Internal cue exposure and the treatment of substance use disorders: lessons from the treatment of panic disorder
Section snippets
Panic disorder and internal cue exposure
A range of early studies documented the importance of exposure to avoided situations for the treatment of panic disorder with agoraphobia (see Clum, Clum, & Surls, 1993). This focus on the feared situation (external cues) occurred despite knowledge that it was the fear of panic attacks (internal cues) that gave these situations their emotional salience. Certainly the stepwise exposure to feared situations led to concomitant exposure to symptoms of panic (patients were anxious, and sometimes
Biological provocation of panic
The initial use of biological provocation procedures for psychosocial treatment is an especially interesting choice given the importance of provocation studies to both biological and cognitive-behavioral models of panic disorder. Biological provocation studies have documented that a wide variety of agents or procedures (e.g., carbon dioxide inhalation, hyperventilation, or sodium lactate or yohimbine administration) were capable of provoking greater anxiety or panic in patients with panic
Fears of anxiety sensations and benzodiazepine taper
Biological provocation studies also provide an apt model for understanding benzodiazepine discontinuation difficulties in patients with panic disorder. We conceptualized BZ discontinuation as a provocation procedure delivered to vulnerable individuals (Otto, Pollack, Meltzer-Brody, & Rosenbaum, 1992). Specifically, we hypothesized that despite the partial or full blockade of panic attacks with BZ treatment, fears of somatic sensations of anxiety may persist, and serve as a diathesis for relapse
CBT for benzodiazepine discontinuation in patients with panic disorder
In our initial investigation (Otto et al., 1993), we studied 33 outpatients with panic disorder who had been treated with high-potency BZs (alprazolam or clonazepam) for a minimum of 6 months, and were seeking help in discontinuing this treatment. These patients were randomly assigned to either a slow-taper condition with physician support, or a slow-taper condition with support plus our 10-session intervention delivered in a group-therapy format. At study end, dramatic differences in
External and internal cues for drug use
Our success with BZ discontinuation led us to consider additional applications of an approach focusing on changing emotional and behavioral responses to somatic sensations. Specifically, we hypothesized that exposure-based procedures might have similar effects for changing drug-use responses to withdrawal sensations and other emotional cues for drug use (Otto et al., 1995).
Much like the initial focus of CBT on agoraphobic situations, earlier work on the treatment of substance abuse focused on
Addressing treatment-resistant drug use
Based on our experiences with patients undergoing BZ taper, we designed and pilot tested a novel treatment that emphasizes interventions to help patients enhance their tolerance of emotional and withdrawal cues for substance use, and respond with more adaptive strategies (Pollack et al., 2002). We targeted this intervention to a cohort of opiate-dependent patients who were failing available and accepted strategies to control illicit drug use among opiate-dependent patients: specifically,
Exposure and alternative strategies for enhancing emotional acceptance
The avoidance of emotional and somatic cues has been central to the conceptualization of our treatment approach to panic disorder, BZ discontinuation, and illicit substance use. In each condition, we argued that sensitivity to internal cues helps drive maladaptive patterns of avoidance. In panic disorder it is the fear of somatic sensations of anxiety that drives the intolerance of not only sensations of anxiety, but also sensations of physiological arousal arising from such normal activities
Summary
For our discussion of substance use disorders, we focused on individuals who used drugs as a way to cope with negative affect. We conceptualized this emotional avoidance in relation to the fears and avoidance of anxiety sensations that characterize panic disorder. In accordance with research on anxiety sensitivity, provocation effects, and the treatment of BZ withdrawal, we discussed the potential value of internal cue-exposure strategies for the treatment of substance dependence. Results from
Acknowledgements
Support for some of the projects describe herein was provided by National Institute of Drug Abuse grants to Dr. Otto (R10 DA 09692) and Dr. Pollack (R01 DA 10040).
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