hysteria (70) scales (the neurotic triad), which combined sug-gest much physiological distress and difficulty adjusting psychologically. Individuals with eleva-tions in these scales often feel fatigued, dysphoric, tense, and nervous all the time and show a tendency to react to stress by developing physical symptoms. Interpersonally, they are likely to lack initiative, be passive in relationships, and may become irritable or hostile if their needs are not met (Greene, 1991).

Elevation in the Psychopathic Deviate (68) scale, particularly in the self-alienation subscale, seems to indicate that the client feels uncomfortable and unhappy with herself. Individuals who score high on this subscale report that they find life uninteresting or unrewarding. They seem to have problems in concentration and may report excessive use of alcohol. Elevation in the Social Introversion (66) scale typically reflects a tendency to avoid groups and feel more comfortable alone or with close friends. Individuals who score high on this scale tend to be overcontrolled and inflexible in their attitudes and opinions. They may be hard to get to know and sensitive to what others think of them (Greene, 1991).

Diagnostic Impression

Laura reported a number of anxiety symptoms that were consistent with the diagnoses of Panic Disorder and Agoraphobia based on criteria described in the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association (American Psychiatric Association [APA], 2013). These symptoms were




the primary motivation for her seeking treatment and appeared to be acute and reflective of her high level of distress at the time of intake. Laura presented with recurrent unexpected panic attacks followed by at least 1 month of worry about having additional attacks, worry about poten-tial consequences of the attacks (i.e., dying from a heart attack), and with behavior changes related to the attacks (i.e., avoiding driving on highways), which justified the diagnosis of Panic Disorder. She also presented with marked anxiety about being in situations in which escape might be difficult in the event of having a panic attack (e.g., being in a car, standing in line, being in a crowd, and shopping alone) and had been avoiding these situations for the past 3 to 4 months or otherwise enduring them with much anxiety. While the time frame for Agoraphobia is typi-cally 6 months, the diagnosis was given provisionally as there was reason to believe symptoms would persist without intervention.

A diagnosis of Posttraumatic Stress Disorder (PTSD) was considered due to the fact that her symptoms began after she was exposed to a traumatic stressor—the suicide of her brother—and continued for several months, but she did not report the full-symptom picture characteristic of PTSD (APA, 2013). For example, she did not report distressing memories, dreams, or other intru-sion symptoms associated specifically with her brother’s suicide and perceived her panic attacks to be uncued, as it is typical in panic disorder.

In addition to panic attacks and agoraphobia, Laura reported symptoms of depression trig-gered by the loss of her brother, which included feelings of sadness, difficulty concentrating, lack of motivation, and feelings of hopelessness. It is possible that her depression symptoms repre-sented an underlying depressive disorder of higher severity and/or chronicity, but they did not meet full criteria for Major Depressive Disorder or Dysthymia. Other Specified Depressive Disorder and uncomplicated bereavement were also considered, but the diagnosis of Adjustment Disorder with Depressed Mood seemed more appropriate based on DSM-5 criteria because Laura’s symptoms appeared in response to a clearly defined stressor, persisted for several months after the loss of her brother, were still causing her distress, and seemed to center on issues beyond the scope of bereavement (APA, 2013).

While not a formal diagnosis in the DSM, Developmental Trauma Disorder (or Complex PTSD) is a good framework for understanding the relationship between the multiple clusters of symptoms that are present in this case (Van der Kolk & Courtois, 2005). This framework recognizes that chronic interpersonal trauma in childhood (i.e., abuse and other forms of maltreatment) often leads to deficits in multiple areas of development (e.g., attachment, affect regulation, interpersonal effectiveness, self-esteem, self-efficacy, and personality), resulting in multiple seemingly unrelated disorders during the life span, which may or may not include PTSD (Gold, 2008). Laura seemed to have multiple socio-emotional deficits associated with interpersonal trauma history in childhood, and they appeared to underline the more acute symptoms of anxiety and depression that were triggered by her brother’s suicide and brought her to treatment. (For a critical evaluation of the Complex PTSD litera-ture and its implications for the DSM-5, see Resick et al., 2012; for pros and cons of includ-ing Developmental Trauma Disorder as a formal diagnosis in the DSM, see Schmid, Petermann, & Fegert, 2013.)

6 Case Conceptualization

A biopsychosocial perspective of Panic Disorder (PD) grounded in learning theory and informed by trauma practice was used to conceptualize the development of Laura’s symptoms and formu-late her treatment plan. This perspective assumes that environmental, biological, and psychologi-cal stressors—or vulnerabilities—have cumulative effects in the individual and contribute to the development and maintenance of PD (APA, 2013; Barlow, 2004).




Environmental Stressors

Laura reported that the unexpected and shocking death of her brother triggered her initial symp-toms of anxiety, which then progressed to include the distinct and unexpected episodes of increased physiological arousal and impending doom that characterized her panic attacks. These panic episodes led to her health concerns and anxiety about future attacks. According to Bouton, Mineka, and Barlow (2001), it is not uncommon that environmental stressors be associated with the onset of PD, causing the conditioning of anxiety and panic to external (e.g., certain places, times, or activities) and internal (e.g., body sensations, thoughts, or feelings) cues. A useful theo-retical construct in understanding the progression of Laura’s symptoms is the notion of interocep-tive conditioning described in a classic article by Goldstein and Chambless (1978). Unlike earlier conditioning theories that focused on the role of conditioning for situational panic (e.g., condi-tioning to external or exteroceptive cues), interoceptive conditioning is very helpful in explaining the cause of more spontaneous or apparently uncued attacks that are the hallmark of PD. According to Goldstein and Chambless (1978), in PD, early somatic and cognitive components of anxiety (interoceptive cues) come to elicit bursts of high anxiety and panic, which in turn produce even greater anxiety about future panics. Through this process, low-level somatic anxi-ety sensations and anxiety-provoking thoughts become the conditioned stimuli associated with higher levels of arousal and panic.

However, the fact that numerous individuals experience unexpected panic under stress and fail to develop anxiety about a possible subsequent attack points to the conclusion that environ-mental stressors and conditioning alone cannot account for the development of PD. In fact, the experience of unexpected panic attacks seems relatively common in the population at large, but evidence suggests that these attacks rarely progress to PD (Bouton et al., 2001).

Individuals with PD differ from those who experience “nonclinical attacks” in that they develop anxiety about potential future attacks, perceive the attacks as uncontrollable and unpre-dictable, and are extremely vigilant for somatic symptoms that might signal the beginning of another attack. Individuals who experience attacks but never develop PD, on the other hand, tend to dismiss the attacks by associating them with some trivial or controllable event. Literature in the field suggests that the presence of biological and psychological vulnerabilities influence the individual’s susceptibility to this type of conditioning (Barlow, 2000; Bouton et al., 2001).

Biological Vulnerabilities

While specific mechanisms of heritability remain unknown, experts believe that multiple genes are involved in creating vulnerability for panic disorder, such that offspring of parents with anxi-ety, depressive, and bipolar disorders are at higher risk (APA, 2013). Barlow (1991) argued that the tendency to react to stress with specific psychophysiological responses (e.g., headaches, gas-trointestinal disturbances, palpitations) seems to run in families and may have a heritable compo-nent as well; thus, similarly to hypertension or headaches, palpitations and other physiological changes associated with panic attacks can be understood as nonspecific responses to stress that predispose one to develop PD.

Laura suffers from MVP, a hereditary heart condition in which the mitral valve billows out and does not close properly, allowing the blood to leak into the left atrium. This disorder is usu-ally benign and typically requires no treatment, but it can produce cardiac and respiratory symp-toms (e.g., sensation of feeling the heartbeat, palpitations, difficulty breathing, fatigue, cough, and shortness of breath) that are essentially identical to symptoms of PD (Raj & Sheehan, 1990).

Early research in the field focused on understanding the relationship between the two condi-tions and hypothesized a causal relationship between MVP and PD. Although more recent studies found no support to this claim (Sadock & Sadock, 2007), the literature suggests that the




coexistence of MVP and PD may at least complicate a client’s condition (Hoehn-Saric & McLeod, 1993). In Laura’s case, her susceptibility to experiencing unexpected physiological arousal (e.g., palpitations and difficulty breathing) may have contributed directly to her first panic attack and the conditioning of her anxiety about future episodes.

Psychological Vulnerabilities

Biddle, Pain, and Tiller (1991) noted that individuals with PD subjectively experience life in a state of arousal considerably higher than normal, showing a tendency to overreact to stressors and lowered ability to cope with them. According to Bandura (1977), anxiety is created when there is an expectation that a particular situation is dangerous or difficult to handle (negative outcome expectation) and that one has limited or no resources to cope or deal with it (low effi-cacy expectation). Consistent with Bandura’s theory, other learning theorists argue that individu-als who grow up with a sense of mastery or control over their environment (including their emotional lives) are less likely to develop mood or anxiety disorders in general. On the other hand, early experience with uncontrollable stress creates a tendency to perceive later life events as unpredictable and/or uncontrollable (Bouton et al., 2001).

Ehlers (1993) noted that many patients with PD have parents who abused substances and demonstrated lack of behavioral and emotional control during their formative years, which is consistent with Laura’s reported family history. Her father had a long-term problem with alcohol, a depressant substance that produces feelings of relaxation or sedation similar to those produced by drugs commonly prescribed for the treatment of anxiety. Ehlers (1993) argued that parents with substance-abuse problems typically lack the ability to deal with life stressors, thus modeling ineffective ways of coping with unexpected events and generating in their children a sense of lack of control over the environment.

Strong empirical support for the role of prior experience with lack of mastery and unpredict-ability in the development of anxiety and mood disorders comes from several experimental ani-mal studies in the learned helpless tradition (Peterson, Maier, & Seligman, 1993). Bouton et al. (2001) proposed that these studies and the social-learning literature consistently support the fol-lowing two assumptions regarding the development and treatment of PD: (a) Early experiences with control and mastery contribute significantly to the level of fear that novel, frightening, or life-threatening events evoke in individuals and (b) learning a sense of mastery and predictability in one or more areas of life can generalize to situations in which other aversive stimuli are involved, thus immunizing the individual against anxiety in the future. These assumptions have implications in the choice of treatment for individuals suffering with PD.

Additional support for the role of prior experience with lack of mastery and unpredictability in creating vulnerability for anxiety disorders comes from clinical literature documenting the relationship between early trauma and difficulty with affect regulation across the lifespan. Complex developmental trauma (CDT) is characterized by repeated incidents of interpersonal trauma occurring at early stages of development (e.g., witnessing domestic and/or community violence, being direct target of abuse, suffering severe neglect) and is a risk factor for panic and other anxiety disorders, as well as several other diagnosable conditions, including mood, sub-stance use, eating, personality, and posttraumatic disorders (Ford, 2005). CDT experts argue that while some forms of trauma typically lead to PTSD, such as combat and disaster trauma, inter-personal trauma in childhood (i.e., other forms of maltreatment) often leads to complex symptom presentations, which may or may not meet full criteria for PTSD but almost invariably results in affect dysregulation and other affective, somatic, behavioral, and characterological problems (Gold, 2008; Van der Kolk & Courtois, 2005).

The long-lasting impact of child maltreatment is attributed not only to trauma but also to the cumulative effects of being raised in home environments that are ill-equipped to meet the




developmental needs of children. Research findings and clinical experience documented in the trauma literature suggest that growing up in abusive, chaotic, and unpredictable homes typically leads to deficits in multiple areas of development, including emotional/self-awareness, affect regulation, self-esteem, self-efficacy, and other socio-cognitive and emotional skills that are important for successful adult living (Gold, 2008; Lanius, Bluhm, & Frewen, 2011; Van der Kolk & Courtois, 2005). Laura reported a significant family history of substance abuse and interper-sonal violence and displayed anxiety and other symptoms consistent with those expected in cases of complex developmental trauma.

The distinction between CDT and other forms of trauma has important implications for clini-cal practice. While exposure-based interventions are typically effective in the treatment of uncomplicated PTSD cases (e.g., posttraumatic stress reactions to single-incident trauma), they can often make symptoms worse for adult survivors of childhood maltreatment if used too early in therapy. Trauma experts argue that adult clients with a history of CDT often need to learn how to regulate affect first before they can safely engage in exploration of trauma content in therapy (Gold, 2008). Many report a history of panic attacks, lack confidence in their ability to regulate their emotions, and have symptoms that meet criteria for panic disorder, which is the case for Laura. In a recent study of best practices for the treatment of complex posttraumatic stress (which includes CDT), a phase-based or sequential approach involving multiple interventions was endorsed by the majority of trauma experts who were surveyed, and emotional regulation train-ing was identified as one of the best first-line interventions in terms of safety, effectiveness, and acceptability by clients (Cloitre et al., 2011).

7 Course of Treatment and Assessment of Progress

Treatment Formulation

Standard CBT protocols for PD typically include education, exposure to interoceptive cues, and cognitive restructuring components, and these were all present in Laura’s treatment. Relaxation training, which typically involves some form of breathing retraining, is currently considered optional in CBT protocols for PD but was included in Laura’s treatment to augment the effects of the other CBT components and promote self-efficacy. (For a comprehensive discussion about standard CBT protocols for PD and the debate over the role of relaxation training, see Clark & Beck, 2010.)

According to Bandura (1977), effective psychological treatments for anxiety disorders are those that strengthen the individual’s expectation of personal effectiveness. Although his theory is considered “cognitive” in that it stresses the role of cognitions in the development of anxiety disorders, he nevertheless argued that “behavioral” interventions seem more helpful in strength-ening self-efficacy than direct attempts to change thinking patterns (Thorpe & Olson, 1990). Physiological monitoring and biofeedback-assisted relaxation training are behavioral techniques that can produce marked changes in clients’ attributions and attitudes regarding anxiety and panic states and in beliefs regarding ability to regulate affect. During biofeedback sessions, physiologi-cal events are monitored on a continuous basis, while detailed information about that physiologi-cal event is given in some sort of feedback such as a computer display, sound, meter display, or series of lights. The feedback system is designed to provide sensitive, instantaneous information that allows the person being monitored to detect very small changes (i.e., changes that the person would not normally be aware of because his or her own sensory system does not detect that event or does not detect such a small change in that event). An example is measuring the time between one heartbeat and the next. Most people can detect when their heartbeat is slow or fast but bio-feedback systems can let the person know if there is one hundredth or even one thousandth of a time difference between two heartbeats.




This sensitive and continuous feedback of physiological information during sessions helps clients suffering from panic disorder to achieve the following: (a) understand the physiological mechanisms involved in anxious and panic states (educational component), (b) become aware of own cognitive/affective triggers of physiological arousal and reattribute symptoms to interocep-tive cues instead of a serious disease (cognitive restructuring or reattribution component), (c) experiment with various cognitive and behavioral relaxation techniques to learn how to reduce physiological activation at will and observe their immediate impact on the autonomic nervous system (relaxation training or skill building component), (d) learn to tolerate distress and regulate affect while talking or thinking about subjects that are distressing to them (exposure-based component), and (e) acquire some degree of voluntary control over their physiological processes, which in turn increases self-efficacy and reduces fear of being overcome by anxiety and panic (desired outcome). Several different physiological processes can be monitored with biofeedback equipment (e.g., skeletal muscle tension, brainwave activity, skin temperature, sweat-gland activity, heart rate, breathing rate), and individuals can train themselves to acquire some degree of voluntary control over one or more of these processes. (For a review of different biofeedback treatment modalities and applications, see Yucha & Montgomery, 2008).

Laura’s biofeedback treatment involved monitoring three physiological processes and training to control one. Finger temperature (TEMP), electrodermal activity (EDG), and electromyo-graphic activity (EMG) of the frontalis muscle were monitored and graphically displayed on the computer screen, providing her with visual information about changes in cognitive arousal (EDG), localized muscle activity (EMG), and overall level of relaxation (TEMP), during times when she was practicing relaxation and also when she was not trying to relax (i.e., when engaged in conversation). During physiological monitoring, Laura’s cognitions were addressed only to the extent of helping her understand their relationship with physiological arousal and their role as potential triggers (interoceptive cues) for anxiety or panic attacks. She was taught how to identify anxiety-provoking patterns of thinking and to actively engage in cognitive and behavioral- emotional regulation strategies for controlling physiological arousal.

Laura’s primary goal during the relaxation training portion of the sessions was to learn how to lower and maintain EDG level below 6 micromhos. Electrodermal activity resulting from the opening and closing of sweat glands in hands and feet is known to be particularly sensitive to cognitive activation (Montgomery, 1998; Montgomery, 2002). It provides information about the internal dialogue of the client and it is therefore considered the preferred biofeedback modality for teaching relaxation to individuals who are very cognitively active (e.g., those who tend to worry or ruminate in their thinking). Auditory feedback was provided during relaxation training, so that Laura could try different techniques with her eyes closed (i.e., the equipment produced a beeping sound when EDG readings were above 6 micromhos). In addition, a computer printout with physiological data recorded during the session was reviewed with the client either at the end of each session or beginning of the next.

Treatment Implementation

Laura participated in 2 pretreatment (intake interview and assessment) and 14 therapy sessions over the course of 6 months. Sessions were initially scheduled on a weekly basis, but after Session 3, they were scheduled less frequently (2-3 times monthly) due to the fact that the client started working and was undergoing dental treatment.

Initial phase. The establishment of a strong therapeutic alliance between the therapist and the cli-ent was the primary focus of the initial phase of the treatment, which included the intake, assess-ment, and treatment Sessions 1 to 3. Also during this phase of treatment, the clinician provided education on the physiological processes involved in anxiety and panic (e.g., blood vessels




constrict, finger temperature decreases, hand sweat increases, overall muscle tone increases, heart rate increases) and the rationale for biofeedback intervention.

Laura was introduced to the biofeedback equipment during the assessment session, after com-pleting the MMPI-2 and self-report measures. She was instructed to alter her EMG readings by raising her eyebrows, frowning, or squinting her eyes and then bring her EMG level back to normal (baseline) by relaxing her facial muscles. She was introduced to biofeedback and self-regulatory techniques with an EMG demonstration because it is easier to control localized mus-cle activity than control any other physiological process. It was expected that, by learning to voluntarily change muscle activity in her forehead, she would feel more confident that she could learn to control other physiological processes and would be motivated to initiate biofeedback therapy.

During Session 1, Laura began relaxation training using a TEMP protocol with added EMG and EDG monitoring. She was taught two relaxation techniques, diaphragmatic breathing and imagery, and was asked to practice them during the session while monitoring her progress on the computer screen. She was told that her goal was to keep her finger temperature above 92° by slowing her breathing and calming her mind. Laura was hypervigilant and tense during most of the session, likely due to the novelty of the situation and some performance anxiety. She had dif-ficulty relaxing and became increasingly frustrated as she watched her temperature go down (dropped almost 6°) instead of going up. Her EDG was erratic and high, fluctuating within the range of 15 to 30 micromhos. The clinician normalized this experience for her, explaining that most people have difficulty relaxing during their first session because they “try too hard” to con-trol their physiology and end up more tense than they were before. The clinician also used the opportunity to explain the relationship between anxiety-provoking thoughts and physiological arousal, helping Laura understand that the more she preoccupies about things the harder it is for her to keep calm. She was asked to practice diaphragmatic breathing and imagery at home at least 1 time daily until next appointment.

Session 2 began with Laura reporting that she started working at an office doing secretarial work for her boyfriend’s best friend, who is an architect. She said that she was feeling less tense in general but talked about difficulties in her relationship with her boyfriend. According to Laura, she felt pressured by her boyfriend to go back to work and thought he should be more patient with her, knowing that she was having “problems with anxiety.” During most of the session, Laura practiced relaxation using an EDG protocol with TEMP and EMG monitoring. She was told that her goal for the session was to lower and maintain her EDG below 12 micromhos and was asked to focus on her breathing and on keeping her mind calm—to “let go” of any preoccupations about home, work, or the biofeedback equipment. Laura was able to lower and maintain EDG below 12 micromhos for approximately 50% of the session. The clinician helped Laura make sense of the EDG print out and highlighted her progress. Laura left the session feeling encouraged and more hopeful that she would be able to learn how to manage her anxiety and decrease frequency of panic attacks. She was given a small handheld thermometer to monitor her finger temperature during the week and was asked to use it several times throughout the day. She was told that moni-toring her finger temperature would help her notice small changes in her anxiety level and use relaxation skills to regulate her affect when needed. In addition, she was told that by becoming more aware of small changes in her anxiety level she would be better able to identify the sources of her anxiety (e.g., thoughts, feelings, or situations).

On Session 3, Laura reported feeling less tense during the week and more able to identify potential sources of anxiety (e.g., she was preoccupied with recent weight gain but wanted to please her boyfriend by cooking elaborate meals at night). Asking the client to recall and discuss anxiety triggers created the opportunity for her to consider alternative ways of dealing with inter-nal and interpersonal conflicts that were causing her emotional distress. Also during this session, the stimulating effects of caffeine and diet pills and their role in anxiety (Schwartz, 2003), as well




as the importance of incorporating relaxing activities in her daily routine (e.g., listening to music, gardening, walking), were discussed. Laura completed an EDG protocol with heart rate (HR) and TEMP monitoring, and practiced relaxation techniques to lower arousal (autogenic phrases were introduced in this session). She was able to reach lower EDG and higher temperature levels dur-ing training.

Middle phase. As treatment progressed, the client became more comfortable in the therapeutic setting and began volunteering more information about herself, particularly her preoccupations with pleasing others and not letting them down. Thus, the middle phase of the treatment focused on talking about those preoccupations, making connections between anxiety-provoking thoughts and physiological distress, exploring effective ways of handling internal and interpersonal con-flicts that were causing her distress, building skills to self-regulate emotions, and improving self-efficacy. Emphasis was placed on reinforcing Laura’s progress, normalizing small setbacks, and helping her stay focused on achieving her treatment goals.

Laura began Session 4 reporting that she had a panic-like episode during the week. Although she more or less “had things under control” when she was not working, she now felt over-whelmed trying to handle all her responsibilities around the house in addition to her new job. During the session, she practiced relaxation using an EDG protocol. She was able to lower EDG somewhat but could not maintain a low level of arousal throughout the session due to difficulty keeping paced respiration (i.e., breathing slowly, deeply, and at regular intervals). The clinician normalized this experience (higher levels of physiological arousal were expected because we were discussing topics that made her anxious) and gave her a handout with instructions for a deep breathing exercise.

In the beginning of Session 5, Laura reported that she felt anxious on several occasions since our last appointment and was able to identify situations, feelings, and thoughts that triggered her anxiety (e.g., conversation with her mother about her brother in jail, feeling responsible for “res-cuing the family’s pride,” and preoccupations about pleasing others, including her family, her boyfriend, and her employer). Laura was very anxious during this session and had a lot of diffi-culty lowering arousal during the relaxation-training portion of the session. The clinician high-lighted the progress she had made in becoming more aware of the sources of her anxiety and in becoming better able to regulate her affect, which prevented anxiety from escalating to panic during the past week.

Session 6 began with Laura reporting that she felt very anxious during a visit to the dentist but was able to complete a difficult dental procedure without having a panic attack. She also talked about her feeling anxious when driving on highways, but it seemed that her anxiety no longer reflected a fear of agoraphobic proportions (she was no longer avoiding highways; she was fac-ing the feared situation with greater confidence that she would be able to keep herself calm enough to drive safely). The clinician normalized her anxiety at the dentist and while driving on busy highways as they reflected normal reactions to stressful life situations. It was important for Laura to be reassured that anxiety is a normal aspect of living (it won’t go away completely) and that it does not need to lead to panic. Laura practiced relaxation using the EDG protocol with TEMP and EMG monitoring and was able to show lower levels of arousal after training. She reported that she had made attempts to incorporate relaxation practices/activities in her daily routine (e.g., gardening) and that she had decreased her medication (Xanax .25 mg) from three to two pills daily.

In Session 7, Laura continued practicing paced respiration and other relaxation skills while monitoring her physiology. She reported that she felt anxious a couple of times since our last appointment but was able to regulate her affect and prevent her anxiety from escalating to panic. She reported feeling more confident that she could use her relaxation training to de-escalate physiological arousal when needed and seemed more aware of the sources of her anxiety. Laura




also reported an increase in her TMJ symptoms that seemed to be associated with her toothache and recent dental procedures. The possibility of initiating biofeedback treatment for TMJ was discussed, but it was agreed that it should wait until she mastered her general relaxation skills.

In Session 8, Laura reported that she felt anxious during the past 2 weeks due to a constant toothache, but she reported no panic attacks, including during dental procedures. She said that she was able to de-escalate when beginning to feel anxious and felt more confident that she could control her physiology and prevent panic. She also reported that she was no longer work-ing everyday as the work at the office had slowed down and they no longer needed her full-time. She was thinking of going back to school and had prepared her resume for applying for other jobs. No computer printouts were produced for this session (and Session 11) due to technical problems with equipment.

Sessions 9 through 11 continued to focus on helping Laura master self-regulating skills and achieve a greater sense of predictability over her environment and her own reactions to stress/anxiety and other distressing emotions. Regarding her biofeedback training, Laura was showing increased ability to control her physiology (Figure 1), which confirmed her progress and encour-aged her to keep using her relaxation training to regulate emotions outside the therapy room. Although she still reported occasional anxiety episodes, she was less fearful that things would get out of her control and seemed more skilled at de-escalating her anxiety. She also reported feeling less preoccupied about how she would handle things in general, even when faced with unex-pected life events (e.g., a death in her boyfriend’s family and the possibility of her boyfriend losing his job). Issues she continued to struggle with were concerns about pleasing others and her need to “rescue her family’s dignity” (e.g., felt pressure by her parents “to do better” than her brothers). Talking about these issues while monitoring own physiology was instrumental in changing Laura’s attributions about anxiety and panic. She was able to understand that interocep-tive cues can lead to a cascade of physiological responses and that seemingly uncued panic states are typically triggered by these cues. Another benefit of monitoring physiology while talking about anxiety-provoking topics was that it offered her an opportunity for experiencing the emo-tional distress they caused her while still feeling in control of her emotions. Because she could see gradual and almost instantaneous changes in her physiology, she could sustain exposure to interoceptive cues and tolerate for longer periods of time the distress they caused her, which reduced her fear of affect dysregulation.

Ending phase. Sessions 12 through 14 focused on reviewing Laura’s progress and discussing her plans regarding possible termination or continuation of treatment with another clinician (due to the fact that the clinician providing treatment was leaving the clinic). Laura had achieved her original treatment goals (she learned to maintain her EDG level below 6 microm-hos and her TEMP above 92° during relaxation training and reported a significant decrease in her panic attacks and an improvement in her ability to engage in relaxation—see Figure 1)—and was debating whether she should continue working on her general relaxation skills, set a new goal of reducing her TMJ symptoms, or terminate treatment. The clinician helped her weigh her options and encouraged her to make her own decision to strengthen her sense of agency over her life.

In Session 12, Laura reported that she had been feeling well despite the fact that she did not get the job she applied for. She continued to work part-time and was looking into the possibility of starting school in the fall. In Session 13, Laura reported that she had an anxiety attack during the week when in bed, prior to falling asleep. Her symptoms included rapid heartbeat and dif-ficulty breathing but were of brief duration and did not escalate to panic due to the fact that she was able to use breathing exercises to control physiological arousal. The clinician and the client discussed potential triggers for this anxiety episode, and Laura was able to identify a preoccupa-tion with disturbing her boyfriend’s sleep (she was watching TV in bed) and a concern about




terminating treatment with this therapist. While helping Laura weigh her options regarding termination, the clinician introduced the topic of relapse prevention and helped her plan what she could do in case she felt that things were starting to get out of hand. Laura completed the posttreatment assessment measures (MMPI-2, BDI, and BAI) in Session 14. She reported a decrease in her TMJ symptoms due to an improvement in her dental problems and told the therapist of her decision to continue biofeedback treatment for a few more sessions.

Termination. Termination was first addressed in Session 10. At that time, the client was informed that the clinician would be leaving the clinic in approximately 8 weeks and a decision had to be

Figure 1. Physiological data across sessions (electrodermal activity and finger temperature).Note. Data were not recorded for Sessions 8 and 11.




made regarding continuation or termination of her treatment. This topic was revisited on Sessions 12, 13, and 14. After reviewing her progress, Laura first considered the possibility of termination, and then decided that it would be best to continue relaxation training for a few more sessions before termination to strengthen her newly acquired skills. She was informed that it would take approximately 4 weeks after our last appointment until she would be able to reinitiate treatment with her new therapist. In case she relapsed before being assigned to a new clinician, she was told that she could contact this therapist for crisis intervention if needed.

Summary. Laura showed significant improvement of her symptoms during the course of treat-ment. She reported increased ability to use relaxation skills to regulate emotions at home and especially during anxiety-provoking situations, such as driving and going to the dentist. She appeared to be more skilled at identifying sources of anxiety (e.g., aspects of her relationship with her boyfriend and parents), as well as at identifying anxiety-provoking patterns of thinking (e.g., “people won’t like me if I am not perfect” or “it is my responsibility to be successful for my family”). In addition, improvement was observed in her ability to reach and maintain lower lev-els of arousal during the session, as evidenced by her lower EDG readings during her last relax-ation training. While she continued to use Xanax, she had reduced the dosage from three to one a day and planned on discontinuing it completely within the following month. Although Laura reported experiencing a few mild to moderate anxiety episodes in the last couple of months of treatment, she reported successfully implementing the relaxation skills she learned during the sessions and was able to de-escalate anxiety when needed to prevent panic attacks.

Laura’s posttreatment MMPI-2 profile reflects a significant reduction in reported symptoms and suggests that she was no longer under acute distress at the time of testing (see Figure 2). Despite her significant overall improvement, a mild elevation on the Hypochondriasis (67) scale still remained, suggesting a tendency to be pessimistic and overly concerned with numerous vague somatic symptoms. Analysis of the validity scales suggests that Laura approached the test-taking task with openness and frankness; therefore, the results were considered valid and indica-tive of her level of emotional functioning at termination (Butcher & Williams, 1996). Her posttreatment BAI and BDI scores suggest that she was experiencing normal levels of anxiety and depression at termination (see Figure 2; Beck & Steer, 1992a; Beck & Steer, 1992b). Continued biofeedback relaxation training would be beneficial to Laura in that it would likely strengthen her emotion-regulation skills and further increase her confidence in her ability to con-trol her physiological responses to distressing internal states.

While Laura achieved remarkable treatment gains in such a limited time, she still had a ten-dency to doubt herself and feel as if she lacked the skills to cope with day-to-day challenges. She had difficulty making decisions on her own and relied on others for emotional reassurance and financial support. In addition, she still concerned a great deal with pleasing others and gaining their approval. These observations were consistent with her pre and posttreatment MMPI-2 results, suggesting that these are more stable traits of her personality, less likely to change in a short-term course of treatment.

8 Complicating Factors

There were no major complicating factors. The client sought treatment on her own, trusted the clinician, and was invested in the therapeutic process. Her dental treatment interfered with the regularity of the sessions but was not an impediment. On the contrary, it provided Laura with the opportunity to apply learned skills outside the therapy room, which helped increase self-efficacy. It is possible that the transfer in clinicians caused premature termination, but Laura was aware that she could access services again at any point in the future should her fear of anxiety/panic




attacks returned. This was Laura’s first time accessing mental health services. It is hoped that, having had a positive experience, Laura will be open to seek help again if she feels the need.

Her use of prescription medication (i.e., benzodiazepines) concurrently with biofeedback ses-sions poses questions regarding whether the medication interfered with the treatment. Benzodiazepines typically have the effect of dampening autonomic arousal (Tulen & Man’t Veld, 1998), which suggests that her biofeedback readings overall might have been lower for TEMP and higher for EDG and EMG had she not been on medication. Despite this, it seems that she still benefited from the physiological monitoring and training. Cognitive shifts in attributions, beliefs, and attitudes regarding anxiety and panic were noted; some level of control of physiological responses was attained as evidenced by biofeedback recordings during relaxation training; and the client reported overall symptom reduction.

Figure 2. Premorbid, pretreatment and posttreatment ranges/scores for the Beck Anxiety Inventory (BAI), pretreatment and posttreatment ranges/scores for the Beck Depression Inventory (BDI), and pretreatment and posttreatment K-corrected scores for the Minnesota Multiphasic Personality Inventory (MMPI-2) scales.




9 Access and Barriers to Care

There were no barriers to care. Services were provided on a sliding fee scale at a community mental health center, and there was no limit to the number of sessions Laura could have had through the biofeedback clinic. Laura’s primary support system (her boyfriend and her mother) encouraged her participation in treatment and paid for her sessions.

10 Follow-Up

Four weeks after termination, a follow-up call was made to check in with Laura and see whether she would like to resume treatment with another clinician. Laura reported that she was able to maintain treatment gains after her last therapy session and felt that she was doing well on her own. She said that she continued to experience anxiety episodes once or twice a week, but symp-toms were not as severe as they were before treatment and no longer felt panic-like to her. More importantly, she no longer felt afraid of having panic attacks and was not experiencing any major impairment in functioning (i.e., agoraphobia). She had decreased the frequency of her medication to “as-needed basis” and had just started a new part-time job.

11 Treatment Implications of the Case

Biofeedback interventions are consistent with learning treatment models as they assume that there is a learned sequence to the development of symptoms and that these symptoms can be treated by establishing a new sequence of learning. It can be argued that CBT without biofeed-back can be sufficient to treat anxiety disorders. However, the literature suggests that biofeed-back-assisted therapy has many advantages over traditional psychotherapy (Montgomery, 2002; Schwartz, 2003) and can be particularly useful in the treatment of panic disorder. The first advan-tage is that biofeedback is confirming and encouraging, as it reinforces clients’ progress in treat-ment and helps to increase confidence in their ability to self-regulate. Second, most clients with panic disorder begin psychotherapy unconvinced that their symptoms are anxiety-based and believe, despite medical reassurance, that there must be some undiagnosed disease process caus-ing their symptoms. To these clients, biofeedback provides concrete and credible evidence of their heightened level of physiological arousal and helps them understand how their bodies react to their distressing thoughts and feelings. Furthermore, Berkow and Fletcher (1992) argue that clients who are taught relaxation techniques in the absence of biofeedback show increased mus-cular tension during the practice while reporting that they are relaxed, which interferes with learning of emotional-regulation skills. Without proper assessment tools, it is indeed difficult to ensure that relaxation strategies are properly implemented and that change is occurring at a phys-iological level. This problem is easily mended with biofeedback because the equipment monitors autonomic functioning and feeds back this information to clients on a moment-to-moment basis.

12 Recommendations to Clinicians and Students

Clinicians interested in incorporating biofeedback interventions in their treatment plans should con-sider the strengths and limitations of this approach. Physiological monitoring can be a powerful intervention for the treatment of PD, particularly when applied in conjunction with other elements of CBT. When clients are able to see changes in their physiology displayed on a computer screen while talking to the clinician about issues that are important to them (or while quietly monitoring their internal dialogue), they begin to see with clarity the often subtle connections that exist between their thoughts and emotions that otherwise would be unperceptible to them. Although these types of connections can be facilitated through psychotherapy without physiological monitoring, the




concrete way in which they are formed during biofeedback sessions can have an even greater impact on the client. This is possibly one of the greatest advantages of the use of biofeedback tech-nology in clinical settings. Another advantage of biofeedback is that it helps clients reframe anxiety as a normal aspect of the human experience that can sometimes be adaptive and consequently become less afraid of experiencing temporary discomfort. This fundamental attitudinal change toward temporary emotional dysregulation often happens naturally in biofeedback sessions. Clients are able to see their own physiology changing constantly on the computer screen, which leads them to recognize that negative emotions can be as fleeting as positive ones. The clinician’s role within this framework is that of an “emotional trainer,” one who guides and encourages clients in the pro-cess of learning and mastering a new set of skills. Clinicians should maintain a supportive, caring, and positive attitude during training sessions, reinforcing clients’ progress at each step of the way, normalizing small setbacks, and helping them stay focused on the positive expected outcomes of their training sessions.

Despite several advantages of incorporating biofeedback interventions into treatment plans, there are very practical limitations to this approach. The costs involved in purchasing biofeedback equipment and providing specialized training to clinicians can be prohibitive in many hospitals and agencies providing mental health care. In addition, training in biofeedback is not readily avail-able, especially within graduate programs where most clinicians acquire basic clinical skills they learn to rely on for future practice. Clinicians planning to acquire biofeedback training at the postgraduate level may need to enroll in graduate-level courses to fill in gaps in foundational knowledge (e.g., biological basis of behavior, if not covered in their program curriculum) before taking continuing education training specifically in the use of biofeedback technology.

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

Cristina L. Magalhães, PhD, is a licensed psychologist in California and an associate professor of clinical psychology at the California School of Professional Psychology at Alliant International University, Los Angeles. Her professional interests include applied biofeedback, trauma psychology, and human diversity issues.

Doil D. Montgomery earned his PhD in psychology from West Virginia University. He retired after 25 years as a professor of psychology from Nova Southeastern University. He has published several articles and chapters in books, and coauthored books in psychology. He is a licensed psychologist in Florida.

Ellen S. Magalhães, PhD, is a licensed mental health counselor in Florida and adjunct faculty at Nova Southeastern University and at the California School of Professional Psychology at Alliant International University, Los Angeles. Her clinical and research interests include applied biofeedback, health promotion, and human diversity issues.

Julie Ngin, MA, is a doctoral candidate at the California School of Professional Psychology at Alliant International University, Los Angeles. Her clinical and research interests include minority stress, academic resilience, test anxiety, and clinical biofeedback.



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