Using behavioral experiments in the treatment of cardiophobia: A case study

305

Using Behavioral Exper iments in the Treatment o f Cardiophobla: A C a s e Study

G e o r g H. Eifert , University o f Ha wa i i , a n d A n g e l a W. Lau , West Virginia University

A 20-year-old female who met DSM-IV criteria for both hypochondriasis and panic disorder (PD) reported intense anxiety~provoking daily chest pain, several panic attacks per month, and firmly believed she was suffering from coronary artery disease. More than 1 O0 emergency room (ER) visits, numerous negative medical tests, reassurance, psychotropic medication, and inpatient psychiatric treatment had failed to improve her condition. In the first 13 sessions, treatment focused on reducing cardiophobic disease fear, chest pain, and avoidance behavior. Behavioral experiments were used to develop alternative symptom explanations and teach the patient to reassure herself. After a patient-initiated treatment suspension, a relapse occurred, with a fear of suffocation and uncontrollable panic becoming the patient's new major concern. The successful treatment of her cardiac disease fear and conviction had not much improved her fear of noncardiac bodily sensations. After an additional 13 sessions focusing on reducing her noncardiac panic symptoms, all measures of panic, illness behavi~ and depression were in the normal or near-normal range. Cardiophobia-related treatment gains were maintained as evidenced by the absence of heart-focused anxiety, disease conviction, ER visits, and doctor phone calls. Occasional panic attacks and chest pain no longer worried the patient. Positive changes were maintained at 8- and 14-month follow-up. We discuss the relation between cardiophobia and panic disorder and suggest several specific treatment steps to ensure changes occur in both problem areas.

M ANY INDIVIDUALS present to emergency room and other medical settings with chest pain for which

no medical explanation can be found (Aikens, Michael, Levin, & Lowry, 1999; Fleet et al., 1996; Gibler et al., 1995). Although some patients will be satisfied with negative medical examination results, and some reassurance to that effect, others will anxiously ruminate about the possibility of suffering from a yet undiagnosed physical disease. These individuals present with different combi- nations and degrees of chest pain, panic, illness fear, and safety-seeking behavior, which suggests they may be suffering from panic disorder a n d / o r hypochondriasis. They are upset and worried about chest pain a n d / o r heart pal- pitations because of their potential negative consequences (e.g., heart attack, death), cont inue to seek help for these symptoms, demand more medical examinations and spe- cialist referrals, and undergo additional costly laboratory tests (Warwick & Salkovskis, 1990).

We use the word cardiophobia as a convenient label for

excessive and clinically significant levels of heart-focused anxiety and illness behavior (e.g., safety-seeking) that oc-

cur in response to presumed cardiac-related sensations and events (Eifert, 1992; see also Beitman et al., 1987; Fleet et al., 1996). At its most basic level, cardiophobia can be characterized as a fear of heart malfunctioning or

disease. At a more complex level, it involves the interplay

Cognitive a n d Behavioral Practice 8, 3 0 5 - 3 1 7 , 2001 1077-7229/01/305-31751.00/0 Copyright © 2001 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

of chest pain, autonomic arousal with some panic symptoms, heart-focused attention, illness beliefs/suspicions, and avoidance behavior. As such, cardiophobia overlaps with features of several D S M categories, including hypochondriasis, panic disorder (PD), and specific phobia (see Table 1 for a summary of these differential diagnostic issues). A number of studies have indeed found a close relation between hypochondriasis, illness phobias, and PD (cf. Eifert, Lejuez, & Bouman, 1998). For instance, Warwick and Sal- kovskis (1990) reported that 59% of hypochondriacal clinic patients also met DSM-III-R criteria for PD. Such high comor-

bidity rates are not surprising in view of the considerable degree of overlap in the behavior of persons with excessive health anxiety and panic-related fear (Salkovskis & Clark, 1993).

At the same time, the specific focus on the heart and its functioning also differentiates cardiophobia from existing re-

Cardiophobia involves the interplay of chest pain, autonomic arousal with some panic symptoms, heart-focused attention, illness beliefs/suspicions, and avoidance behavior.

lated D S M categories. For instance, cardiophobia per- tains specifically to the fear of heart-related events, sensations, and functioning rather than a variety of bodily sensations as in PD. As such, cardiophobia tends to be tightly cue controlled. For example, a fear of dying of a heart attack is elicited and becomes salient only during episodes

306 Eifert & Lau

Table I Summary of Key (Essential) and Common Diagnostic Features of Cardiophobia, Hypochondriasis, and Panic Disorder

Preoccupation Physical Disease Safety" with Heart Symptoms Disease Fear Conviction Seeking

Cardiophobia Essential/yes Yes (cardiorespiratury) Yes Yes Yes

Hypochondriasis No No Yes; often diffuse; could Yes Yes involve any bodily system

Panic disorder No Yes, but could involve No No Yes any bodily system

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of acute chest pain a n d / o r hear t palpitat ions. In this way, ca rd iophob ia represents a dist inct concern that is differ- en t from fears about o ther anxiety-related bodily sensations and events (e.g., social events). In a similar way, cardio- phob ia differs fi-om o the r types of heal th-rela ted anxiety in that it is specific to the hear t ra ther than the more diverse and frequent ly general ized heal th concerns of individuals with hypochondriasis (Bass, 1990; Eifert et al., 1998).

Nevertheless, adop t ing a DSM perspective, one could argue that ca rd iophob ia is a specific form of hypochon- d r i a s i s - - a hybrid of excessive heal th anxiety (Salkovskis, 1996) and disease phobia (Marks, 1987). Indeed, the DSM-

IV (American Psychiatric Association, 1994, p. 463) even uses "preoccupat ion and fear of having cardiac disease" as an example of hypochondriasis , a l though the DSM is in-

consistent about this issue: It also ment ions fear of con- tracting an illness as an exam- pie of "specific phobia, other type" (p. 407). Thus, it seems that ca rd iophobia does not fit neatly into any one of these diagnostic categories. For instance, an individual with car- d iophob ia may meet 50% of the cri teria for hypochondr ia- sis and PD, or 100% of the criteria for PD and 50% of specific phobia and pain d isorder (Eif- err, Zvolensky, & Lejuez, 2000). Consequently, patients may re- ceive no diagnosis, or a diagno-

sis of one d i sorder that may prevent fur ther investigation of problemat ic symptoms not related to that diagnosis. Individuals also may, at different times, exhibi t different combina t ions of i l lness-related and panic-re la ted b e h a ~ ior. The present case exemplif ies these intr icate diagnostic issues and points to the necessity of individualizing t rea tment to ensure that all the various aspects of the p rob lem are targeted in t rea tment (cf. Eifert et al., 2000).

Traditionally, individuals with hypochondrias is were cons idered difficult to treat and prognosis was regarded

as p o o l For instance, early studies found 40% of pat ients with pr imary hypochondrias is to be unchanged or worse tollowing a variety of psychological intervent ions (e.g., Kenyon, 1964). Al though patients with unexp la ined physical symptoms and heal th anxiety still pose a considerable chal lenge for therapists, cognitive-behavioral in- terventions have yielded encourag ing results. Based on the not ion that the core p rob lem of individuals with hypochondrias is is their persis tent mis in terpre ta t ion of es- sentially harmless bodily sensations, cognitive-behavioral t rea tment is d i rec ted at evaluating alternative, nonthreat - en ing explanat ions of body-related observations that patients mis in terpre t as signs of serious disease (Salkovskis, 1996; Warwick & Salkovskis, 1990). Two possible explanations for the pat ient 's p rob lem are cons idered alongside each o the r ra ther than as mutually exclusive alternatives. Patients are then asked to engage in a variety of behavioral exper iments to test these new explanat ions. In behavioral terms, the key funct ion of exposure exercises and the prevent ion of safety-seeking behavior is to allow patients to come into contact with the actual cont ingencies of engaging in heal thy behavior (Eifert et al., 1998). For instance, patients learn that their hear t rate increases when they walk up several flights of stairs, but that they will not die as a result of these normal bodily changes.

Salkovskis and Warwick (1986) repor ted two successfully t reated single cases of pr imal T hypochondr ias is using behavioral methods. In ano the r study, Visser and Bouman (1992) found that *our of six hypochondr iaca l patients improved significantly following in vivo exposure, safety- seeking prevent ion, and cognitive therapy. Interestingly, the behavioral componen t s of this study (exposure and response prevent ion) appea red to have accounted for more of the i m p r o v e m e n t than the cognit ive compo- nent. The positive results of these single-case studies were suppor ted in a cont ro l led trial that showed cognitive- behavioral therapy to be super ior to a wait-list control condi t ion (Warwick, Clark, Cobb, & Salkovskis, 1996),

The frequently intr icate relat ions between heal th anxiety and panic suggest that some patients may require t rea tment that focuses both on il lness-related fear as well as panic. This article presents the case of a young woman

Treatment of Cardiophobia 307

(Kate) who met DSM-IVcri ter ia for bo th hypochondr ias is and PD. She also is a " textbook case" of ca rd iophob ia (Eifert, 1992). In addi t ion to the key feature of cardio- p h o b i a - - a p reoccupa t ion with the hear t and its func- t ioning based on the bel ief that symptoms will lead to negative consequences (e.g., hear t attack, d e a t h ) - - K a t e also exhib i ted the four c o m m o n features that card iophobia shares with aspects of hypochondriasis , specific disease phobia , and PD: physical symptoms, disease fear, presence of organic disease or disease conviction, and safety- seeking behavior. Specifically, the pa t ien t r epor t ed severe anxiety-provoking daily chest pain and firmly bel ieved she was suffering f rom coronary ar tery disease (CAD). Al- though she also r epor t ed o the r panic symptoms (e.g., dizziness, shortness of breath) , the clinically dominan t symptom initially was chest pain and the associated fear of dying of a hear t attack. In contrast to a pat ient with "pure" PD who would typically only worry about dying of a hear t at tack while having a panic attack, our pat ient also wor- r ied about CAD when she d id no t exper ience chest pain or o the r physical symptoms. Numerous negative medical test results with r epea ted reassurance by physicians, different anxiolytics and an t idepressant medicat ions, as well as two psychiatric inpa t ien t hospital izat ions had failed to improve her condi t ion.

Dur ing the course of t rea tment , a shift in the pat ient 's clinical presenta t ion f rom predominan t ly ca rd iophobic symptoms and behavior to suffocation-related panic exempl i f ied bo th the close but also somewhat i n d e p e n d e n t relat ion between heal th anxiety and PD (Salkovskis & Clark, 1993). Specifically, we found that the partially successful t r ea tment of cardiac disease fear and conviction did not improve fear of o ther bodi ly sensations such as suffocation, shortness of breath, and dizziness. Indeed , systematic observat ion suggested that the successful treat- men t of the pat ient ' s ca rd iophobic fears and avoidance behavior b rough t o the r panic symptoms more to the forefront . Behavioral exper iments , inc luding innovative exposure techniques, and self-reassurance strategies were used to specifically address both he r ca rd iophobic fear and behavior as well as fears of suffocation that became p r o m i n e n t at a later stage of t rea tment . Using this case study as an example , we will discuss the concept of cardiophobia , its re lat ion to PD, and suggest specific t rea tment strategies to ensure changes occur in both p rob lem areas.

Case Information and Asse s sment

Case Information Kate, a 20-year-old obese Caucasian female, was re-

fe r red to us after an unsuccessful 1-week t rea tment at an inpa t ien t psychiatric hospital where she had been admit- ted following 8 months of r epea ted visits to the ER. Kate r epo r t ed exper ienc ing severe chest pain that would

occur for several hours each day. Occasionally, the pain would radiate down her neck, jaw, arm, and a r o u n d her back. Kate also r epo r t ed o ther panic symptoms bu t indicated that she was no t "as worried" abou t them. She be- gan exper ienc ing chest pain about 6 years ago, a few months after both he r maternal g randparents had d ied of myocardial infarctions within weeks of one another. A close relative who had survived a heart at tack had in fo rmed Kate that "the surest sign of an immi- nen t hea r t at tack is r ecu r ren t chest pain." She was firmly convinced that he r chest pain indicated that she had serious CAD and that she was soon going to die from it. Negative results from numerous physical ex- ams, labora tory tests, X rays, and EKGs failed to reassure he r that he r hea r t was healthy. Hospi tal records revealed she had visited the ER an average of four times each week for 8

T h e f r e q u e n t l y

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months. She also r epo r t ed calling her family physician three to four times a week. As a consequence of he r frequent ER visits and hospitalizations, Kate was in deb t for over $10,000.

Kate was a single m o t h e r who was living at home with he r m o t h e r and pa te rna l g randmother , and had l imited social suppor t outside he r family. He r m o t h e r carr ied a diagnosis of un ipo la r depression, and, as descr ibed by Kate, displayed excessive somatizat ion and reassurance- seeking behavior. Kate's p reoccupa t ion with chest pa in and having CAD adversely affected her daily funct ioning. She was unemployed , seriously l imited in carrying out daily activities (e.g., do ing laundry, runn ing errands , going out with fr iends) , and was even fearful of lifting he r 2-year-old son because those activities "might be too much" for he r heart . Kate r epo r t ed depressed mood, feelings of worthlessness, hopelessness, helplessness, and suicidal ideation. She also engaged in some obsessive checking behavior a round the house, but the intensity of such behavior was no t clinically significant. She was mostly housebound , and r epo r t ed staying in bed all day because " I 'm sick." As a teenager, she had been briefly hospital- ized with a diagnosis of ad jus tment d i sorder with depressed mood. Kate was overweight by 50 pounds and did no t engage in any exercise behavior for fear of "put- t ing too much strain" on her heart . She den i ed a lcohol or illicit d rug use but admi t ted to smoking at least one pack of cigarettes pe r day and daily caffeine consump- t i o n - a n interes t ing inconsistency with he r o the r cardioprotective behaviors.

308 Eifert & Lau

A s s e s s m e n t

At the beg inn ing of a 4-week baseline assessment period, Kate completed a battery of self-report questionnaires. She also completed the same questionnaires after t reatment (post), and dur ing 8-month and 14-month follow-up visits to her home. In addition, Kate main ta ined a daily self-monitoring log where she recorded the n u m b e r of ER visits, family physician contacts, panic attacks, and chest pain ratings. A summary of the assessment schedule and their purpose is presented in Table 2.

Questionnaires. The Cardiac Anxiety Quest ionnaire (CAQ; Eifert et al., 2000) is an 18-item self-report measure that assesses key features of heart-focused anxiety (Eifert, 1992) on three factor-analytically derived CAQ scales: (a) fear of and worry about heart disease (fear), (b) avoidance of activities that increase cardiac activi~ and physical arousal (cardioprotective avoidance behavior), and (c) heart-focused at tent ion and anxious monitoring of heart activity (attention). Each item is rated on a 5-point Likert scale as to how frequently the behavior typically occurs, with response anchors ranging from 0 (never) to 4 (always). A total score is calculated by sum- ming all responses to individual items and dividing the sum by the n u m b e r of total test items. As the subscales have different numbers of items, subscale scores are com- puted by first calculating the unweighted sum of all items of each subscale and then dividing the unweighted sum by the n u m b e r of subscale items. Thus, total and subscale scores can range from 0 to 4.0. The CA.Q has been dem- onstrated to be valid, and its internal consistency is ade- quate: the Cronbach alpha coefficient for the total scale

is 0.83 and alpha coefficients for the fear, avoidance, and at tent ion subscales are 0.83, 0.82, and 0.69, respectively (Eifert et al.).

We also administered the Illness Attitude Scales (IAS; Kellner, Abbott, Winslow, & Pathak, 1987). According to a recent factor-analytic investigation (Hadjistravropoulos & Asmundson, 1998), this 27-item quest ionnaire assesses beliefs and illness behavior associated with illness-related fears on five scales: fear of illness and pain, symptom effects, harmful habits, disease phobia and conviction, and fear of death. Each item is rated on a 5-point Likert scale, with response anchors ranging from 0 (no) to 4 (most of the time).

The Body Sensations Quest ionnaire (BSQ; Chamb- less, Caputo, Bright, & Gallagher, 1984) is a 17-item self- report quest ionnaire that assesses an individual 's fear of bodily sensations associated with autonomic arousal. Re- spondents rate the degree to which they experience anxiety as a result of bodily sensations on a 5-point scale, with anchors ranging from 1 (not frightened~worried by sensation) to 5 (extremely fiightened/worried by sensation).

The Anxiety Sensitivity Index (ASI; Peterson & Reiss, 1992) is a 16-item self-report quest ionnaire that assesses an individual 's level of fear of anxiety-related symptoms (e.g., rapid heart beat) based on the belief that such sensations have negative consequences. Patients rate the degree to which they agree or disagree with each item on a 5-point scale, with anchors ranging from 0 (very little) to 4 (very much).

The Panic Attack Quest ionnaire (PAQ; Norton, Dor- ward, & Cox, 1986) lists 17 somatic and cognitive syrup-

Table :~ Summary of Schedule of Assessments and Their Purpose

Measure Purpose/Target Sessions

Administered

Pre Break Post F/U

Ongoing AssessmenLs ER visits Doctor phone calls VAS ratings Chest pain ratings

Questionnaires Cardiac Anxiety Questionnaire Illness Attitude Scales Body Sensations Questionnaire Anxiety Sensitivity Index Beck Depression Inventory

Panic Ratings Severity Frequency Fear of future attacks Control perception Safety perception

Reassurance/safety seeking X Reassurance/safety seeking X Heart-focused anxiety X Intensity and wor D, X

Heart-focused anxiety, Illness beliefs/behavior Fear of bodily sensations Fear of anxiety consequences Depressed mood

Severity of panic attacks Frequency of panic attacks Fear of fi~ture attacks Perceived control over panic Perceived safety during panic

X X X X X X X X X X X X X X X X

X X X X X X X X X X X X X X X X X X X X

X X X X X X X X X X X X X X X X X X X X


toms of panic as described in DSM-III-R. The presence and severity of each symptom is rated on a scale ranging from 0 (not experienced) to 4 (very severe). Kate also rated how much control she perceived over symptoms, how safe she felt while experiencing symptoms, and how fearful she was of future symptom episodes. These ratings were made on a scale from 0 (no) to 8 (extreme).

The Beck Depression Inventory (BDI) is a 21-item self- report scale assessing recent symptoms of depression (Beck, Rush, Shaw, & Emery, 1979) with high validity and good internal consistency (average of 0.86 across studies). Each item includes four response options (0 to 3).

Ongoing assessment. During a 4-week baseline and throughout the treatment, Kate kept a daily log of the n u m b e r of ER visits and phone calls to doctors. Using a scale from 0 (no) to 8 (extreme), she also rated (a) chest pain intensity and (b) worries about chest pain. In addition, she recorded panic attacks on the Panic Attack Record (Barlow & Craske, 1994). At the beg inn ing of each session, Kate completed five visual analogue scales (VAS) assessing core features of heart-focused anxiety (Eifert, 1992). On five 100-mm lines that had two response anchors (0 --- not at all and 100 = all the time), Kate indicated how much dur ing the past week she (a) feared and worried about CAD, (b) avoided activities that could br ing on symptoms, (c) paid at tent ion to her heart, (d) sought help and reassurance from doctors and family when she had symptoms, and (e) believed she had CAD. Each session, we also asked Kate to rate the likelihood of dying from a heart attack if symptoms occur in the next week (0 = no chance to 100 = absolute certainty). During exposure exercises, Kate made separate ratings of her level of fear and discomfort (SUDS) on a scale ranging from 0 (none) to 100 (extreme).

T r e a t m e n t C o u r s e a n d O u t c o m e

Baseline and Pretreatment Data In the 4-week period preceding behavioral t reatment

(pre), Kate made a total of 16 visits to the ER and 78 phone calls to various doctors (average weekly numbers are displayed in Figure 1). Figure 1 also shows that she reported high levels of worries about chest pain and near-maximum levels of chest pain intensity. Her VAS rating (Figure 2) indicated that she was 100% convinced of having CAD, and she rated a 90% likelihood of dying from heart disease. Scores on the CAQ (Table 4) and VAS ratings of disease conviction, fear of CAD, avoidance, at tention, and safety seeking were at maximum or near-maximum levels (see Figure 2). Table 4 shows that she made simi- larly high ratings on all IAS subscales. ASI, BSQ, and BDI scores also were significantly elevated, indicating high levels of fear and severe depression (see Table 4). Figure 3 shows that she reported experiencing 10 panic attacks

Table 3 Summary of Key Treatment Components Targeting Various Dimensions

and Symptoms of Heart-Focused Anxiety

Dimensions/ Symptoms Treatment Strategies and Techniques

Preoccupation with heart

Disease fear

Disease conviction

Physical (panic) symptoms

Safety/reassurance seeking

Demonstrate that chest pain/heart sensations are not dangerous

• Reduce avoidance/expose to cardiac-related stimuli

Extinction of fear and exposure to avoided activities • Exposure to interoceptive (particularly

cardioceptive) cues • Reinforce "dangerous" behavior (e.g., strenuous

exercise) Testing alternative symptom explanations

• Explain impact of anxiety/tension of body (chest pain)

• Conduct behavioral experiments to test hypotheses

• Review evidence for/against heart disease • Review evidence for cardiac vs. tension chest pain

Reduce chronic tension and overbreathing • Chest muscle relaxation • Teach slow diaphragmatic vs. thoracic breathing

Extinction of help and reassurance seeking • Refuse further tests • Review results of previous tests • Withhold reassurance • Do physical exercise while preventing pulse

checking

dur ing that time and maximum levels of fear of future attacks. She did not engage in any type of exercise and avoided strenuous activities that she believed to be harmful to her heart•

We saw Kate approximately twice a week for a total of 26 sessions. Each session lasted approximately 75 minutes.

Treatment Phase I (Sessions 1 to 13) In the first phase of treatment, we targeted Kate's ex-

cessive reassurance-seeking behavior, disease conviction, and cardioprotective avoidance behavior• Treatment con- sisted of (a) prevent ing reassurance-seeking behavior, (b) relaxation training, (c) providing Kate with more ac- curate explanations for her chest pain, (d) conduct ing mini-experiments to support these alternative explanations, (e) developing self-reassurance strategies, and (f) exposure to heart-related interoceptive cues and previously avoided situations.

At the beg inn ing of treatment, we explicitly asked Kate to refrain from making any ER visits and phone calls to doctors• We educated her on the relationships between hyperventilation, muscle tension, chest pain, and other panic symptoms• Then we started a relaxation t raining program focusing on chest wall muscles and diaphrag-

310 Eifert & Lau

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Figure I . Kate ' s week ly Visual A n a l o g u e Scale (VAS) rat ings of hea r t - focused anxiety. On con t i nuous 1 0 0 - m m lines tha t had two re- s p o n s e ancho r s (0 = not at all and 100 = all the time), Kate rated h o w m u c h s h e "feared and worr ied a b o u t hear t d i s ease" (fear of CAD), "be l ieved I had CAD" (CAD d i s e a s e convict ion) , " avo ided activi t ies tha t could bring on s y m p t o m s " ( ca rd iop ro tec t ive avo id - ance) , "paid a t ten t ion to m y heart" (hear t - focused at tent ion) , and " s o u g h t he lp and r e a s s u r a n c e f rom doc to r s and family w h e n I had s y m p t o m s " ( sa fe ty - seek ing behavior) . Sess ion 14 (break) ma rked t he pa t i en t - s e l ec t ed s u s p e n s i o n of t r e a t m e n t ; this rat ing w a s ob- ta ined w h e n Kate r e tu rned to r e s u m e t r ea tmen t .

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Figure Z. Top section: Weekly averages o f Kate's dai ly ratings o f chest pain intensity and worr ies about chest pain (range: 0 = n o n e to 8 = e x t r e m e ) . Bottom section= Total number o f ER visits and doctor phone calls per week as recorded by Kate in a dal ly log dur ing t reatment and fol low-up. Pretreatment EE visits were recorded from patient 's hospital records and averaged over 4 weeks. The accu- racy o f Kate's self-reported ER visits dur ing the fo l low-up period were cross-checked with hospital records.

31Z Eifert & Lau

Table 4 Results of Questionnaire Assessments

Treatment

Measure Pre Post

Follow-Up

8 Months 14 Months

Cardiac Anxiety Questionnaire Total score 3.8 0.7 0.4 Fear subscale 3.6 0.5 0.4 Avoidance subscale 4.0 1.0 0.6 Attention subscale 4.0 0.6 0.2

Illness Attitude Scales Won T about illness and pain 4.0 1.1 1.2 Symptom effects 4.0 0.3 0.0 Health habits 1.3 1.3 1.3 Disease phobia and conviction 2.9 0.3 0.3 Thanatophobia 3.7 0.7 1.3

Body Sensations Questionnaire 4.9 1.5 1.4 Anxiety Sensitivity Index 47 10 15 Beck Depression Invento W 40 4 4

asked Kate to walk rapidly up and down several flights of stairs. When Kate ar- rived for her next session with intense chest pain, we again suggested to her to walk quickly up and down four flights of stairs to test the alternative explanat ion

0.4 that her symptoms were the result of 0.6 chronic hyperventilation rather than 0.0 CAD. To her surprise, her chest pain did 0.6 not increase (as would have been likely if

she had CAD) but actually decreased 1.2 0.2 and eventually disappeared completely. 1.3 This effect might have occurred due to 0.4 an increased CO 2 product ion counter- 1.6 acting the hyperventilation-induced hy- 1.4

14 pocapnia and alkalosis (O2/CO 2 imbal- 11 ance) that possibly contributed to her

chest pain on arrival. This behavioral experiment had a profound impact on her and increased her compliance with

other behavioral prescriptions. Giving up avoidance behavior and engaging in exercise behavior enabled Kate to contact the actual cont ingencies of such behavim: For instance, a heart rate increase due to physical activity does not lead to more chest pain (and cardiac death) but tends to reduce chest pain over time. Each week, Kate was also assigned cont inued self-exposure exercises as homework.

matic breathing to alleviate pressure on her chest caused by hyperventilatory thoracic breathing. In addition, we ex- plained to her the differences between angina pain and chest pain (e.g., angina pain is typically brought on by exertion and tends to disappear when the patient rests, whereas chest wall pain can start at any time, may last for several hours, and is unaffected by rest). We asked Kate to apply this knowledge to herself and come up with a list of reasons, in her own words, why her pain was not "heart pain" and why her chest pain was not symptomatic of CAD or an i m m i n e n t heart attack. Kate dictated these statements to the therapist, who typed them into a com- puter and pr inted a copy for her. We asked Kate to read these statements twice daily and to carry the list with her so that she could read the statements whenever she no- ticed her chest pain and anxiety increasing. The main purpose of this technique was to teach Kate the skill of se/f-reassurance that would effectively compete with her medical reassurance seeking (ER visits, doctor calls). In time, Kate was able to reassure herself when she had chest pain without reading the statements.

We also created a hierarchy of cardiophobic avoidance behavior. This hierarchy included cardioprotective behavior such as avoiding exertion (e.g., walking a round the block, visiting relatives, going to the mall, going out with friends, lifting her son, doing housework, exercising, caffeine consumption). The hierarchy also included avoidance behavior cued by cardiac events and situations (e.g., watching the television show ER, watching surgery videos, and going to a hospital coronary care unit) . Each week, we exposed her to one or more of the hierarchy items. We also asked her to watch videos of open-heart surgery and of a rapidly beat ing h u m a n heart fihned dur ing open-heart surgery. In the third t reatment session, we

Results o f Treatment Phase I Treatment led to a rapid decline of medical reassur-

ance seeking (Figure 1) and disease conviction (Figure 2). By the 12th session, Kate had not called her physician regarding cardiac-related concerns for 3 months and had only made one visit to the ER (after Session 13). She was performing household duties on a daily basis, played with her son, and walked for extended periods of time for exercise. She also engaged in social activities with friends without fear of having a heart attack. Her mood had improved, and she had begun to make lifestyle changes (i.e., smoking cessation program, losing weight via exercise and healthier diet). She also was p l ann ing to at tend beauty college. She reported six panic attacks since treat- men t started bn t was not fearful of future attacks. Al- though she con t inued to feel some tightness in her chest, she was using her self-reassurance statements to reduce any worries about chest pain. Her probability estimates of dying from a heart attack if symptoms occur decreased from 90% (pretreatment) to 35% (Session 12).

Relapse and Treatment Phase II (Sessions 14 to 26) As indicated, Kate experienced one relapse and went

to the ER before Session 13 in early December. At that

Trea tmen t of Ca rd iophob ia 3113

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FIsure 3. Top section: Ratings of 17 somatic and cognitive symptoms of panic (PAQ; Norton et al., 1986). The typical severity of each symptom is rated on a scale ranging from 0 = n o t e x p e r i e n c e d to 4 = very s eve re (possible range of scores: 0 to 68). Bottom section: Kate's ratings of how much control she perceived over symptoms, how safe she felt while experiencing symptoms, and how fearful she was of future symptom episodes. Ratings were made on a scale from 0 (none) to 8 ( ex t reme) at pretreatment, after t reatment Phase 1 and relapse (break), after the final treatment session (post), and 8 and 14 months after treatment termination.

314 Eifert & Lau

Sess ions 15 to 2 6 focused on

(a) e x p o s u r e to

breathing C02-

enr iched air to

specif ical ly

address the fear of choking;

(b) renewed exposure to

avoided s i tuat ions

and exercise; (c) con t inued ches t -

musc le re laxat ion

t raining and

b rea th ing

retraining, and

(d) self-reassurance t echn iques .

t ime, she was suffering from a severe cold and her VAS ratings (Figure 2) of heart-focused fear, avoidance, attention, and disease conviction re tu rned to h igher levels following the ER visit. In view of the upcoming Christmas holidays, and against our advice, Kate dec ided to suspend t rea tment after Session 13. When she re tu rned for treat- men t 2 months later, she had expe r i enced over 10 panic attacks dur ing the break and had made eight visits to the ER. She had been hospi ta l ized and kept for observation once after having a panic attack. She also had been vohm- tarily commi t t ed to a psychiatric day hospital due to he r

renewed excessive medical reassurance seeking. A psychia- trist had pu t he r on 20 mg flu- oxet ine (Prozac) and 2.5 mg c lonazepam (Klonapin) .

The day hospital asked us to reassess Kate, and she re- quested to resume t reatment . Dur ing the interview (Session 14), she indica ted that although she con t inued to exper ience some heart-focused anxiety and chest pain, they were at a r educed level com- pared to pre t rea tment levels (see Figures 1 and 2). She repor ted that over the course of the previous 2 months, a fear of suffocation and uncontrollable panic had become her major concerns, with choking and shortness of brea th be ing her most p rominen t panic symptoms. As a consequence of this shift f rom predomi-

nantly card iophobic symptoms and behavior to suffoca- t ion-related panic, we expanded the focus of t rea tment to t the remain ing sessions to address her fear of future panic attacks and dea th by suffocation. Specifically, t rea tment in Sessions 15 to 26 focused on (a) exposure to b rea th ing CO2-enriched air to specifically address the fear of choking; (b) renewed exposure to avoided situations and exercise; (c) con t inued chest-muscle relaxation training and brea th ing retraining, and (d) sell-reassurance techniques.

Interocept ive exposure was ta i lored to Kate's most p r o m i n e n t fear of suffocation by expos ing her to twelve t5-second inhalat ions of 20% CO2-enriched air using a me thodo logy that we employed in several anxiety-related lab exper iments (e.g., Eifert, Forsyth, Zvolensky, & Lejuez, 1999). COx-enriched air creates a n u m b e r of breathing- re la ted panic symptoms (part icularly breathlessness and choking sensations) and has been found to induce panic attacks in individuals with PD (Rapee, Brown, Antony, &

Barlow, 1992). Escape and avoidance of symptoms is im- possible as physiological changes occur on an uncondi - t ioned basis as a direct result of blood-gas changes. After the first trial, Kate exhibi ted intense arousal and fear and gave a rat ing of 90 for both he r fear and discomfort . After the 12th trial, SUDS ratings of fear had dec l ined to 25, whereas physical responses r ema ined intense and were ra ted as 70. We also conduc ted two exposure sessions in a coronary care unit to address remaining illness-related fears.

We no ted that Kate was still hyper~'entilating on a regular basis, and that tension levels in her shoulder and neck regions were so high that one shoulder habitually rested at a h igher posi t ion than the othei: We ta i lored re- laxat ion t raining and brea th ing re t ra in ing to focus on the uppe r body region. Due to high chronic tension levels in that par t of he r body, Kate found it difficult to use s tandard t ighten-relax techniques, and we i m p l e m e n t e d s t re tch ing / re laxa t ion exercises for her u p p e r body region. Al though we encouraged Kate to reduce her daily nicot ine consumpt ion and suggested a variety of healthier meals to improve her diet, we did not spend much therapy time on these matters.

Results of Treatment Phase II As can be seen from Figures 1, 2, and 3, Kate responded

quickly and positively to the resumpt ion of behavioral t reatment . She did not re turn to the ER after resuming t rea tment and made no p h o n e calls to doctors. VAS ratings of heart-focused fear, avoidance, a t tent ion, safety seeking, and disease conviction decreased substantially. Within 3 weeks, he r probabi l i ty estimates of dying from a panic attack decreased ti-om 70% to 30%. She also was able to effectively apply self-reassurance statements when she exper ienced a panic attack.

At terminat ion, Kate was exper ienc ing only occasional l imited-symptom attacks, and was no longer fearful of having future attacks (see Figure 3). Her CAD disease fear and conviction ratings had decreased from 100% (pre t rea tment) to 5%, and o the r VAS ratings of heart- focused anxiety ranged from 8 to 15 (Figure 2). She esti- mated the probabi l i ty of dying from a panic attack to be 0%. Figure 1 shows that chest pain intensity and worries about chest pain also decreased substantially. The same pat te rn of findings was ref lected in normal or near n o r m a l - r a n g e scores on all quest ionnaires (see Table 4). Kate was exercising regularly, had r educed her daily nico- tine consumpt ion from 20 cigarettes to 5 cigarettes, was regularly eat ing heal th ier meals, had moved into her own apa r tmen t with he r son, and was employed part-time.

Follow-up Results Four months after terminat ion, Kate contac ted the

therapis t by phone and r epor t ed she was do ing well. She


had no t exper i enced any panic attacks, but con t inued to occasionally sense some mild "sensations" and chest pain that no longer worr ied her. She also r epo r t ed working

full-time. Eight months after te rminat ion , we visited Kate in he r

home for a regular follow-up assessment. She had no t been to the ER or called a medical doc tor since treat- men t was terminated . Chest pain intensity and worries about chest pain con t inued to decrease, as did he r VAS ratings of heart-focused fear, avoidance, a t tent ion, and safety seeking (see Figure 2). This pa t te rn of findings was also ref lected in low scores on the CAQ and IAS subscale scores, which were in the noncl inical range (see Table 4). BSQ, ASI, and BDI scores r ema ined in the normal or near-normal range (Table 4). In view of he r initial excessive help-seeking and firm illness beliefs, it is part icularly noteworthy that he r scores on the IAS symptom effects and disease fea r /convic t ion subscales, as well as VAS ratings of disease fear and conviction, r ema ined in the nonclinical range. Her panic symptom severity and f requency con t inued to decline, and she was no longer afraid of future attacks (Figure 3). She con t inued to be socially active, and was enro l led in beauty college.

At a 14-month follow-up visit, assessments showed that Kate basically maintained all her improvements (see Table 4 and Figures 1, 2, and 3).

D i s c u s s i o n

The present case shows the close but also somewhat in- d e p e n d e n t relat ion between heal th anxiety and PD (War- wick & Salkovskis, 1990). The pa t ien t initially p resen ted with p r e d o m i n a n t heart-focused anxiety, firmly believing she was suffering from CAD. Al though she also r epor t ed noncard iac panic symptoms, she almost exclusively focused on chest pain and cardiac ac t iv i ty-re la ted symptoms. These physiological symptoms fueled her inces- sant, unjustif ied fears and convictions that she was going to die from CAD. At the same time, he r heal th anxiety and hypersensitivity to cardiac and respiratory symptoms made her more susceptible to having panic attacks. Thus, this case is an interes t ing example of how excessive illness anxiety and panic d i sorder may "feed" on one ano the r (Salkovskis & Clark, 1993).

Trea tment methods for the pat ient ' s heart-focused anxiety and disease conviction were similar to the treat- men t typically prescr ibed for PD (e.g., tension reduct ion, exposure to previously avoided interocept ive cues). The specific focus of these methods , however, was somewhat different. For instance, we focused specifically on cardiac- re la ted cues and used interocept ive exposure and o ther behavioral exper iments as means to he lp the pat ient develop alternative explanat ions for he r bodily sensations. Thus, the pat ient l ea rned ways to reassure herself ra ther

than seeking reassurance from medical professionals. Unfortunately, improvements in the pat ient ' s fear of hear t - re la ted sensations in the first t r ea tment phase d id not general ize to reduce fear of o ther panic symptoms. A comple te improvemen t occur red only when those noncardiac panic symptoms (e.g., fear of choking) were specifically ta rge ted in the second t r ea tment phase following

a relapse. In a series of behavioral exper iments , the pa t ien t was

able to exper ience the actual cont ingencies re la ted to her cardiac and noncardiac- re la ted fears. For instance, the pa t ien t l ea rned that c l imbing stairs leads to tem- pora ry harmless d i scomfor t (e.g., breathlessness) r a the r than chest pain, and a result- ant hear t rate increase does no t lead to cardiac death. Fur- ther, by tai lor ing exposure exercises to Kate's specific fears (e.g., b rea th ing CO 2 for he r choking fear), we were not only able to extinguish fear responses, but the specific exposure exercises and o ther behavioral exper iments served to develop and suppor t credible alternative explanat ions for he r symptoms. Several authors (e.g., Salkovskis & Warwick, 1986) have previously stressed the impor tance of developing credible al ternative symptom explanat ions (cf. Eifert, 1992). In combina t ion with her ability to develop more realistic explanat ions for physiological symptoms, he r ability to reassure herself al- lowed her to reduce her avoidance behavior and increase heal thy behavior. This resulted in the ext inct ion of condi- t ioned disease fears and the reduct ion of safety-seeking and reassurance-seeking behavior. Thus, the pa t ien t was able to learn lasting self-reassurance skills. This ability to reassure herself general ized across situations and across different fears.

It a p p e a r e d that Kate's positive response to the first phase of t rea tment po ten t i a ted her improvements in the second t rea tment phase, and her ul t imate t rea tment gains were impressive. After a total of 26 t rea tment sessions, medical reassurance seeking, CAD disease conviction, and fear of choking were comple te ly e l iminated. The pa t ien t r epo r t ed greatly r educed chest pain and frequency of panic attacks. He r scores on the IAS, BSQ, ASI, and BDI were largely within normal limits. At posttreat- ment , the pa t ien t was employed, had moved into he r own apa r tmen t with he r son, and was socially active. She also made several lifestyle changes. She was exercising on a regular basis, was on a smoking-cessation program, and had changed her diet to lose weight. These improvements were main ta ined 8 - a n d 14-months pos t t rea tment .

This case is an

interest ing

e x a m p l e of h o w

e x c e s s i v e illness

anxiety and panic

disorder may

"feed" on o n e

another.

316 Eifert & Lau

T h e p a t i e n t

l e a r n e d t h a t h e a r t

r a t e i n c r e a s e d o e s

n o t l e a d t o c a r d i a c

d e a t h .

As ind ica ted , Kate d id n o t e x p e r i e n c e ches t pa in and

start to worry a b o u t hea r t disease unt i l a few m o n t h s af ter

b o t h h e r ma te rna l g r a n d p a r e n t s had d i ed o f myocard ia l

infarct ions . Kate t h e r e f o r e exempl i f i e s the r epea t ed ly

d e m o n s t r a t e d re la t ion be tween exposu re to physical

symptoms and disease in the family, and the d e v e l o p m e n t

o f excessive illness anxie ty in y o u n g adults, par t icular ly

w h e n individuals e x p e r i e n c e symptoms that they c a n n o t

easily exp la in o r u n d e r s t a n d (Eifert, 1992; Flor, Bir-

baumer , & Turk, 1990; Kell-

net , 1986). Fo r instance, Eif-

er t and Forsyth (1996) f o u n d

that e x p o s u r e to hea r t disease

in pa ren t s may m a k e observ-

ing ch i l d r en m o r e vu lne rab l e

to d e v e l o p i n g fears o f hear t

disease. A c c o r d i n g to Kate,

h e r m o t h e r had a l o n g history

o f excessive somat iza t ion and

reassurance-seek ing behavior , m a k i n g it likely that o u r

pa t i en t had b e e n e x p o s e d to illness behav io r f r o m early

in life. Aikens et al. (1999) also f o u n d that y o u n g age,

chron ic i ty o f n o n o r g a n i c ches t pain, the p r e s e n c e o f car-

diac a n d pan ic symptoms, as well as his tor ical exposu re to

card iac- re la ted c o n c e r n s are all associa ted with e levated

repor t s o f card iac distress and ER uti l izat ion. Fur ther -

m o r e , the dea th o f a relat ive o r f r i end f r o m cardiac dis-

ease has b e e n shown to p rec ip i t a te c a r d i o p h o b i c con-

cerns and behav io r in relat ives o f the deceased (Eifert,

H o d s o n , Tracey, Seville, & Gunawardane , 1996; Parkes,

1972).

Finally, the p r e s e n t case exempl i f i e s bo th the vir tue

a n d pitfalls o f ind iv idua l iz ing t r e a t m e n t - - p a r t i c u l a r l y in

cases with p rob lems , such as ca rd iophob ia , that e x t e n d

b e y o n d the strict b o u n d a r i e s o f o n e d iagnost ic ca tegory (Eifert, Schul te , Zvolensky, Lejuez, & Lau, 1997; Eifert ,

Zvolensky, & Lejuez, 2000). If we had simply fo l lowed the

s t andard m a n u a l for PD (Barlow & Craske, 1994), we

wou ld have sufficiently addressed the m u l t i t u d e o f Kate's

fears o f bodi ly sensat ions early in t r ea tment . As a resnlt ,

we m i g h t have b e e n able to p r e v e n t the re lapse she expe-

r i enced . But because disease conv ic t ion and illness fear-

r e la ted avo idance behav io r are no t par t o f the manua l ,

we m i g h t have n e g l e c t e d these impor t an t , and initially

d o m i n a n t , aspects o f Kate's p rob lems , resu l t ing in con-

t inu ing p r o b l e m s for the pat ient . O n the o t h e r hand , by

indix4dualizing t r e a t m e n t and focus ing on only the car- d i o p h o b i c fea tures o f h e r p rob lems , we d id no t pay suffi-

c ien t a t t en t ion to h e r m o r e gene ra l panic concerns ,

which m i g h t have c o n t r i b u t e d to the re lapse she exper i -

enced . Thus , o u r case il lustrates, o n c e again, how focus-

ing t r e a t m e n t on only o n e i m p o r t a n t p r o b l e m area can

lead to i n c o m p l e t e ou tcomes , leaving pat ients p r o n e to

relapse. W h a t is r e q u i r e d is a theory-dr iven a p p r o a c h that

he lps to o rgan ize and re la te the var ious aspects o f the

p r o b l e m and t h e n targets all r e l evan t dys func t iona l

b e h a v i o r - - w i t h o r w i thou t a manua l . If we had fo l lowed that strategy f r o m the beg inn ing , we m i g h t have b e e n

able to p r even t Kate 's re lapse in the m i d d l e o f t r ea tment .

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We are grateful to Michael Zvolensky for his valuable comments on the manuscript. We also thank John Sorrell for assisting with the data analysis and for preparing the figures.

Address correspondence to Georg H. Eifert, 3950 Kalai Waa St., #T- 101, Wailea-Maui, HI 96753; e-mall: [email protected].

Received: June 4, 1999 Accepted: November 1, 1999

Introducing Flexibility in Manualized Treatments: Application of Recommended Strategies to the

Cognitive-Behavioral Treatment of Bipolar Disorder

A u d e H e n i n , M i c h a e l W. O t t o , a n d N o r e e n A. R e i l l y - H a r r i n g t o n

Massachuset ts General Hospi ta l and H a r v a r d Medica l School

WeU-controUed treatment outcome studies have provided a wealth of evidence for the efficacy of specific manualized treatments for psychiatric disorders. In the face of these triumphs, there has been renewed attention to ways of modifying treatment manuals to better address the diverse needs of individuals. In this article we report on the application of recent recommendations for enhancing flexibility in manualized treatments. In particular, we discuss the use of phases and modules of treatment applied according to case-formulation worksheets to address the needs of patients with bipolar disorder. Case examples are used to illustrate the application of this modular treatment approach.

O NE MANIFESTATION o f r e c e n t advances in clinical re-

s ea rch a n d p rac t i ce is tha t e n o u g h we l l - con t ro l l ed

t r e a t m e n t - o u t c o m e trials o f p s y c h o t h e r a p y have b e e n con-

Cognitive and Behavioral Practice 8, 3 1 7 - 3 2 8 , 2001 1077-7229/01/317-32851.00/0 Copyright © 2001 by Association for Advancement of Behavior Therapy. All fights of reproduction in any form reserved.

d u c t e d so tha t manua l -dr iven , empir ical ly s u p p o r t e d treat-

m e n t s can n o w be ca ta loged , d i s s emi n a t ed , a n d d e b a t e d

(Chambless , 1998; St rosahl , 1998; Wilson, 1998). Infer-

e n c e s f r o m c o n t r o l l e d clinical trials o f p s y c h o t h e r a p y are,

o f course , b a s e d o n the a g g r e g a t e d da ta f r o m diverse in-

dividuals. In m o s t trials, t he se indiv iduals sha re in com-

m o n the i r p r i m a r y c o m p l a i n t - - o f t e n o p e r a t i o n a l i z e d by

d i a g n o s i s - - b u t may d i f fer s ignif icant ly in t he behav io ra l

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