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Behavioral Activation for Comorbid PTSD and Major Depression: A Case Study P a t r i c k S. M u l i c k , Gonzaga University A m y E. N a u g l e , Western M i c h i g a n University The present investigation details the assessment and use of Behavioral Activation (BA ) therapy to treat a 37-year-old male police officer~military veteran suffering from posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). This case study is an attempt to expand empirical knowledge regarding BA, comorbid PTSD and MDD, and treatment outcome research specifically relevant to these comorbid diagnoses. The BA treatment consisted of 11 sessions, which occurred on a weekly basis. Self-report data were gathered at each session and again at midpoint between each session. At posttreatment assessment, self-report and observer-rated data indicated that the client no longer met criteria for either PTSD or MDD. Results at 1-month follow-up suggested that the therapeutic gains were not only maintained, but that the client continued to improve. It is argued that BA may be an effective treatment for comorbid PTSD and MDD and the theoretical rationale is provided.

HERE IS A GROWING body of evidence that supports the use o f psychosocial treatments for posttraumatic stress d i s o r d e r (PTSD). These interventions fall broadly into the category o f cognitive behavioral therapy (CBT). T h e r e are several variants of CBT, i n c l u d i n g p r o l o n g e d e x p o s u r e t h e r a p y or implosion, cognitive therapy, stress inoculation training, a n d eye m o v e m e n t d e s e n s i t i z a t i o n a n d reprocessing (Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; Rothbaum, Meadows, Resick, & Foy, 2000). A m o n g these interventions, exposure therapy is frequently c o n s i d e r e d a first-line p s y c h o t h e r a p e u t i c t r e a t m e n t for PTSD (Ballenger et al., 2001; R o t h b a u m et al., 2000). However, there are elements o f exposure-based interventions that may limit the utility a n d g e n e r a l applicability o f the treatment. F o r example, t r e a t m e n t o u t c o m e research has d e m o n s t r a t e d that exposure-based PTSD treatments are associated with high rates o f t r e a t m e n t n o n c o m p l i a n c e (Foa, R o t h b a u m , Riggs, & Murdock, 1991; Tarrier et al., 1999; Vaughan & Tarrier, 1992), high d r o p o u t rates (between 30% to 50%; Schnurr, 2001), a n d the observation that some patients fail to enroll because they are intimid a t e d o r may find the t r e a t m e n t too aversive ( R o t h b a u m et al., 2000; Scott & Stradling, 1997). Additionally, treatm e n t o u t c o m e studies have d e m o n s t r a t e d that CBT interventions are most effective in treating reexperiencing and hyperarousal symptomatology a n d have less impact o n those symptoms that fall within the avoidance cluster (Blake & S o n n e n b e r g , 1998). Finally, high rates o f c o m o r b i d i t y occur frequently a m o n g individuals with PTSD a n d there currently is no empirical work to guide clinicians on how to treat PTSD when it co-occurs with a n o t h e r Axis I dis-

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order (Shalev, Friedman, Foa, & Keane, 2000). These factors

may limit the effectiveness o f exposure-based treatments with clinical p o p u l a t i o n s that practitioners regularly see; a n d may indicate the n e e d for alternative t r e a t m e n t strategies as either adjunctive o r stand-alone interventions for PTSD that are m o r e palatable a n d m o r e effective. Research on the c o m o r b i d i t y o f PTSD a n d m a j o r depressive d i s o r d e r (MDD) suggests co-occurrence rates o f the two disorders that e x c e e d what would be e x p e c t e d as an effect o f simple coincidence (Blanchard, Buckley, Hickling, & Taylor, 1998). T h e c o n c u r r e n t rates o f PTSD a n d MDD in some studies have b e e n as high as 65%, with lifetime prevalence rates o f c o m o r b i d PTSD and MDD (C-P/D) o f a p p r o x i m a t e l y 95% (Dow & Kline, 1997). N u m e r o u s explanations have b e e n offered to a c c o u n t for the prevalence o f C-P/D, i n c l u d i n g the overlap o f c o m m o n symptoms, c o m m o n causation, and sequential causation models (Shalev et al., 1998). It has b e e n suggested that C-P/D is n o t two separate disorders, b u t is b e t t e r characterized as o n e single diso r d e r whose s y m p t o m picture is a c c o u n t e d for by the overlap o f the criteria for the two individual d i s o r d e r s f o u n d within the Diagnostic and Statistic M a n u a l for Mental Disorders (DSM-F~; A m e r i c a n Psychological Association, 1994). However, some researchers maintain that PTSD a n d MDD can be c o n c e p t u a l i z e d as separate disorders and provide evidence to s u p p o r t this view (Blanchard et al., 1998; Bleich, Koslowsky, Dolev, & Lerer, 1997; Shalev et al., 1998). T h e sequential causation m o d e l o f understanding C-P/D has investigated the sequential p a t t e r n o f symptom d e v e l o p m e n t (Kessler et al., 1995; M e l l m a n et al., 1992). Results o f this research indicate that depressive symptoms generally seem to e m e r g e after the developm e n t of PTSD symptoms, suggesting that depression may be an ancillary c o n s e q u e n c e o f PTSD. T h e lack of consensus c o n c e r n i n g the u n d e r s t a n d i n g

Behavioral Activation for PTSD and MDD: Case Study o f C-P/D does n o t p r e c l u d e the n e e d to e x p l o r e effective t h e r a p e u t i c interventions for this p o p u l a t i o n . Conventional efficacy studies often exclude individuals with comp l e x symptomatology or, in the case o f c o m o r b i d diagnoses, choose to treat o n e d i s o r d e r while m o n i t o r i n g effects of the t r e a t m e n t o n a s e c o n d disorder. N e i t h e r m e t h o d directly attempts to e x a m i n e the specific hypothesis o f how to treat two c o m m o n l y co-occurring disorders concurrently (Nishith, Hearst, Mueser, & Foa, 1995). There are a n u m b e r o f PTSD t r e a t m e n t studies that have concurrently m o n i t o r e d PTSD a n d depressive syrnptomatology a n d a p o r t i o n o f these studies have d e m o n s t r a t e d a r e d u c t i o n in b o t h types o f symptoms (Boudewyns & Hyer, 1990; Foa, Hearst-Ikeda, & Perry, 1995; F o a et al., 1991; Keane, Fairbank, Caddell, & Zimering, 1989; Resick & Schnicke, 1992; R o t h b a u m et al., 2000; Vaughan et al., 1994). While this research suggests efficacy for CBT in treating this c o m o r b i d condition, to o u r knowledge, only o n e study exists that was d e s i g n e d specifically to empirically e x a m i n e the effectiveness o f a psychological intervention for treating individuals with C-P/D. Nishith a n d colleagues (1995) c o m b i n e d stress inoculation, cognitive restructuring, a n d imaginal a n d in vivo e x p o s u r e to treat a 37-year-old w o m a n who was the victim o f a severe sexual assault. Treatment resulted in a significant decrease in both PTSD a n d depressive symptomatology. This case study p r o v i d e d initial s u p p o r t for the effectiveness of psychological interventions in r e d u c i n g p r o b l e m symptoms associated with C-P/D. However, Nishith a n d colleagues (1995) c o n c l u d e d that while their t r e a t m e n t demonstrates promise, m o r e research was n e e d e d to e x a m i n e which components o f their t r e a t m e n t were effective a n d necessary for recovery. It is i m p o r t a n t to n o t e that the t r e a t m e n t comp o n e n t s utilized by Nishith a n d colleagues (1995) were standard PTSD interventions. The possibility exists that contemporary depression interventions might also demonstrate c o m p a r a b l e reductions across the c o m o r b i d conditions. Behavioral Activation (BA) t r e a t m e n t for depression is a behavioral intervention that e m e r g e d f r o m the dismantling research o f Beck's Cognitive T h e r a p y for Depression (Beck, Rush, Shaw, & Emery, 1979; Martell, Addis, & Jacobson, 2001). Initial research has d e m o n s t r a t e d that BA is effective at reducing depressive symptoms (Jacobson et al., 1996). J a c o b s o n a n d colleagues r a n d o m l y assigned 152 d e p r e s s e d subjects to o n e o f t h r e e treatments, two of which were derived f r o m the c o m p o n e n t s o f CBT: (1) BA; (2) automatic thoughts (AT), which was a combination o f BA a n d skills to modify a u t o m a t i c dysfunctional thoughts; o r (3) "full" CBT (CT), which consisted of BA, modification o f a u t o m a t i c dysfunctional thoughts, a n d changing core dysfunctional schemas. Participants in each t r e a t m e n t c o n d i t i o n received their p r e s c r i b e d t r e a t m e n t over the course o f 16 weeks with a m a x i m u m o f 24 sessions. Assessment o f the participants' symptomatology was

c o n d u c t e d before t r e a t m e n t began, at the time o f termination, a n d at 6-, 12-, 18-, a n d 24-month follow-up utilizing the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) a n d the H a m i l t o n Rating Scale for Depression (HRSD; Hamilton, 1960), b o t h of which m e a s u r e depressive thoughts, behaviors, a n d emotions. T h e r e were no significant differences between the t r e a t m e n t groups at the time o f t e r m i n a t i o n o r u p to 2 years p o s t t r e a t m e n t (Gortner, Gollan, Dobson, &Jacobson, 1998;Jacobson et al., 1996). Given the p r o m i s i n g results o f BA a n d the overlap between PTSD a n d MDD symptomatology, BA may be an effective a n d efficient t r e a t m e n t o p t i o n for treating individuals with C-P/D. T h e rationale for utilizing BA to treat the C-P/D p o p u l a t i o n stems f r o m similar t h e o r e t i c a l u n d e r p i n n i n g s o f the cognitive-behavioral a n d behavioral interventions typically used to treat PTSD. Cognitive-behavioral a n d behavioral therapies for PTSD place an emphasis o n targeting a n d r e d u c i n g avoidance behaviors. Typically, individuals d i a g n o s e d with PTSD have b e g u n to organize their lives a r o u n d avoiding r e m i n d e r s a n d r e c o l l e c t i o n s o f their traumatic e x p e r i e n c e s (van d e r Kolk, McFarlane, & van d e r Hart, 1996). T h e avoidance a n d social withdrawal behaviors serve to maintain PTSD symptomatology. T h e f o u n d a t i o n for m a n y PTSD treatments is that individuals l e a r n a new behavioral r e p e r t o i r e that reduces distress related to their t r a u m a e x p e r i e n c e s (Blake & S o n n e n b e r g , 1998). Similarly, Martell a n d colleagues (2001) stated that depression results from individuals e n g a g i n g in avoidance behaviors that reduce contact with positive reinforcers. T r e a t m e n t with individuals who have d e v e l o p e d this avoidant behavioral p a t t e r n involves assisting t h e m in developing a b r o a d e r a n d m o r e flexible behavioral repertoire that e x p a n d s t h e i r contact with the world a r o u n d t h e m a n d ultimately e n h a n c e s t h e i r lives. T h e tenets u n d e r l y i n g BA view d e p r e s s i o n as the result o f changes in a person's life circumstances which result in a r e d u c t i o n o f r e i n f o r c e m e n t for that individual (Lewinsohn, 1974). O n c e symptoms of depression develop, the negative ways in which individuals r e s p o n d to their envir o n m e n t s act to exacerbate the symptoms, resulting in even fewer o p p o r t u n i t i e s for m o r e prosocial o r functional behavior to be reinforced. T h e goal of BA is to activate individuals in o r d e r to maximize the o p p o r t u n i t i e s they have to contact possible reinforcers in their e n v i r o n m e n t (Martell et al., 2001). Based o n this u n d e r l y i n g conceptualization a n d goal, the overall p u r p o s e s o f BA t r e a t m e n t for d e p r e s s i o n a r e to: (a) d e t e r m i n e t h e life circumstances that precipitated the depressive symptoms; (b) d e t e r m i n e the c o p i n g patterns that e x a c e r b a t e d the depressive symptoms; a n d (c) develop a t r e a t m e n t p l a n for i m p r o v i n g the c o p i n g strategies a n d p r o v i d i n g access to m o r e reinforcing life circumstances (Martell et al., 2001). Since BA targets avoidance, withdrawal, isolation,

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Method Identifying Information T h e client, Bruce, is a 37-year-old married, Caucasian male. H e was r e f e r r e d to o u r psychology d e p a r t m e n t by a physician's assistant from a local m e n t a l health clinic for symptoms associated with depression a n d PTSD. T h e clie n t d i d n o t receive any m o n e t a r y c o m p e n s a t i o n for his participation a n d stated that he was n o t seeking service o r disability c o m p e n s a t i o n .

Historical Information Bruce served as a police officer for 9 years d u r i n g the 1980s a n d 1990s. Additionally, d u r i n g the last 6 years o f this p e r i o d he c o n c u r r e n t l y served in the special operations division o f the military. His military position req u i r e d missions in foreign countries three o r four times a year. T h e d u r a t i o n o f the missions r a n g e d from 4 days to 1 m o n t h . Bruce r e p o r t e d m a n y traumatic events d u r i n g this period. These events included: (a) attempts on his life while serving as an u n d e r c o v e r officer a n d d u r i n g the course o f his military service; (b) investigating transportation accidents (plane a n d automobile), a n d (c) witnessing o t h e r accidental deaths.

Therapeutic History Brnce h a d consistently e x p e r i e n c e d psychological difficulties since May 1985. Prior to presenting for treatment

at o u r clinic, he h a d received individual o u t p a t i e n t therapy for depression a n d PTSD intermittently over the previous 2 years. This i n c l u d e d a 2-week admission to a partial hospitalization p r o g r a m in July o f 2000. H e h a d b e e n receiving p s y c h o p h a r m a c o l o g i c a l t r e a t m e n t for the 9 m o n t h s p r i o r to his initial assessment for the t r e a t m e n t p r e s e n t e d here. At the time o f the initial assessment, a n d for the d u r a t i o n o f the t r e a t m e n t , he was stabilized on Zoloft (50 m g / d a y ) , Buspar (30 m g bid), a n d Risperdal (1 m g / d a y ) .

Presenting Complaints Overall, Bruce p r e s e n t e d as a cooperative, motivated, a n d h o n e s t individual. T h r o u g h the p r e t r e a t m e n t assessment, baseline phase, a n d initial p a r t o f the t r e a t m e n t phase, his affect was extremely flat a n d he was withdrawn d u r i n g his in-session interactions. Bruce p r e s e n t e d with concerns regarding the persistent and severe nature o f his symptoms. At the time o f the initial intake, he r e p o r t e d that he h a d n o t b e e n able to find work that he enjoyed because his symptoms were too severe. Since he h a d retired from the police force a n d the military he h a d h e l d seven or eight m e n i a l jobs. H e h a d b e e n working in the automotive industry for the past 4 months. H e r e p o r t e d that his j o b h e l d no e n j o y m e n t for him, b u t was something that he could h a n d l e because it r e q u i r e d little o f him. His social contacts were limited to interactions with his wife. Bruce r e p o r t e d he previously h a d a fairly large n u m b e r of friends, b u t that h e h a d lost contact with most o f t h e m over the past few years. H e a t t r i b u t e d this loss o f social s u p p o r t to the severe n a t u r e o f his psychological symptoms. Due to the severity o f his symptoms, Bruce f o u n d it difficult to engage in activities outside o f his h o m e alone. H e rarely went s h o p p i n g or r a n o t h e r e r r a n d s without the a c c o m p a n i m e n t o f his wife. H e stated that when he was alone he h a d n o one to h e l p him cope if an intrusive m e m o r y o r flashback was triggered. W h e n Bruce's symptoms were at their worst he would react by "going grim." H e described this reaction as mildly dissociating f r o m his s u r r o u n d i n g s a n d c o m p l e t e e m o t i o n a l n u m b i n g . This p e r i o d o f "going grim" would last anywhere from 1 day to 1 week. H e expressed great distress over his reactions because it caused him to feel like he was "a freak" a n d as if he could n o t function like a n o r m a l person. H e stated that in the past he had "drank, fought, and chased women" to cope with the way he felt. H e c o m m e n t e d that he s t o p p e d those activities several years ago because they only s e e m e d to cause him m o r e difficulties; however, he stated that n o t h i n g else s e e m e d to work as an alternative. In response to interview items, Bruce c o n f i r m e d that he was experiencing a loss o f interest, restlessness, fatigue, feelings o f worthlessness, difficulty concentrating, suicidal ideations, intrusive memories, nightmares, flashbacks,

Behavioral Activation for PTSD and MDD: Case Study e m o t i o n a l a n d physiological reactions to cues, avoidance behaviors, difficulty r e m e m b e r i n g i m p o r t a n t aspects o f certain traumas, feeling cut off f r o m others, difficulty sleeping, irritability, a n d e x a g g e r a t e d startle responses. F u r t h e r m o r e , he stated that he h a d difficulty c o p i n g with r e e x p e r i e n c i n g symptoms, such as intrusive memories, flashbacks, a n d nightmares. Based o n Bruce's clinical presentation, specifically his r e p o r t of e x t r e m e social isolation a n d avoidant c o p i n g strategies, it was d e t e r m i n e d BA may be an effective t h e r a p e u t i c intervention in treating his C-P/D symptoms. Assessment Measures PTSD Symptom Scale (PSS). T h e PSS was d e v e l o p e d by Foa, Riggs, Dancu, a n d R o t h b a u m (1993) to assess the p r e s e n c e a n d frequency o f PTSD symptoms in individuals who have e x p e r i e n c e d a traumatic event. T h e PSS has 17 items that are scored on a 4-point scale (0 = not at all to 3 = 5 or more times per week~very much~almost always). T h e PSS d e m o n s t r a t e d high i n t e r n a l consistency (c~ = .91) a n d the internal consistency for the subscales were .78, .80, a n d .82, respectively. Beck Depression Inventory-Second Edition (BDI-II). T h e BDI-II (Beck, Steer, & Brown, 1996) has excellent psychometric p r o p e r t i e s a n d is sensitive to clinical c h a n g e (Beck et al., 1996; Steer, Ball, Ranieri, & Beck, 1997). It contains 21 items that are designed to assess 21 different symptoms associated with depression. It utilizes a 4-point Likert-type scale, r a n g i n g f r o m 0 to 3, to m e a s u r e the subject's depressive symptomatology over the past 2 weeks. Automatic Thoughts Questionnaire (AT@. T h e A T Q was d e v e l o p e d by H o l l o n a n d Kendall (1980) to m e a s u r e the frequency o f o c c u r r e n c e o f a u t o m a t i c negative thoughts believed to be associated with depression. T h e items are r a t e d on a 5-point scale (1 = not at all, 2 = sometimes, 3 = moderately often, 4 = often, a n d 5 = all the time). T h e A T Q is significantly c o r r e l a t e d with the BDI a n d the MMPI depression scale at p < .01 a n d has high i n t e r n a l consistency (or = .96). Revised Hamilton Rating Scale for Depression (RHRSD). T h e RHRSD (Warren, 1996) is an observer-rated instrum e n t utilized to m e a s u r e the severity o f depressive symptoms. It contains 22 items a n d has descriptive a n c h o r points for each of the values for each item. Cognitive items assess hopelessness, helplessness, a n d worthlessness, b u t are n o t c o m p u t e d in the total score for severity. O f the 17 scored items, 9 are r a t e d on 5-point scales (0 to 4) a n d 8 on 3-point scales (0 to 2). T h e total possible scores range from 0 to 52. Stnzctured Clinical Interview for DSM-IV (SC1D). T h e SCID (First, Spitzer, Gibbon, & Williams, 1997) is a semistruct u r e d interview, i n t e n d e d to be a d m i n i s t e r e d by a t r a i n e d clinician. T h e i n s t r u m e n t is i n t e n d e d to be utilized with adults a n d is d e s i g n e d to assess 33 frequently d i a g n o s e d

disorders f o u n d in the DSM-IV. T h e psychomen'ic d a t a on the SCID confirms it to b e a reliable instrument. T h e reliability of the SCID has b e e n established in n u m e r o u s studies (Segal, Hersen, & Van Hasselt, 1994; Williams et al., 1992). Clinician-Administered PTSD Scalefor DSM-1V (CAPS). The CAPS is a stpactured interview that is d e s i g n e d specifically to assess for symptoms o f PTSD (Blake et al., 1997). T h e CAPS provides b o t h a d i m e n s i o n a l a n d categorical a p p r o a c h to the assessment o f PTSD a n d distinguishes between frequency a n d intensity o f symptomatic experiences (Weiss, 1997). Both d o m a i n s are r a t e d o n 5-point scales r a n g i n g from 0 to 4. T h e psychometric p r o p e r t i e s of the instrument are respectable, with a k a p p a coefficient o f .78, internal consistency a l p h a coefficient o f .94, a n d test-retest reliability r a n g i n g between .90 a n d .98. Procedure Assessment Bruce was assessed p r i o r to the first session, at posttreatment, a n d 1 m o n t h following the termination of treatment. D u r i n g the p r e t r e a t m e n t assessment, Bruce comp l e t e d a brief d e m o g r a p h i c questionnaire, the BDI-II, a n d ATQ. Additionally, he was interviewed using the SCID, the CAPS, a n d the RHRSD. Initial interview sessions t o o k a p p r o x i m a t e l y 2 hours to complete. Due to revisions in the selection o f assessment instruments, the PSS was n o t i n c l u d e d in the p r e t r e a t m e n t assessment. However, the PSS a n d BDI-II were a d m i n i s t e r e d d u r i n g a n d between each t h e r a p y session. A r e m i n d e r call was m a d e to Bruce on the d e s i g n a t e d m i d p o i n t day between sessions to ensure c o m p l e t i o n o f the measures. As a result o f schedule conflicts, t h e r e was a 2-week hiatus between t r e a t m e n t session 9 a n d 10. In an a t t e m p t to ensure some assessm e n t consistency, the subject c o m p l e t e d the self-report measures twice d u r i n g this period, once each week. Following the c o m p l e t i o n o f treatment, Bruce r e t u r n e d for a p o s t t r e a t m e n t interview, which consisted o f him completing the BDI-II, PSS, a n d ATQ. Additionally, Bruce was again interviewed using the CAPS, SCID, a n d RHRSD. O n e m o n t h following the e n d o f treatment, Bruce ret u r n e d for a follow-up interview, again c o m p l e t i n g the BDI-II a n d PSS. T h e first a u t h o r c o n d u c t e d all assessm e n t a n d t r e a t m e n t sessions. Therapeutic Intervention Bruce a t t e n d e d 11 sessions. Sessions o c c u r r e d on a weekly basis a n d each session lasted a p p r o x i m a t e l y 1 hour. T h e first session following the p r e t r e a t m e n t assessm e n t was used as a d a t a g a t h e r i n g a n d i n f o r m a t i o n a l session. It consisted of the client c o m p l e t i n g all self-report measures a n d the therapist e x p l a i n i n g the p r o c e d u r a l aspects o f the treatment. No specific therapeutic techniques

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were used d u r i n g this session. BA was initiated d u r i n g Session 2 a n d c o n t i n u e d over the next 9 sessions. Each BA session consisted of three distinct parts: (a) Beginning: the client completed the weekly self-report measures (PSS a n d BDI-II) a n d the client a n d therapist established the a g e n d a to be followed for the session; (b) Middle: the client a n d therapist worked o n targeted t r e a t m e n t goals that were placed o n the a g e n d a for that session; a n d (c) Ending: the client a n d therapist reviewed the topics discussed a n d established new between-session work. T h e between-session work varied from week to week, b u t always i n c l u d e d Bruce c o m p l e t i n g the self-report measures a n d a daily log, which asked h i m to track his daily activities o n an hourly basis. Additional between-session work consisted of a n u m b e r of activities, such as g e n e r a t i n g discussions with coworkers, having specific discussions with his spouse, a n d a r r a n g i n g social outings with friends with whom he had lost contact. I n early stages of t r e a t m e n t a majority of session time was spent educating the client o n the BA conceptualization of depression a n d traumatic stress, the rationale beh i n d the utilization of this i n t e r v e n t i o n for treatment, going over the client's daily log, a n d exploring the client's b e h a v i o r a l patterns. Following the initial sessions, the focus shifted to helping the client examine areas of his life where he was b e i n g active versus passive. This examination was i m p o r t a n t to help the client see how he had become avoidant a n d passive in a majority of areas of his life. O n c e the passive/active distinction was presented, m u c h of the sessions consisted of h e l p i n g the client to become more active a n d e n g a g e d in his life. The client reported that the emphasis o n being active in his life helped h i m to develop a sense of control over his symptomatology. The last session was spent reviewing the skills that the client had l e a r n e d a n d discussing how to utilize these skills when he e n c o u n t e r s difficulties in the future. T h r o u g h o u t the t r e a t m e n t phase, the therapist att e m p t e d to utilize standard therapeutic interventions outlined by Martell a n d colleagues (2001). Specific homework assignments i n c l u d e d contacting friends with whom he had lost contact, having l u n c h with coworkers, a n d actively coping with reexperiencing a n d hyperarousal symptoms, rather than passively isolating (i.e., going for a walk, talking to someone). The most frequently utilized, a n d most effective, i n t e r v e n t i o n was having Bruce track his daily activities a n d events. This daily log e n a b l e d the client to visually see how his passive coping strategies were ineffective. Adherence and competence check. In the interest of addressing t r e a t m e n t fidelity a n d a d h e r e n c e to the BA protocol, we were able to obtain feedback regarding the therapist's a d h e r e n c e to BA for one r a n d o m l y selected session. The feedback was provided by one of the individuals who was responsible for the training a n d supervision of the BA

Table 1 Therapist Competence Ratings Using the Behavioral Activation for Depression Scale

Item

Rating (0-6)

General Therapeutic Skills 1. Setting the session agenda 2. Feedback regarding client understanding 3. Therapist understanding of client's experience/communication 4. Interpersonal effectiveness of therapist 5. Collaboration established between therapist and client 6. Pacing and efficient use of time Conceptualization, Strategy, and Technique 7. Developing and describing functional analysisof activity 8. Focus on key behaviors 9. Quality of therapist BA strategy for change 10. Skillful application of BA techniques 11. Ability to incorporate homework

4 = Good 3 = Satisfactory 4 = Good 5 = Very good 3 = Satisfactory 3 = Satisfactory

4 = Good 5 = Very good 5 = Very good 4 = Good 4 = Good

therapists in the originalJacobson et al. (1996) study. The therapist's p e r f o r m a n c e was assessed using the Behavioral Activation Therapy for Depression Scale (BATS), which is a scale designed to measure competence, or the quality of the application of various BA techniques a n d therapeutic skill. T h e BATS is modified from the Mental Health Collaborative Study Psychotherapy Rating Scale (Hollon, Evans, Elkin, & Lowery, 1984) used in the NIMH T r e a t m e n t of Depression Collaborative Research Program t r e a t m e n t o u t c o m e study (Elkin et al., 1989). For each of 11 items, the therapist's behavior is rated using a 7-point scale (0 = poor to 6 = excellent). In general, the therapist's level of c o m p e t e n c e was evaluated to be in the 4 (good) to 5 (very good) range. N o n e of the items were evaluated to be lower than 3 (satisfactory). Therefore, the competence ratings for the therapist were j u d g e d by the expert rater to be more t h a n acceptable. F u r t h e r m o r e , the rater indicated that based o n performance, the therapist would likely be selected to participate in a BA outcome study. T h e actual ratings of the therapist's p e r f o r m a n c e are provided in Table 1.

Results Pretreatment Assessment At the time of the p r e t r e a t m e n t assessment, Bruce m e t criteria for both PTSD a n d MDD, as d e t e r m i n e d by the CAPS a n d the SCID, respectively. A n overview of Bruce's rating o n the CAPS (Table 2) indicates that, quantitatively, taken as a whole those symptoms c o n t a i n e d within the avoidance cluster of PTSD were the most troublesome to the client. Within this cluster, Bruce's symptoms of anhed o n i a a n d sense of a f o r e s h o r t e n e d future were most

Behavioral Activation for PTSD and MDD: Case S t u d y

frequent and most intense. Bruce's score o n the R H R S D was a 26, w h i c h w o u l d place h i m in the category o f severely depressed. Additionally, Bruce's score o f 95 o n the A T Q suggests that h e was e x p e r i e n c i n g f r e q u e n t a n d persistent occurrence of automatic negative thoughts. Visual Inspection of Data From PTSD and Depression Measures T h e d a t a o b t a i n e d at e a c h assessm e n t p o i n t , g a t h e r e d f r o m t h e selfreport outcome measures, are pres e n t e d in T a b l e 3 a n d g r a p h e d in F i g u r e 1. At the t i m e o f the pretreatm e n t assessment Bruce's scores for b o t h PTSD a n d d e p r e s s i o n self-report m e a s u r e s were in the severe range. T h e r e was a r e d u c t i o n in scores for all m e a s u r e s o v e r the c o u r s e o f treatm e n t , with a n o t i c e a b l e d e c r e a s e occ u r r i n g toward the e n d o f t r e a t m e n t .

383

Table 2 Pre- and Postassessment CAPS Scores

Symptom Intrusive memories Nightmares Flashbacks Psychological distress Physiological distress Avoid thoughts etc. Avoid activities etc. Lack memory Anhedonia Detached Restricted affect Foreshortened future Sleep troubles Irritability Concentration difficulty Hypervigilance Startle response Total re-experiencing Total avoidance Total hyperarousal Total symptoms Subjective distress Social functioning Occupational functioning

Pre-F

Pre-I

Pre-T

Post-F

Post-I

Post-T

3 2 3 2 1 4 2 2 4 2 2 4 2 1 1 2 4 11 20 10 41 3 3 3

4 3 3 2 4 2 2 2 4 4 2 4 2 2 2 3 4 16 20 13 49

7 5 6 4 5 6 4 4 8 6 4 8 4 3 3 5 8 27 40 23 90

4 1 1 2 1 4 2 0 0 2 1 1 3 0 2 4 4 9 10 13 32 1 1 1

1 3 3 2 2 2 1 0 0 1 1 1 2 0 1 3 3 11 6 9 26

5 4 4 4 3 6 3 0 0 3 2 2 5 0 3 7 7 20 16 22 58

Posttreatment and Follow-Up Note. Individual symptom cluster scores and the overall symptom total score are in bold. Assessment At the time of the posttreatment assessment, B r u c e n o l o n g e r m e t criteria for e i t h e r P T S D o r M D D , as d e t e r m i n e d by t h e this process. B r u c e stated t h a t it h a d b e e n years since h e s t r u c t u r e d interviews. T h e p o s t t r e a t m e n t CAPS d a t a are h a d felt like h e h a d this m u c h c o n t r o l in his life. H e exp r e s e n t e d in Table 2. T h e m o s t n o t a b l e r e d u c t i o n in p r e s s e d that h e was able to take t h e skills t h a t h e h a d s y m p t o m a t o l o g y for the CAPS o c c u r r e d with the avoidl e a r n e d a n d apply t h e m to o t h e r areas that h e was struga n c e s y m p t o m cluster. F u r t h e r m o r e , Bruce was n o l o n g e r gling with in his life. B r u c e h a d b e g u n to r e e n g a g e in e x p e r i e n c i n g a n h e d o n i a a n d his sense o f a f o r e s h o r t e n e d m a n y activities. F o r instance, B r u c e u s e d to h a v e a very future was only o c c u r r i n g at a m i l d f r e q u e n c y a n d i n t e n s i ~ successful side business as a m a g i c i a n / e n t e r t a i n e r ; howBruce's score o f 52 o n the A T Q d e m o n s t r a t e d a substantial ever, his s y m p t o m s a n d d i s c o m f o r t a r o u n d p e o p l e h a d d r o p f r o m pre- to p o s t t r e a t m e n t . O n e m o n t h after his last f o r c e d h i m to q u i t this type o f work. By the e n d o f treatt r e a t m e n t session, the client's self-report m e a s u r e scores m e n t , B r u c e h a d b e g u n his business a g a i n a n d h e was i n d i c a t e d that h e c o n t i n u e d to e x p e r i e n c e a r e d u c t i o n in c o n d u c t i n g m u l t i p l e large shows e a c h w e e k e n d . At t h e b o t h his M D D a n d P T S D s y m p t o m s . B r u c e ' s s e l f - r e p o r t p o i n t o f t h e follow-up assessment B r u c e was in t h e p r o scores at the time o f t h e p o s t t r e a t m e n t a n d follow-up assesscess o f d e c r e a s i n g his p s y c h o t r o p i c m e d i c a t i o n s a n d his m e n t s fall in the m i l d r a n g e o n all measures. p r i m a r y c a r e p r o v i d e r h a d a l r e a d y d i s c o n t i n u e d his use o f Zoloft. Client's C o m m e n t s o n B A T r e a t m e n t B r u c e r e p o r t e d t h a t h e was e x t r e m e l y p l e a s e d with the Posttreatment Injury p r o g r e s s h e h a d m a d e o v e r t h e c o u r s e o f his BA treatSix weeks f o l l o w i n g t e r m i n a t i o n o f BA t r e a t m e n t , m e n t . Additionally, h e stated t h a t h e h a d l e a r n e d n e w B r u c e was i n v o l v e d in an industrial a c c i d e n t that i n v o l v e d skills t h a t h e l p e d h i m to m a n a g e his P T S D a n d depressive a 2 2 - p o u n d slab o f r o c k falling o n his h e a d a n d r e n d e r i n g s y m p t o m s r a t h e r t h a n allowing "his s y m p t o m s to m a n a g e h i m u n c o n s c i o u s . T h e a c c i d e n t r e s u l t e d in c o g n i t i v e difh i m . " H e stated t h a t t h e m o s t h e l p f u l t h i n g a b o u t t h e ficulties a n d a d e t e r i o r a t i o n o f B r u c e ' s fine m o t o r skills. t r e a t m e n t was b e i n g t a u g h t h o w to e x a m i n e his own life to B r u c e r e p o r t e d t h a t w h i l e his a c c i d e n t a n d r e s u l t i n g injud e t e r m i n e w h e n a n d w h e r e h e was b e i n g passive a n d h o w ries h a d h a d an i m p a c t o n his progress, h e was utilizing to b e c o m e active in t h o s e situations. H e r e p o r t e d t h a t the skills h e h a d l e a r n e d in t h e r a p y to establish goals f o r c o m p l e t i n g a n d r e v i e w i n g his daily l o g was a vital t o o l in h i m s e l f a n d ti T to r e m a i n as active as possible.

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Mulick & Naugle Table 3 Monitoring Treatment Progress Session

PSS

BDI-II

Pre-assessment Session 1 Between Session 1 BA Session 1 Between BA 1 BA Session 2 Between BA 2 BA Session 3 Between BA 3 BA Session 4 Between BA 4 BA Session 5 Between BA 5 BA Session 6 Bem,een BA 6 BA Session 7 Between BA 7 BA Session 8 Between BA 8 BA Session 9 Between BA 9,1 Between BA 9.2 BA Session 10 Postassessment 1-month follow-up

N/A 34 27 27 26 26 23 25 32 29 29 24 40 31 26 23 23 39 28 21 19 15 14 14 8

29 21 24 21 24 18 21 19 28 28 28 23 47 31 22 22 16 27 27 12 13 10 13 12 7

Discussion T h e present case study provides e n c o u r a g i n g support for the efficacy o f a 10-week BA intervention in treating both PTSD and depressive symptomatology. The self-report and observer-rated data indicate that Bruce no l o n g e r m e t criteria for either PTSD or MDD at the e n d of treat-

5O 45 40 35 30 25 20 15 10 5 0

Figure 1. Treatment progress: PSS and BDI.

m e n t . As e v i d e n c e d by his p o s t t r e a t m e n t CAPS score falling in the m o d e r a t e / s e v e r e range, Bruce was still exp e r i e n c i n g some f r e q u e n c y and intensity o f PTSD symptomatology; however, his verbal self-report p r o v i d e d evid e n c e that these symptoms n o l o n g e r had a clinically significant impact on his social or occupational functioning. T h e data collected at a 1-month follow-up indicate that Bruce not only m a i n t a i n e d these therapeutic gains, but that he c o n t i n u e d to improve. It is i m p o r t a n t to address the variability f o u n d within Bruce's self-report data. As part o f our general clinic procedures, t r e a t m e n t was initiated at the second session following the initial assessment. Empirically, it would have b e e n desirable to c o n d u c t a m o r e rigorous single-subject design with an e x t e n d e d baseline to d e m o n s t r a t e f u r t h e r symptom stability and greater e x p e r i m e n t a l control. However, the d u r a t i o n of the symptom presentation and Bruce's extensive t r e a t m e n t history provide evidence o f the chronic nature of his symptoms. T h e r e are two spikes in the data that o c c u r r e d when Bruce c o m p l e t e d the measures between Session 5 and Session 6 and w h e n he c o m p l e t e d the measures at Session 8. T h e r e were specific events s u r r o u n d i n g b o t h o f these increases in symptom severity. In the first instance, there had b e e n an abundance o f news in press and on TV r e g a r d i n g a specific political figure's actions while in Vietnam and on an American missionary plane being shot down in a South American country. Both o f these events related closely to Bruce's own past traumatic experiences. In the second instance, there had b e e n significant marital discord that had occ u r r e d p r e c e d i n g the a p p o i n t m e n t . In b o t h cases, the issues were placed o n that session's a g e n d a and m a d e part o f the therapeutic process. Specifically, Bruce was asked to describe his behavioral response after e n c o u n t e r i n g these triggers. T h e client r e p o r t e d that in all the cases he immediately e x p e r i e n c e d "going grim" and went to his b a s e m e n t to be alone. In the first instance he stayed in his b a s e m e n t for a couple o f days, missed work, and did not interact with his wife. This behavioral response, the effect on his psychological well being, and alternative behavioral responses were discussed in detail. Much time was spent reminding the client that depression and PTSD symptoms are exacerbated w h e n he was passive, and b r a i n s t o r m i n g ideas for how he could have b e e n m o r e active in his response. For instance, the client suggested that he could have gone for a walk, gone out with friends, talked with his wife, a n d / o r c o n t i n u e d to go to work. T h e client r e p o r t e d at future sessions that similar events and situations were no longer having such a severe impact

Behavioral Activation for PTSD and MDD: Case Study o n his symptoms. Bruce c o m m e n t e d that in the past he h a d tried to cope with PTSD a n d depression by going in the b a s e m e n t a n d shutting out the world. W h a t BA h a d taught him was to d o the opposite. H e discovered that to feel b e t t e r he n e e d e d to go o u t a n d "be active in the world." The client's ability to apply the information l e a r n e d in session to situations outside the clinic provides evid e n c e that the e d u c a t i o n a l c o m p o n e n t s o f BA were und e r s t a n d a b l e a n d a p p l i c a b l e for this client. This develo p m e n t o f knowledge a n d skills s h o u l d assist in relapse prevention. T h e r e are a n u m b e r o f interesting points to address c o n c e r n i n g this case. First, the focus of t r e a t m e n t never involved e d u c a t i n g or c o n d u c t i n g in vivo o r imaginal exposure with Bruce. T h e sessions consisted o f discussing Bruce's p a t t e r n o f avoidance o f specific types o f activities a n d the way that he consistently r e s p o n d e d to stress in his life. T i m e was s p e n t on e x p l o r i n g ways in which Bruce could b e c o m e m o r e active a n d e n g a g e d in these situations. It appears that the process o f h e l p i n g Bruce bec o m e m o r e active in his life a n d d e v e l o p i n g his skills o f b e i n g able to e x a m i n e his own behavioral p a t t e r n was effective at r e d u c i n g the symptoms he was experiencing. Second, the majority o f Bruce's i m p r o v e m e n t was seen after eight sessions. While there was some decrease in symptomatology over the first p a r t o f therapy, Bruce's data present m u c h m o r e variability d u r i n g these sessions. However, there is a dramatic i m p r o v e m e n t following Session 8. It is possible that the i m p r o v e m e n t at this p o i n t was associated with B .ruce's a t t a i n m e n t o f an effective understanding o f how his symptoms were a c o n s e q u e n c e of his context, o r his p e r s o n - e n v i r o n m e n t interactions, a n d applying this u n d e r s t a n d i n g to analyzing a n d modifying his behavior. Martell a n d colleagues (2001) state that the goal of BA is n o t simply getting a client to b e c o m e active; rather, it is getting the client to engage in the right activities. "The client is taught to l o o k carefully at h e r life a n d to b e c o m e an e x p e r t o n h e r daily behaviors a n d the consequences of h e r behaviors" (Martell et al., 2001, p. 54). T h e client must increase those activities that are going to increase his or h e r contact with reinforcers in his or h e r e n v i r o n m e n t . The process o f analyzing one's activities a n d resulting m o o d s takes time a n d practice, which may a c c o u n t for m o r e i m p r o v e m e n t in later sessions. Third, the quantitative data indicate BA d e m o n s t r a t e d the greatest r e d u c t i o n on those symptoms that fall in the avoidance cluster o f PTSD, which contains the majority o f overlapping symptoms in the diagnostic criteria of PTSD a n d MDD. T h e i m p r o v e m e n t in this a r e a is n o t unexpected given the rationale b e h i n d a n d therapeutic techniques utilized with BA. Given this finding, the high overlap o f symptomatology between PTSD a n d MDD, a n d BA's p r i o r empirical evidence for its effectiveness in treating MDD, it is necessary to e x a m i n e w h e t h e r BA was

treating b o t h PTSD a n d MDD or simply the latter. W h e n looking at the pre- a n d post-assessment CAPS data it is possible to e x a m i n e specific symptoms where Bruce d e m o n s t r a t e d i m p r o v e m e n t by e x a m i n i n g only those symptoms where h e e x p e r i e n c e d at least a 2-point r e d u c t i o n in his total score (frequency + intensity). Bruce h a d a total o f 9 symptoms with this level o f r e d u c t i o n , 4 of these symptoms were o v e r l a p p i n g a n d 5 were PTSD-unique. These d a t a d e m o n s t r a t e that Bruce i m p r o v e d in a greater n u m b e r of PTSD-unique symptoms than in those symptoms that overlap the two disorders. Additionally, the qualitative data suggest that BA d i d h e l p the client c o p e with the r e e x p e r i e n c i n g a n d hyperarousal symptoms. Specifically, Bruce indicated that these symptoms no longer h a d a significant i m p a c t on his social o r Occupational functioning. While he still e x p e r i e n c e d intrusive m e m o ries, flashbacks, nightmares, a n d e x a g g e r a t e d startle response with r e g u l a r frequency a n d m o d e r a t e intensity, h e was able to m a n a g e these symptoms. BA d i d n o t eliminate Bruce's symptoms; rather, it a p p e a r e d to give him the skills he n e e d e d to effectively m a n a g e them. T h e reduction and management of PTSD-unique symptoms, along with C-P/D c o m m o n symptoms, indicates that BA h a d some efficacy in treating symptoms o f b o t h disorders. While it is difficult to p r e d i c t how well this t r e a t m e n t may generalize to o t h e r individuals, with o t h e r symptom presentations, a n d who were e x p o s e d to o t h e r traumatic experiences, the results are encouraging. Bruce h a d exp e r i e n c e d a n u m b e r o f traumatic events. T h e success of the t r e a t m e n t at h e l p i n g with the symptoms associated with all events presents p r o m i s e for its effectiveness with a variety of traumas. T h e possible generalizability o f BA should n o t be overlooked a n d makes it worthy o f f u r t h e r empirical investigation. With BA the client is t a u g h t to e x a m i n e all areas o f his or h e r life, t r a u m a r e l a t e d a n d otherwise, to d e t e r m i n e where he or she needs to bec o m e m o r e active. T h e s t a n d a r d techniques utilized to treat PTSD typically only address those areas that were affected by the traumatic experience. This difference m i g h t indicate that BA is m o r e suited for treating individuals with c o m o r b i d conditions such as C~P/D, especially those that engage in a high level of avoidance behavior. T h e r e are a few limitations of this case study that we s h o u l d address. First, the first a u t h o r c o n d u c t e d all assessments a n d t r e a t m e n t sessions. While future empirical examination would necessitate i n d e p e n d e n t assessors a n d therapists, this investigation was c o n d u c t e d as a clinical case study, r a t h e r than a systematic e x p e r i m e n t a l design. T h e c u r r e n t m e t h o d o l o g y was utilized to g e n e r a t e inform a t i o n as to how BA may be a p p l i e d in a typical clinical setting. A s e c o n d limitatio n is that BA t r e a t m e n t was initia t e d before the client's symptoms h a d r e a c h e d a stable baseline. While the start o f t r e a t m e n t was consistent with the expressed goal of following standard clinical procedure,

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Mulick & Naugle it d o e s l i m i t i n f o r m a t i o n t h a t c a n b e d r a w n f r o m t h e d a t a . Third, the high frequency of the administration of the self-report m e a s u r e s m a y h a v e b e e n t o o t a x i n g o n t h e client. While the data were beneficial, the frequent measurem e n t m a y h a v e r e s u l t e d i n t h e c l i e n t b e i n g less d i l i g e n t r e g a r d i n g c a r e f u l a s s e s s m e n t o f his P T S D a n d M D D symptomatology. T h e p r e s e n t r e s u l t s d o p r o v i d e s o m e s u p p o r t f o r B A as a t r e a t m e n t f o r C - P / D . B a s e d o n t h e s e p o s i t i v e results, it w o u l d b e i m p o r t a n t f o r f u t u r e r e s e a r c h to e x a m i n e t h e effectiveness o f B A w i t h a l a r g e r n u m b e r o f subjects. W h i l e it h a s b e e n s h o w n t h a t B r u c e e x p e r i e n c e d s i g n i f i c a n t imp r o v e m e n t , h e is j u s t o n e i n d i v i d u a l . Invariably, o t h e r p e o p l e will r e s p o n d d i f f e r e n t l y to BA. F u t u r e r e s e a r c h , w i t h l a r g e r s a m p l e sizes, m a y p r o v i d e e v i d e n c e as to t h e c h a r a c t e r i s t i c s o f i n d M d u a l s f o r w h o m this m i g h t b e a n effective t r e a t m e n t . Similarly, w h i l e B r u c e e x p e r i e n c e d a n u m b e r o f t r a u m a t i c events, t h e r e a r e m a n y c o m m o n types o f t r a u m a (i.e., s e x u a l assault, c h i l d h o o d a b u s e ) t h a t m a y r e s p o n d d i f f e r e n t l y to BA. R e s e a r c h t h a t w o u l d b e inclusive of a larger variety of traumatic experiences m i g h t i n d i c a t e w h i c h t r a u m a s B A is effective i n t r e a t i n g . Finally, if f u t u r e r e s e a r c h c o n t i n u e s to s h o w t h a t BA's eff e c t i v e n e s s is c i r c u m s c r i b e d to r e d u c i n g t h e f r e q u e n c y a n d i n t e n s i t y o f t h o s e s y m p t o m s i n t h e a v o i d a n c e cluster, t h e n it m i g h t b e b e n e f i c i a l to e x a m i n e t h e e f f e c t i v e n e s s o f a c o m b i n a t i o n t r e a t m e n t to a d d r e s s t h e o t h e r sympt o m clusters. F o r i n s t a n c e , g i v e n t h e p r o v e n e f f e c t i v e n e s s o f e x p o s u r e t h e r a p y , a c o m b i n a t i o n B A / e x p o s u r e treatm e n t m a y b e m o r e effective at r e d u c i n g t h e f r e q u e n c y a n d i n t e n s i t y o f all s y m p t o m c l u s t e r s o f P T S D . T h e p r e s e n t case s t u d y o f a 37-year-old m a l e w i t h a complex and varied trauma history suggests that BA may b e a n effective a n d e f f i c i e n t i n t e r v e n t i o n f o r c o n c u r renfly treating PTSD and MDD symptomatology. Of note is t h e p a r t i c i p a n t ' s e x t r e m e l y p o s i t i v e e v a l u a t i o n o f BA. G i v e n w h a t m a n y c o n s i d e r to b e t h e aversive n a t u r e o f exposure treatments, the palatability of BA should not go unnoticed. These results provide a different option for t h e r a p i s t s w h o a r e a t t e m p t i n g to t r e a t i n d i v i d u a l s w h o have been diagnosed with PTSD and MDD.

References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Ballenger, J. C., Davidson, J. R. T., Lecrubier, Y., Nutt, D.J., Kirmaym, L.J., Lepine,J., Lin, K., Tajima, O., & Ono, Y (2001). Consensus statement on transcultural issues in depression and anxiety from the International Consensus Group on Depression and Anxie~ Journal of Clinical Psyehiatry, 62(Suppl. 13), 47-55. Beck, A. T., Rush, A.J., Shaw, B. E, & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-Second edition (manual). San Antonio, TX: The Psychological Corporation.

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Blake, D. D., & Sonnenberg, R. T. (1998). Outcome research on behavioral and cognitive-behavioral treatments for trauma sm~ivors. In V. M. Follette,J. I. Ruzek, & E R. Abueg (Eds.), Cognitive-behavioral therapies for trauma (pp. 15-47). NewYork: The Guilford Press. Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Charney, D. S., & Keane, T. M. (1997). Clinician-administered PTSD Scale for DSM-IV. Journal of Traumatic Stress, 8, 75-90. Blanchard, E. B., Buckley, T. C., Hickling, E.J., & Taylor, A. E. (1998). Posttraumatic stress disorder and comorbid major depression: Is the correlation an illusion?Journal of Anxiety Disorders, 12, 21-37. Bleich, A., Koslowsky, M., Dolev, A., & Lerer, B. (1997). Post-traumatic stress disorder and depression. British Journal of Psychiatry, 170, 479-482. Boudewyns, R A., & Hyer, L. (1990). Physiological response to combat memories and preliminary treatment outcome in Vietnam veteran PTSD patients treated with direct therapeutic exposure. Behavior Therapy, 21, 63-87. Dow, B., & Kline, N. (1997). Antidepressant treatment of posttraumatic stress disorder and major depression in veterans. AnnaL~ of Clinical Psychiatry, 9, 1-5. Elkin, I., Shea, T., Watkins,J. T., Imber, S. C., Sotsky, S. M., Collins@ E, Glass, D. R., Pilkonis, R A., Leber, W. R, Fiester, S.J., Docherty, J., & Parloff, M. B. (1989). NIMH Treaunent of Depression Collaborative Research Program. Archives of GeneralP~chiatry, 46, 971-982. First, M. B., Spitzer, R. L., Gibbon, M., & Williams,J. B. W. (1997). Structured Clinical [nteraiew for DSM-IV Axis I Disorders-Clinician Version (SC1D-CV). Washington, DC: American Psychiatric Press. Foa, E. B., Hearst-Ikeda, D, & Perry, K~J. (1995). Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting" and Clinical Psychology, 63, 948-955. Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459-473. Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Jo'nrnal of Consulting and Clinical Psychology, 59, 715 - 723. Gortnm, E. T., Gollan, J. K., Dobson, ~ S., &Jacobson, N. S. (1998). Cognitive-behavioral treatment for depression: Relapse prevention. Journal of Consulting and Clinical Psychology, 66, 377- 384. Hamihon, M. (1960). A rating scale for depression.Journal of Neurology, Neurosurgery, and Psyrhiatry, 23, 56-61. Hollon, S. D., Evans, M. D., Elkin, I., & Lowery, A. (1984, August). Systems for rating" therapies of depression. Paper presented at the 92nd Annual Convention of the American Psychological Association, Toronto, Ontario, Canada. Hollon, S. D., & Kendall, E C. (1980). Cognitive self-statements in depression: Development of an automatic thoughts questionnaire. Cognitive Ttwrapy and Research, 4, 383-395. Jacobson, N. S., Dobson, K. S., Truax, E A., Addis, M. E., Koemer, K., Gollan, J. K., Gortner, E., & Prince, S. E. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295 - 304. Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam veterans. Behavior Therapy, 20, 245-260. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General P~chiatry, 52, 1048 - 1060. Lewinsohn, E M. (1974). A behavioral approach to depression. In R.J. Friedman & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research. Washington, DC: Winston-Wiley. Marks, I., Lovell, ~ , Noshirvani, H., Livanou, M., & Thrasher, S. (1998). Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring: A controlled study. Archives of General Ps~chiatry, 55, 317-325. Martell, C. R., Addis, M. E., &Jacobson, N. S. (2001). Depression in context: Strategiesfor guided action. NewYork: W. W. Norton.

E m o t i o n s a n d T r e a t m e n t o f GAD

Mellman, T. A., Randolph, C. A., Brawman-Mintzer, O., Hores, L. E, & Milanes, E J. (1992). Phenomenology and course of psychiatric disorders associated with combat-related posttrauinatic stress disorder. AmericanJournal of Psychiatry, 149, 1568-1574. Nishith, R, Hearst, D. E., Mueser, K~T., & Foa, E. B. (1995). PTSD and major depression: Methodological mad treatment considerations in a single case desigla. Behavior Therapy, 26, 319-335. Resick, E A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical PsyehoP ogy, 60, 748-756. Rothbanm, B. O., Meadows, E. A., Resick, R, & Foy, D. W. (2000). Cognifive-behavioral therapy. In E. B. Foa, T. M. Keane, & M.J. Friedman (Eds.), Effective treatmentsfor PTSD: Practiceguidelinesfivm the International Societyfor Traumatic Stress (pp. 60-83). NewYork: The Guilford Press. Schnurr, E E (December, 2001). Outcomeof a randomized trial of group therapyfor PTSD. Symposium presented at the 17th annual meeting of the International Society for Traumatic Stress Studies, New Orleans, LA. Scott, M.J., & Stradling, S. G. (1997). Client compliance with exposure treatments for posttraumatic stress disorder. Journal of Traumatic Stress, 10, 523-526. Segal, D. L., Hersen, M., & Van Hasselt, V. B. (1994). Reliability of the Structured Clinical Interview for DSM-III-R:An evaluative review. ComprehensivePsychiatry, 35, 316- 327. Shalev, A. Y, Friedman, M.J., Foa, E. B., & Keane, T. M. (2000). Integration and summary. In E. B. Foa, T. M. Keane, & M.J. Friedman (Eds.), Effective treatmentsfor PTSD: Practiceguidelinesfivm the International Societyfor Traumatic Stress (pp. 60-83). New York: The Guilford Press. Shalev, A. Y., Freidman, S., Peri, T., Brandes, D., Sahm; T., Orr, S. P., & Pitman, R. K. (1998). Prospective study of posttraumatic stress disorder and depression following a trauma. AmericanJournal of Psychiat*5, 155, 630-636. Steer, R. A., Ball, R., Ranieri, W. E, & Beck, A. T. (1997). Further evidence for the construct validity of the Beck Depression InventoryII with psychiatric outpatients. PsychologicalReports, 80, 443-446. Tarrier, N., Pilgrim, H., Sommerfield, C., Faragher, B., Reynolds, M.,

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Graham, E., & Barrowclough, C. (1999). A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67, 13-18. van der Kolk, B. A., McFarlane, A. C., & van der Hart, O. (1996). A general approach to treatment of posttraumatic stress disorder. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Trau-

matic stress: The effects of overwhelming experienceon mind, body, and society (pp. 417-440). New York: The Guilford Press. Vaughan, K., Armstrong, M. S., Gold, R., O'Connor, N.,Jenneke, W., & Tarrier, N. (1994). A trial of eye movement desensitization compared to image habituation training and applied muscle relaxation in posttraumatic stress disorder. Journal of Behavior Therapy and Experi.nwntalPsyehiatry, 25, 283-291. Vaughan, K., & Tarrier, N. (1992). The use of image habituation training with post-traumatic stress disorder. BritishJournal of Psychiatry, 161, 658-664. Warren, W. L. (1996). Manual for the Revised Hamilton Rating Scalefor Depression. Los Angeles: Western Psychological Services. Weiss, D. S. (1997). Structured clinical interview techniques. InJ. E Wilson & T. M. Terence (Eds.), Assessingpsychological trauma and PTSD (pp. 493-511). New York: The Guilford Press. Williams, J. B. W., Gibbon, M., First, M. B., Spitzer, R. L., Davies, M., Borns, J., Howes, M.J., Kane, J., Pope, H. G., Rounsaville, B., & Wittchen, H. (1992). The Structured Clinical Interview for DSMIII (SCID): Mnltisite test-retest reliability. Archives of GeneralPsychiatry, 49, 630-636. The authors wish to thank Christopher Martell, Ph.D., Clinical Assistant Professor of Psychology at the University of Washington and private practitioner, who served as the therapist rater for this case study. His feedback and knowledge regarding Behavioral Activation was invaluable. Additionally, we would like to thank Sarah Kingsley for her assistance in the collection and analysis of data. Address correspondence to Patrick Mulick, Ph.D., Department of Psychology, Gonzaga University, Spokane, WA, 99258; e-mail: mulick@ gonzaga.edu.

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The Clinical Application of Emotion Research in Generalized Anxiety Disorder: Some Proposed Procedures Jonathan

D. H u p p e r t

a n d A m i e C. Alley, University o f P e n n s y l v a n i a

Major psychological theories of generalized anxiety disorder (GAD) have begun to suggest that worry may function as avoidance of emotions. On the basis of these findings, a number of researchers have begun to develop techniques to address emotional deficits in GAD. Howev~ most techniques suggested to date have been from outside a cognitive-behavioral ( CBT) model of treatment, making the integration of these techniques more difficult for CBT therapists. We propose a CBT model of addressing emotional avoidance through (a) learning to identify emotions and their possible evolutionary functions, (b) creating an emotion hierarchy to systematically address different emotions, (c) using imaginat exposure to increase tolerance to different emotions, and (d) eliminating behavioral avoidance of emotional experiences.

Cognitive

and Behavioral

Practice

11,387-392,

2004

1077-7229/04/387-39251.00/0 Copyright © 2004 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved. [~

Continuing

Education

Quiz located

on p. 447.

ECENT CONCEPTUALIZATIONS o f g e n e r a l i z e d a n x i e t y d i s o r d e r (GAD) h a v e b e g u n to e m p h a s i z e t h e fact that worry may interfere with the processing o f e m o t i o n a l i n f o r m a t i o n (Borkovec & Inz, 1990; M e n n i n , Turk, H e l m b e r g , & C a r m i n , 2004; R o e m e r & Orsillo, 2002). W h e n