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Chapter: Essentials of Psychiatry: Anxiety Disorders: Social and Specific Phobias

Refractory Patients and Nonresponse to Initial Treatment

Predictors of Treatment Outcome, Relapse and Return of Fear, Refractory Patients and Nonresponse to Initial Treatment.

Predictors of Treatment Outcome


Few studies have examined predictors of outcome for treatment of specific and social phobias. However, the few studies that do exist fall into two main categories. First, several investigators have attempted to match treatment strategies to specific charac-teristics of patients. Secondly, several studies have examined the relationship between individual differences (e.g., duration and severity of illness, personality factors) and response to treatment.


Much more research is needed to identify predictors of outcome with CBT and especially with pharmacological treatment. For example, little is known about the effectiveness of treatments for specific and social phobias in special populations (e.g., elderly persons, culturally diverse groups). There has also been a lack of research on the impact of comorbidity on success of treatment with specific phobias.


Relapse and Return of Fear


With respect to specific phobia, it is common for some return of fear to occur in the presence of the phobic stimulus Relapse following treatment of a specific phobia is believed to be rare. A number of variables have been identified that predict return of fear including distraction during exposure, a relatively quick reduction in fear during exposure, a relatively slow reduction in fear during exposure, higher initial heart rate, spacing of expo-sure sessions and the degree to which the exposure stimuli are varied, the tendency to over associate fear-relevant stimuli with aversive.


Refractory Patients and Nonresponse to Initial Treatment


Several variables may lead to an initially poor treatment re-sponse. Anticipating potential difficulties will help increase treatment efficacy. Possible reasons for a worse outcome include poor compliance, poor motivation and poor understanding of the treatment procedures. In addition, interpersonal issues and other possible conflicts may interfere with the successful treatment of specific and social phobias.


Patients fail to comply with treatment procedures for a va-riety of reasons. In the case of pharmacological treatments, pa-tients may avoid taking medications because of side effects, lack of confidence in efficacy, or preference for an alternative type of treatment. If patients are not compliant with medications, the physician should attempt to identify the reasons for poor compli-ance and to suggest methods of increasing compliance or chang-ing to another type of treatment.


In the case of CBT, common reasons for poor compliance are anxiety about conforming to treatment, lack of time and lack of motivation to conduct the treatment properly. Because CBT re-quires patients to confront the situations they fear most, patients often feel extreme anxiety about participating in the treatment. Patients should be reassured that their anxiety is normal and that they will never be forced to do anything that they are unwilling to try. Furthermore, the difficulty of exposure tasks should be increased gradually to maximize treatment compliance. If pa-tients do not have the time or motivation to conduct treatment as suggested, therapists should be willing to find ways to make the treatment more accessible to the patient. For example, involve-ment of a friend or relative of the patient as a coach may allow the patient to conduct more practices without the therapist’s as-sistance. The therapist could also explore the possibility that the patient consider beginning treatment later, when more time is available.


Poor motivation can lead to poor compliance with the treat-ment procedures. If a patient’s symptoms are not especially se- vere, the distress and impairment created by the disorder may not be enough to motivate the patient to take medications regularly or to confront the phobic situation in a systematic way. Furthermore, as a patient improves in treatment, she or he may experience a de-crease in motivation. Patients should be encouraged to continue with treatment assignments even after improvement. More com-plete improvements may protect against a return of symptoms.


Finally, treatment procedures may be complicated for some patients. This is especially the case for CBT. Patients may fail to complete homework assignments (e.g., monitoring anxious cognitions) simply because the treatment rationale and the specif-ics of how to conduct the treatment procedures were not made clear. Therefore, therapists should continually assess the patient’s understanding of the treatment procedures.

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