Effectiveness of an Individualized Case Formulation-Based CBT for Non-responding Youths with Anxiety Disorders

Abstract

The study examined the effectiveness of an individualized case formulation-based cognitive behavior therapy (CBT) for youths (9–17 years) with anxiety disorders and their parents after unsuccessful treatment with a manualized group CBT program (the Cool Kids). Out of 106 participant youths assessed at a 3-month follow-up after manualized CBT, 24 were classified as non-responders on the Clinical Global Impression-Improvement scale (CGI-I), and 14 of 16 non-responders with anxiety as their primary complaint accepted an offer for additional individual family CBT. The treatment was short-term (M sessions = 11.14) and based on a revised case formulation that was presented to and agreed upon by the families. At post-treatment, nine youths (64.3 %) were classified as responders on the CGI-I and six (42.9 %) were free of all anxiety diagnoses, while at the 3-month follow-up 11 (78.6 %) had responded to treatment and nine (64.3 %) had remitted from all anxiety diagnoses. Large effect sizes from pre- to post-individualized treatment were found on youths’ anxiety symptoms, self-reported (d = 1.05) as well as mother-reported (d = .81). There was further progress at the 3-month follow-up, while treatment gains remained stable from post-treatment to the 1-year follow-up. Results indicate that non-responders to manualized group CBT for youth anxiety disorders can be helped by additional CBT targeting each family’s specific needs.

Appendix: A Case Vignette

Presenting Picture

Lise (fictitious name; ID 8) was a 13-year old girl, who attended 6th grade and lived with both of her parents. She was the youngest of four children, one of which had moved from home. Her parents contacted the Anxiety Clinic because Lise was afraid something horrible would happen to her mother. For instance, she was afraid that her mother might die in a car accident or from a heart attack. This negatively affected her school attendance, social activities with peers and the family life, because she wanted to be with her mother at all times. From the diagnostic interview, it was concluded that Lise had a primary SAD diagnosis, a comorbid generalized anxiety disorder and panic disorder (see Table 1). Parents reported feeling stressed, since both were working fulltime, and three of their children had an ADHD diagnosis that demanded a lot of attention.

History

At the intake interview, parents reported that Lise showed the first signs of separation anxiety when she had to start at early childhood care. Her difficulties escalated in the 3rd grade, when she stayed home from school for half a year. She underwent psychiatric evaluation that resulted in an ADHD diagnosis for which she received medication. Lise also saw a psychologist for 12 sessions and was helped to gradually attend a new school. Nevertheless, she was only able to attend the new school occasionally and only if her mother accompanied her.

Manualized Treatment

Lise had difficulties completing tasks in the group, as because of her ADHD she became easily distracted. Furthermore, the family had difficulties completing exercises on cognitive restructuring between sessions, because Lise became irritated with her father, when he posed questions that were meant to challenge her erroneous attributions, as she felt he did not take her difficulties seriously. On the other hand, the mother had a tendency to reassure Lise, instead of challenging her worries. As the mother herself reported, sometimes it was easier to stay home from work, rather than having to deal with an extremely anxious child. Therefore, the parents had very different ways of handling her anxiety. Lise idealized the mother and devaluated the father, demanding for instance that he (not the mother) should sit behind the wheel, so he would be the one killed in a possible car accident. The family was introduced to the principles of graduated exposures, but it was difficult for them to practice systematically, because of a hectic and chaotic everyday in the family. The therapist reported having difficulties to follow-up on the family’s work as closely as needed, while there was not enough time to address the problematic family dynamics in a group setting.

Outcome of Manualized Treatment

Lise made some progress during the manualized treatment, as she started spending more time with her father and on “good days” she would go to school alone. She and her mother reported decreased anxiety levels after the end of treatment (see Fig. 1). Nevertheless, the diagnostic interviews at post-treatment and at the 3-month follow-up indicated she had not remitted from her anxiety diagnoses and she was classified as a non-responder (see Table 1), so she was offered further treatment. Lise’s case formulation, as presented at the clinical staff meeting and the family, is displayed in Fig. 2.

Fig. 2

Case formulation of Lise. a Case formulation as presented at clinical staff meeting. b Case formulation as presented to family

Individualized Treatment

The treatment consisted of eight sessions, the first four every week and the remaining every other week. From therapy start, the family’s homework was closely monitored, the therapist following up at each session the entries on exposure work made by the family, in the booklet they were given. Lise had difficulties with completing the exposure exercises due to her anxiety escalating very rapidly, making it hard for her to use the techniques. Interoceptive exposures were practiced in the session and Lise at first laughed when seeing the therapist hyperventilating, then when she started to hyperventilate, she felt dizzy, got scared and thought: this will end badly. She was encouraged to challenge her catastrophizing thoughts and she got a cue card with the alternative thought: I have some techniques I can try out. I am sure I can make this stop. Lise made progress in staying home for longer intervals and when she would get thoughts such as: what if they never come home? They could be dead, she tried to ignore them by focusing on what she was doing. When she got anxious in school, she reported tackling the butterflies in the stomach by trying to breathe more calmly, as she was taught to do in therapy sessions. She commented on her progress: Now I am a bit more like the others, doing the same things as them. Nevertheless, Lise would easily become discouraged and it was hypothesized that the ADHD contributed to her difficulties in having an overview of her progress and drawing learning from her experiences, negatively impacting her motivation. She was therefore given a success-diary in which she would write down her success-experiences and what she had learned. The individualized format allowed the therapist to spend some time with the parents alone during the sessions, where behaviors that contributed to the maintenance of Lise’s anxiety were discussed. During those sessions, a trained graduate student would conduct in vivo exposures with Lise, where she would practice taking the bus. The parents developed a more consistent way of handling her anxiety, assisting her in the implementation of techniques and praising her for bravery. Instead of creating “stepladders” of graduated exposures, they were presented with an alternative graphical presentation of behavioral experiments that was more flexible and easy for them to follow.

Outcome of Individualized Treatment

Lise made great progress during the individualized treatment, as she for instance became able to stay home alone for 2 h and she ended up taking the bus alone to school on a daily basis. At post-treatment and at the 3-month follow-up, Lise was classified as a responder (see Table 1). Self-reports showed that Lise and her mother experienced a significant decrease in anxiety levels, which remained low at the 3-month and at the 1-year follow-up assessments (see Fig. 1). The mother evaluated the therapy they had received:

It [the individualized treatment] was intense…but also good. We had already learned the techniques and gotten a lot out of being together with the others. Now we needed to work more intensively and it was very good that it was always adjusted in order to fit exactly to what Lise needed. It wouldn’t have helped being in a group again…We needed this continuous monitoring in order to get to the bottom of things…breathing exercises might for instance not be something all children need, but we couldn’t get any further, until Lise learned to tackle the symptoms.