The Use of Videoconference in the Treatment of Panic Disorder With Agoraphobia in a Housebound Woman

1 Theoretical and Research Basis for Treatment

According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000; DSM-5; APA, 2013), panic attacks are discrete periods of time in which an individual experiences intense fear or discomfort and a minimum of four additional symptoms which reach a peak within minutes. These additional symptoms can be somatic (e.g., heart palpitations, sweating, trembling, shortness of breath, stomach distress) or psychological (e.g., feelings of unreality or detachment from oneself, fear of losing control, fear of dying) in nature. Panic Disorder (PD) is diagnosed when an individual experiences recurrent, unexpected panic attacks accompanied by at least 1 month of persistent worry about having another panic attack, concerns about the implications of the attacks, or behavioral changes related to the attacks (APA, 2013). Panic Disorder is sometimes comorbid with Agoraphobia (PD/A), in which the affected individual experiences significant anxiety about being in places or situations in which it would be difficult to escape or to receive assistance if a panic attack were to occur and avoids such situations or endures them with extreme distress (APA, 2013).

Patients with PD and PD/A may be treated with cognitive-behavioral therapy (CBT), antidepressant and/or benzodiazepine medication, or a combination of CBT and medication. CBT and medication are superior to control conditions (e.g., Clum, Clum, & Surls, 1993; Gould, Otto, & Pollack, 1995). Medication treatment can be helpful in reducing anxiety symptoms in the short-term; however, patients risk relapse when medications are discontinued (Batelaan, Van Balkom, & Stein, 2012). Without treatment, symptoms are not likely to improve (Kessler et al., 2006).

CBT for PD typically involves a combination of psychoeducation, the development of coping and cognitive skills, and exposure to feared bodily sensations and situations. Meta-analytic reviews have shown that exposure to feared bodily sensations, called interoceptive exposure (IE), is the essential component of CBT treatment (e.g., Chambless & Peterman, 2004; Sanchez-Meca, Rosa-Alcazar, Marin-Martinez, & Gomez-Conesa, 2010). During IE, patients are asked to perform activities like spinning in a chair to induce the symptoms they experience during panic attacks, continuing with the activity until habituation occurs and the sensation is no longer anxiety-provoking (Craske & Barlow, 2008). The process of IE also indirectly challenges maladaptive cognitions about feared somatic sensations by demonstrating to the patient that the feared sensation does not inevitably lead to a panic attack (Craske & Barlow, 2008).

Although CBT yields good outcomes for many patients with PD/A, the very nature of the disorder makes treatment access much more difficult. Patients with severe Agoraphobia may not be willing to leave their homes for treatment (DeCola & Craske, 2002) and may have difficulty finding a mental health professional willing to provide in-home treatment. The movement toward incorporating technology into mental health treatment offers a potential solution to the problem of treating individuals who, given the nature of their disorder or through some other circumstance (e.g., lack of transportation, lack of trained professionals in a rural area) have difficulties accessing evidence-based treatment (Gros et al., 2013). Telehealth is a broad term that describes the provision of health care services via video, voice, or text (Perle & Nierenberg, 2013). While the earliest telehealth interventions made use of web-based text messaging or telephone, recent technological advances have allowed researchers and clinicians to evaluate the utility of videoconference as method of service delivery. A recent review of studies using evidence-based psychotherapies (EBPs) delivered via videoconference revealed that psychotherapy delivered in this yielded clinically significant improvements in symptoms of anxiety disorders, major depressive disorder, eating disorders, and addictive behaviors (Gros et al., 2013). In addition to symptom improvement across studies, patient acceptability ratings of treatment were generally high.

To date, three studies have examined the use of videoconference in the treatment of PD. First, Bouchard and colleagues (2000) conducted a 12-session open trial of CBT for PD/A with eight participants at a remotely located outpatient clinic. Patients reported statistically significant improvement in panic frequency, panic-related apprehension, self-efficacy, and trait anxiety. Treatment was also well-received by study participants as show by high scores on a measure of therapeutic alliance and positive qualitative feedback. A later study by Bouchard and colleagues compared the efficacy of face-to-face CBT with that of CBT delivered via videoconference in a sample of 21 adults with PD/A at a remote outpatient clinic. Overall, CBT delivered via videoconference was found to be as effective as face-to-face CBT, though patients in the telehealth condition actually reported greater reductions in panic frequency than those in the in-person condition. Eighty-one percent of telehealth patients reported that they were panic-free at post-treatment and 91% of patients reporting that they were panic-free at 6-month-follow-up (Bouchard et al., 2004). The authors also found that the therapeutic alliance developed in both conditions was similar. Results from a case study involving the treatment of a PD/A via videoconference at a rural outpatient clinic showed similar improvements in PD/A along with improvements in major depressive disorder (Cowain, 2001).

The use of videoconference in the treatment of PD/A in remote outpatient clinics treatment represents an important advance in the treatment of this disorder, as patients who would have been less likely to complete treatment due to avoidance of lengthy travel were able to benefit from treatment. However, it is unclear whether homebound patients with more severe agoraphobic symptoms would be able to benefit from and actively engage in treatment delivered in this way. Given that PD is unlikely to remit without treatment (Kessler et al., 2006), determining whether treatment delivered via videoconference is efficacious for this patient population represents a critical development in the treatment of severe PD/A.

2 Case Introduction

Rachel, a 30-year-old Caucasian woman, contacted a university psychology clinic seeking treatment for recurrent panic attacks that began 2 years earlier and prevented her from leaving her house and the surrounding yard for the past 12 months. Rachel’s symptoms prevented her from working, attending events at her son’s school, or participating in leisure activities (e.g., going to the beach, local theme parks, or auto races).

3 Presenting Complaints

Rachel’s panic attacks began 2 years prior to her assessment. She experienced her initial unexpected panic attack at work during a period of high stress in her personal life (e.g., conflict with partner, financial strain, job stress) followed by a second panic attack 3 days later. Rachel then experienced unexpected panic attacks several times per week. Shortly after her panic attacks began, Rachel sought therapy at a community counseling center. She was instructed in visualization and breathing exercises but found those techniques to be minimally beneficial. As Rachel’s panic attacks increased in frequency and occurred in a number of different places in the community, Rachel limited the number of places she was willing to go outside of her home out of fear that she would have another panic attack and would be unable to leave and/or would embarrass herself if another attack occurred. Rachel also reported symptoms of depression which she attributed to her inability to leave her home, hold a job, and function in her role as a mother. When Rachel first began experiencing panic attacks, her primary care physician prescribed alprazolam. He later added the tricyclic antidepressant (TCA) nortriptyline. At the time of her assessment, Rachel was taking 0.5 mg alprazolam twice daily for panic symptoms and 50 mg nortriptyline once daily for depressive symptoms. Shortly before her assessment, Rachel began a fitness routine consisting of light cardiovascular exercise and yoga after reading that exercise could lead to reductions in anxiety. She described exercising as somewhat helpful but also indicated that she had difficulty with cardiovascular exercise because the sensations of increased heart rate and sweating made her fearful of having a panic attack. With the exception of migraine headaches which began after PD/A onset, Rachel reported that she was in good health.

4 History

Rachel was born and raised in the suburbs of a major city in the southeastern United States, where she lived with her biological parents and two older sisters until her parents divorced when she was 12 years old. Rachel described her father as an alcoholic and indicated that he was physically abusive, hitting her and her sisters with belts or sticks when they misbehaved. Following her parents’ divorce, Rachel lived with her mother and sisters. Rachel and her mother argued frequently and at age 16, Rachel’s mother kicked her out of the house. Rachel moved in with her older sister who lived nearby. Rachel attributed being kicked out largely to her mother’s difficulties with anxiety and panic symptoms and indicated that her mother thought she was “too much to handle.” Rachel’s mother frequently experienced panic attacks while Rachel was growing up and often refused to leave the house. At the time of Rachel’s assessment, her mother had not left her home in 8 years.

At intake, Rachel lived in the same town where she grew up with her long-term boyfriend and their 10-year-old son. Rachel and her boyfriend ended their romantic relationship several times when their son was very young, but they had been in a committed relationship for 5 years prior to assessment. Rachel’s boyfriend assumed responsibility for many household duties when Rachel’s symptoms prevented her from leaving the house, but Rachel worried about the toll the added responsibility took on him. Her boyfriend’s alcohol consumption had increased markedly since the onset of Rachel’s Agoraphobia and was a frequent source of conflict in the relationship. Rachel also worried about the impact her anxiety disorder had on her son.

Rachel had a high school education and worked in the food service industry from the time she was 16 years old, first as a server and then in managerial positions. She was working as the general manager of a local fast-food restaurant when her panic attacks began. Rachel was terminated from employment shortly thereafter, and although she was told that her termination was due to financial problems in the company, she believed she was terminated because of her panic attacks. Rachel’s PD/A symptoms left her unable to seek other employment and she began collecting disability payments shortly before beginning treatment.

5 Assessment

Rachel’s assessment was conducted in her home by two clinical psychology doctoral students in. Following a psychosocial interview, the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; APA, 1994) was administered. Rachel also completed the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), and Personality Assessment Inventory (PAI). Although Rachel reported feeling anxious throughout the assessment sessions and was visibly trembling at the beginning of each assessment session, she provided detailed responses to questions, cited specific behavioral examples, and expressed a belief that being open and honest during the assessment would best inform treatment.

ADIS-IV

The ADIS-IV (Brown, DiNardo, & Barlow, 1994) was used to assess for PD/A and other frequently comorbid conditions (e.g., Generalized Anxiety Disorder, Posttraumatic Stress Disorder [PTSD], Major Depressive Disorder, Substance Use Disorders). Information obtained via the ADIS-IV indicated that Rachel’s symptoms met DSM-IV-TR criteria for PD/A. At onset, Rachel experienced unexpected panic attacks on a daily or near-daily basis. At the time of her assessment, Rachel reported experiencing panic attacks 2 to 4 times per month. She was able to identify situational triggers (e.g., going past her “safe zone” in the front yard, waiting for her son to get home from school in a storm), but many panic attacks still seemed to come “out of the blue.” Rachel’s panic attacks were characterized by racing heart, chills and hot flushes, dizziness and unsteadiness, tingling in hands and feet, trembling, shortness of breath, nausea or stomach distress, feelings of unreality, and fear of dying, all of which Rachel rated as a severe or very severe. Rachel also reported sweaty hands and neck and chest pain during panic attacks and assigned a moderate severity rating to those symptoms. Rachel estimated that the symptoms peaked within 2 min and resolved within 5 to 10 min. Rachel reported constant worry and apprehension that she would have another panic attack and reported making significant behavioral changes to minimize the risk of experiencing panic attacks, including avoiding leaving the house, exercising only when others were around, avoiding sex, avoiding thrilling movies, and avoiding cold. Although Rachel had taken diet pills on the day of her first panic attack, she discontinued their use immediately following the attack and denies use of other stimulants except a single small cup of coffee several days per week. Rachel’s last physical examination was 1 year prior to assessment (after the onset of panic attacks) and did not reveal any general medical conditions that were responsible for her panic attacks.

Rachel’s fears about having a panic attack prevented her from leaving her “safe zone” (her house and a portion of the surrounding yard) due to fears that she would have a panic attack and be unable to escape the situation without embarrassing herself. Rachel began avoiding situations following the onset of her panic attacks 2 years prior to assessment and her “safe zone” gradually decreased in size. In year prior to assessment, Rachel left her “safe zone” three times due to concerns about her son getting home from school in bad weather and experienced a panic attack each time. Rachel stated that her agoraphobic symptoms “completely changed who [she was].” She rated the level of interference and level of distress she experienced secondary to her symptoms as very severe. As displayed in Table 1, Rachel reported very severe apprehension and avoidance regarding nearly every situation outside her home.

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Table 1.

ADIS Ratings for Apprehension and Avoidance in Agoraphobic Situations.

Situation	Pretreatment Apprehension	Pretreatment Avoidance	Posttreatment Apprehension	Posttreatment Avoidance
Driving locally	8	8	4	4
Driving long distances or on interstates	8	8	4	4.5
Riding in car	8	8	1	0
Grocery stores	8	8	3.5	2
Malls	8	8	4.5	4
Crowds	8	8	5	4.5
Public transportation	8	8	NA b	NA b
Air travel	8	8	4	4
Doctor/dentist visits	8	8	6	5.5
Hairdresser	8	8	3	4
Waiting in line	8	8	3.5	1.5
Taking walks	8	8	0	0
Bridges	8	8	4	0
Being at home alone	3.5	3	0	0
Being out of town	8	8	5.5	4.5
Movie theaters; arenas	8	8	3.5	2.5
Restaurants	8	8	4	1.5
Church	8	8	3	4
Enclosed places: Elevators	8	8	7	4
Enclosed places: Small rooms/tunnels	8	8	5.5	2.5
Open spaces (e.g., parks, parking lots)	8	8	0	0
Work a	8	8	7	7

Note. Items are rated on a 0 to 8 scale where 0 = no apprehension or avoidance due to fear of having a panic attack and 8 = extreme apprehension or avoidance due to fear of having a panic attack. ADIS = Anxiety Disorders Interview Schedule for DSM-IV.

a

Ms. R has not yet had the opportunity to return to work but expresses a desire to do so with continued treatment.

b

Ms. R indicated that she has not had the opportunity to take public transportation and declined to rate these items.

With regard to other anxiety disorders, Rachel reported some symptoms of Generalized Anxiety Disorder (e.g., frequent worry about finances and her son), but further queries suggested that many of the worries were related to consequences of PD (e.g., being fearful that she would never be able to work again, whether her son would be angry with her due to the interference PD/A symptoms caused in their lives) and thus were better accounted for by a diagnosis of PD/A. In addition, although Rachel reported childhood physical abuse, she did not meet DSM-IV-TR criteria for PTSD. Rachel’s avoidance of public places was due to concerns about having panic attacks and/or being unable to escape and was not tied to unreasonable concerns about safety. She did express fears about walking down her street alone at night, but these fears were rational given recent criminal activity in the neighborhood. Any changes in cognition and mood (i.e., feeling badly about oneself and estranged from others after the onset of Agoraphobia) or in arousal and reactivity (e.g., concentration problems, sleep disturbance) were tied specifically to PD/A symptoms and did not pre-date PD/A onset. She denied additional symptoms and denied all Cluster B symptoms of PTSD; thus PTSD was ruled out as a differential or comorbid diagnosis.

Based on information obtained via the ADIS-IV, Rachel also met DSM-IV-TR criteria for Major Depressive Disorder at the time of assessment. Rachel reported that for the 6 weeks prior to the assessment, she felt uninterested in things she used to enjoy most of the day, nearly every day. She also reported insomnia, psychomotor retardation, loss of energy and fatigue, and worthlessness and feelings of inappropriate guilt. Rachel denied significant weight changes, concentration problems, and suicidal ideation during that 6-week period. Rachel reported a previous major depressive episode occurring over a 3-month period shortly after her panic attacks began. She attributed both major depressive episodes to her distress over her panic attacks and their impact on her life.

6 Case Conceptualization

The development of PD/A is best understood from a biopsychosocial perspective (Barlow, 2002), with biological and psychological vulnerabilities interacting with social and environmental factors to contribute to the onset of PD, and conditioning playing a major role in the maintenance of PD. A meta-analytic review by Hettema, Neale, and Kendler (2001) yielded a heritability estimate of .43 for PD, so Rachel’s report that her mother suffered from panic attacks while she was growing up was not surprising. The exact mechanism by which biology impacts the development of PD has not been determined, but it is likely that neurobiological over-reactivity plays a role (DeCola & Craske, 2002). Anxiety sensitivity, which refers to an individual’s tendency to respond fearfully to anxiety-related physical sensations such as racking or pounding heart, rapid breathing, gastrointestinal distress, or dizziness (Reiss, Peterson, Gursky, & McNally, 1986) represents a psychological vulnerability for the development of PD. In women, there is evidence that anxiety sensitivity is genetic and environmental (Taylor, Jang, Stewart, & Stein, 2008), which is consistent with Rachel’s family history. Not only did Rachel likely learn to react fearfully to somatic symptoms from her mother, but she observed her mother coping with panic symptoms by avoiding feared situations, creating additional vulnerability for the development of PD/A.

Rachel experienced her initial panic attack while at work in a quick-service restaurant during the lunch rush. She recalled feeling anxious immediately prior to the attack, because her boss was in the restaurant and was upset about the business’s finances. Retrospectively, Rachel reported experiencing several stressors at that time, including problems with her boyfriend, financial concerns, and worries about her son’s behavior at school. Thus, Rachel’s initial panic attack likely was a product of her biological and psychological vulnerabilities and present stressors. Initial panic attacks are conceptualized as misfirings of the body’s natural fear responses (Barlow & Craske, 2007). In this sense, they often are described as false alarms. Repeated unexpected panic attacks in the weeks and months after the initial panic attack lead to interoceptive conditioning of fear and anxiety about somatic symptoms such that physiological sensations like increased heart rate or sweating become learned alarms for panic attacks. These repeated panic attacks also serve to increase anxiety and apprehension regarding the reoccurrence of attacks. The increased anxiety leads to hypervigilance about bodily sensations, which in turn contributes to additional attacks. Rachel described a similar cycle following her initial panic attack. She also reported a general tendency toward responding anxiously to stressors (e.g., feeling subjectively anxious about her family’s future following a disagreement with her boyfriend and experiencing somatic symptoms). Rachel’s tendency toward anxiety in those situations created more opportunities for associations between low-level physiological symptoms and full-blown panic attacks to be solidified. In addition, Rachel’s perception that she had been fired from her job due to her panic attacks likely heightened her sense of apprehension about the potential consequences of attacks.

As Rachel experienced more panic attacks, she began avoiding places where the attacks occurred. During her assessment, she described how her “safe zone” got smaller and smaller until it consisted only of her house and the immediately surrounding yard. This kind of avoidance behavior likely developed in part via observational learning through watching her mother avoid situations as a means of coping with panic attacks and in part through negative reinforcement because avoidance behavior resulted in a decrease in anxious apprehension about having another panic attack. Rachel’s other reported safety behaviors, such as exercising only when someone else was home, were also maintained via negative reinforcement.

7 Course of Treatment and Assessment of Progress

Treatment began immediately following completion of the assessment. There were four components to treatment: (a) Psychoeducation and Coping Skills, (b) IE, (c) In Vivo Exposure, and (d) Consolidation of Treatment Gains. There were a total of 78 treatment sessions which occurred over 34 weeks. Treatment progress based on cognitive-behavioral principles, rather than a specific manualized protocol, guided the number of sessions. Although this relatively high number of sessions often is not feasible across settings treatment for this client was provided by two postmasters doctoral students in clinical psychology, allowing for a more flexible schedule to ensure habituation at each treatment phase. Treatment sessions were initially held in the client’s home and then conducted via videoconferencing using a free videoconference system until in vivo exposure sessions were conducted out in the community. Consistent with evidence that IE is the essential element of CBT for PD/A and that the addition of cognitive therapy does not offer significant benefits above and beyond behavior treatments (e.g., Meuret, Wolitzky-Taylor, Twohig, & Craske, 2012), the primary focus of treatment was continued exposure to feared somatic sensations and feared situations.

IE (Sessions 2-62)

Sixty IE sessions were conducted over 19 weeks. Rachel was seen between 1 and 5 times per week, with the modal number of sessions per week being 4 (mean number of sessions per week = 3.15). The first IE session was conducted in Rachel’s home. Rachel was asked to do a number of activities designed to elicit the same symptoms she experienced during panic attacks, including running in place, spinning in a chair, overbreathing, breathing through a straw, staring at herself in the mirror, lifting her head quickly, and tensing her body. Rachel did each activity for 1 to 2 min and provided a Subjective Unit of Distress (SUDS) rating for each one using a 0 to 10 scale (0 = no anxiety, 5 = moderate anxiety, 10 = extreme anxiety). Information from this interoceptive assessment was used to establish a hierarchy for IE. Rachel’s hierarchy appears in Table 2.

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Table 2.

Interoceptive Exposure Hierarchy.

Activity	Peak SUDS rating at interoceptive assessment b	Peak SUDS rating following treatment b	Number of sessions required for between-session habituation
Spinning in Chair	9	4	29
Drinking-Straw Breathing	9	4	3
Lift Head Quickly	8	NA a	NA a
Run in Place	8	4	4
Overbreathing	8	4	20
Stare at Self in Mirror	7	3	5
Tense Body	6	4	3

Note. SUDS = Subjective Unit of Distress.

a

Repeatedly lifting her head quickly during one exposure session caused Ms. R to experience neck stiffness. Because similar sensations of dizziness could be elicited by asking Ms. R to spin in a chair, we agreed to move up her hierarchy without completing that item.

b

SUDS ratings were obtained using a 0 to 10 scale, where 0 = no anxiety, 5 = moderate anxiety, and 10 = severe anxiety. Ms. R’s day-to-day rating of her anxiety was a 3/10; thus, a peak of 4/10 indicates that these exercises resulted in only a slight temporary increase in anxiety at following repeated exposure.

Each IE session lasted approximately 30 min and followed the same format. We began by reviewing assigned homework, which typically required that Rachel practice the IE exercise, and, as treatment progressed, perform in vivo exposure assignments in her neighborhood. As part of the homework review, we also addressed any psychosocial factors that interfered with Rachel’s progress, including discord with her partner or anxiety-provoking comments from Rachel’s mother and sister. Next, an IE exercise was completed, obtaining a baseline SUDS rating prior to starting the exercise and additional SUDS ratings at 30-s intervals. Exposure exercises were discontinued when one of three criteria were met: (a) when Rachel’s SUDS rating decreased below baseline, (b) when Rachel’s SUDS rating decreased to at least 50% of its peak, or (c) when Rachel’s SUDS rating returned to baseline and remained there for 5 min. Each item on the hierarchy was deemed complete when Rachel experienced a peak SUDS rating no higher than 4/10 and returned to her baseline SUDS rating of 3/10 within approximately 3 min for several consecutive sessions. As each item on the hierarchy neared completion, Rachel also provided information about her subjective experience of the exercise (e.g., “I’m bored with that one now,”) which helped to guide treatment. During most IE sessions, only one exposure exercise was completed; however, on days when Rachel was nearing completion of a hierarchy item, she often requested to begin the next hierarchy item concurrently to make efficient use of her sessions. After the exposure exercise was completed, Rachel and the treatment provider agreed on additional homework assignments and scheduled her next session.

Rachel’s first four IE sessions were conducted in her home by both treating clinicians. However, concerns about the safety of returning to the client’s home due to crime in the neighborhood emerged at that time and treatment was temporarily delayed. In consultation with the faculty supervisor on the case, the clinicians offered Rachel the opportunity to continue treatment via videoconferencing. Rachel felt discouraged over the need to discontinue in-home services but was willing to continue treatment in this way.

Sessions followed the same format as described hereinbefore, with Rachel and one of the treating providers interacting remotely. Moving to this treatment modality offered the advantage of being able to have shorter, more frequent sessions, likely increasing the rate of between-session habituation and also facilitating Rachel’s completion of between-session homework assignments by providing her with regular encouragement and feedback. Completing IE via videoconference did present unique challenges, however, including ensuring that Rachel was willing and able to complete the exercises on her own. The primary consideration was ensuring Rachel’s safety. She was in good physical health and was already engaging in cardiovascular exercise at the beginning of treatment, suggesting that she would be able to tolerate IE activities. We maintained an ongoing dialog about Rachel’s reaction to the exposure exercises, and in the case of lifting her head quickly, we discontinued the exercise and moved up the hierarchy because it unexpectedly induced a migraine headache following a session. This was the only adverse event reported during treatment. We needed to make sure that Rachel had the necessary supplies for each session (e.g., a drinking straw, a chair to spin in).

Although she expressed worry and anxiety about completing IE, Rachel’s attendance at sessions was consistent and she was willing to participate in all of the exposure exercises. The rate at which Rachel progressed through IE was impacted by two factors: psychosocial stressors and homework compliance. Rachel’s in-session SUDS ratings were impacted by the extent to which she was having difficulties in her relationships with her long-term boyfriend or her mother and sisters. Rachel’s baseline SUDS rating for the majority of her sessions was 3/10 and she reported that this was consistent with her average level of anxiety on a daily basis. However, if Rachel had an argument with a family member during the 12 to 24 hr prior to her session, her baseline SUDS rating typically rose to 5/10. This then impacted Rachel’s SUDS ratings during exposure. In these instances, IE was continued until Rachel’s SUDS rating decreased by half or reached her usual baseline of 3/10, rather than discontinuing based on the baseline rating that was inflated by other factors. Psychosocial stressors also had an impact on Rachel’s homework compliance. If she was arguing with family members, she often did not complete homework assignments, and failure to complete homework assignments increased the time to between-session habituation. The impact of these factors was particularly evident during the overbreathing phase of treatment, where Rachel achieved habituation within each session but required 20 sessions to achieve habituation between sessions and move up the hierarchy.

After 24 sessions of IE, Rachel expressed a desire to begin moving beyond her “safe zone” at home and trying to get out of the house. At that time, a hierarchy of exercises to complete outside her home but within her neighborhood was designed (e.g., walking to the end of her safe zone, sitting in her car, walking across the street, walking to the light post, driving around the block). Rachel began completing these assignments on her own or with her 10-year-old son, ensuring each time that she was mindful of her SUDS ratings and did not discontinue an activity until habituation occurred. Rachel’s understanding of behavioral principles and the rationale for treatment were essential to her successful completion of these activities, as was her insight about her own behavior. In discussing her homework assignments, she often described instances where she made conscious decisions to continue an exercise despite feeling acutely anxious (e.g., “I knew that if I didn’t want to keep doing it, I had to,”) or to stop engaging in an avoidance behavior (e.g., realizing that she was only going outside if no neighbors were outside and subsequently challenging herself to go outside when there were neighbors present). Cognitive strategies were used at this stage to help Rachel distinguish between rational and irrational fear so that she could be successful with the assignments in her neighborhood. For example, Rachel’s fear of walking down the street alone after dark was rational because of recent criminal activity. However, her fear of leaving her home in the middle of the day when several neighbors were outside was irrational and would have continued to prevent her from enjoying her life. She used this information to schedule certain tasks (e.g., standing across the street until habituation occurred) during certain times of day.

As exercises within Rachel’s neighborhood were getting easier for her to complete, we generated a list of activities Rachel could complete near her neighborhood. These included going to the park down the street, riding bikes with her son, and going to the convenience store around the corner. Again, Rachel exhibited the same level of willingness to engage with treatment. As evidence of her motivation for recovery, Rachel frequently exceed expectations for homework compliance (e.g., driving to her sister’s house several miles away and remaining until habituation occurred, without formal assignment from therapists). At Session 60, Rachel set a goal of spending a minimum of 2 hr outside her home each day. She was able to successfully meet this goal most days for the remainder of treatment.

Rachel’s progress during the IE phase of treatment was reflected by successful within- and between-session habituation to feared somatic sensations. Table 2, which displays Rachel’s IE hierarchy, includes her peak SUDS ratings for each hierarchy item at pre-treatment and at the final IE session for that item. The number of sessions required for between-session habituation is also displayed. Also, Rachel’s ability to leave her home during this phase of treatment reflects her progress toward decreasing the severity of Agoraphobia symptoms.

8 Complicating Factors

There were several complicating factors in Rachel’s treatment. First was the need to shift from in-person IE to IE delivered via videoconference. This change was made due an instance of criminal activity in the neighborhood that prevented the clinician’s from returning to the client’s home. Navigating this issue with the client presented challenges, as it was important to validate Rachel’s realistic concerns about safety without reinforcing her agoraphobic symptoms. This was accomplished through a series of discussions about rational and irrational fear. In Rachel’s case, being fearful of walking alone at night in her neighborhood was rational; refusing to leave her home in the middle of the day when other neighbors were present was not. In addition, Rachel initially felt discouraged about the need to discontinue home visits. Validating these feelings and having an open discussion about Rachel’s views on proceeding via videoconference was an important step in maintaining engagement in treatment.

Service delivery via videoconference presented its own unique challenges. Rachel was provided with information about the potential risks or challenges (e.g., confidentiality issues, completing IE without a therapist present in the room) and benefits (e.g., increased flexibility in delivery of treatment, frequent shorter contacts with therapists) of completing IE via this modality. Frequent discussions about process-related issues complemented IE by ensuring that technical difficulties were not adversely impacting treatment (e.g., difficulty hearing treatment providers, equipment failures), and that Rachel felt supported even though the therapists were not physically present with her. Although Rachel initially expressed anxiety about completing IE without a therapist in the home due to her fear of the physical sensations, Rachel’s physician was in agreement with the proposed treatment plan because Rachel did not carry any medical diagnoses that warranted special consideration (e.g., uncontrolled asthma). Unexpectedly, Rachel reported that the IE exercise of lifting her head quickly, which she completed in session one with little discomfort, induced a migraine headache following her session. As such, we did not complete this item on the hierarchy and moved to the next IE exercise. This type of modification to the hierarchy was very similar to a modification that would be made based on feedback provided by the patient in traditional face-to-face therapy. Additional planning also was required to ensure that Rachel had the supplies needed for IE (e.g., straws, a chair that spins) given that the therapists were unable to bring them to session as they would in face-to-face therapy and Rachel was unable to shop on her own during IE. Overall, Rachel reported a high level of satisfaction with treatment via videoconference.

Rachel’s symptom presentation was significantly more severe than is typically seen in an outpatient setting, Though standard CBT 12-session protocols are much shorter than the course of Rachel’s treatment, the standard CBT protocol has been shown to result in full symptom remission in only 32% of individuals diagnosed with PD with mild Agoraphobia (Barlow, Gorman, Shear, & Woods, 2000). This suggested that a larger dose of treatment was needed to address Rachel’s symptoms. The authors chose to rely on behavioral principles of extinction to determine the length of treatment, a strategy that was encouraged by clinical supervisors to ensure that the patient achieved symptom remission. This treatment strategy was also possible because the psychology training clinic is often less restricted by time and financial considerations than many other treatment settings. Given the complexity of needing to first provide psychoeducation, then to achieve habituation to perceived panic symptoms in a multi-item hierarchy, then to further achieve habituation to a wide-ranging in vivo exposure hierarchy (e.g., from standing in front of her house in daylight to taking an overnight trip out of town), an expectation of completing treatment in 12 sessions would have been unrealistic.

An additional issue related to the use of videoconference in treatment and to the number of sessions is the extent to which Rachel’s treatment may have reinforced agoraphobic avoidance by allowing her to complete treatment without leaving the house or created dependence on the therapist by allowing frequent contact. In this particular case, providing in-home assessment and treatment via videoconference allowed the patient to begin treatment despite the significant limitations in functioning she experienced as a result of her disorder. Discussion about leaving the house and participating in enjoyable activities was initiated by Rachel during her first session and Rachel began completing in vivo exposure assignments between sessions early in treatment. While some patients may experience in-home or videoconference IE sessions as a way to receive treatment for panic without addressing agoraphobic symptoms, Rachel used the videoconference IE sessions as a tool for addressing panic symptoms and preparing her to engage in in vivo exposure. With regard to frequency of contact, Rachel expressed a desire to reduce her panic symptoms as quickly as possible. Her frequent in-session practice of IE exercises (as often as 4 times per week) was accompanied by repeated independent practice of these exercises as well as in vivo exposure practice. Had Rachel not been engaging in these activities on her own, the issue of dependency would need to be considered more carefully. In addition, the frequency of contact with therapists was reduced over time based on Rachel’s needs. Once in vivo exposure exercises completed in public places with the therapist present were minimally anxiety-provoking, session frequency was reduced to once per week with continued assignment of in vivo exercises to be completed by Rachel on her own.

Finally, Rachel’s comorbid diagnosis of Major Depressive Disorder (MDD) represents a complicating factor. However, Rachel’s depression was not treated separately because it appeared to develop as a result of the extent of impairment due to PD/A. She denied experiencing depressive symptoms prior to the onset of her panic attacks. In addition to the temporal relationship among symptoms, research has also suggested that the presence of comorbid depression does not adversely affect the outcome of CBT treatment for PD/A (Emmrich et al., 2012). Throughout treatment Rachel raised additional concerns, including conflict with her partner and lack of perceived support and treatment interfering behaviors from her mother and siblings. These issues were addressed only to the extent that they interfered with treatment for PD/A to ensure that she could continue to make progress. For example, when Rachel’s concerns about her partner’s alcohol use escalated during her own treatment, she was provided with referral information so that he could seek treatment and we briefly discussed strategies to reduce conflict in the home. Rachel’s mother and sisters, all of whom suffer from anxiety disorders, often made discouraging comments to Rachel or suggested that she would be better off if she did not complete homework assignments. Rachel gradually began to set better boundaries with family members, including refusing to talk to her sisters immediately before treatment sessions, and also started to recognize when her family members’ comments were a product of their own anxiety rather than fears based in reality.

9 Access and Barriers to Care

Recent estimates suggest only 45% to 53% of those suffering from PD/A seek treatment within any given year (Kessler et al., 2006; Mackenzie, Reynolds, Cairney, Streiner, & Sareen, 2012). In Rachel’s case, the most significant barrier to treatment was the presence of severe Agoraphobia which prevented her from visiting an outpatient clinic for the majority of treatment sessions. Until Rachel contacted the training clinic, she had been unable to find a treatment provider willing to provide in-home services. Even if Rachel had been able to find a treatment provider in the community, her financial limitations likely would have prevented her from receiving the same intensity of treatment provided. After having difficulty finding appropriate treatment, Rachel was discouraged when the therapists were not able to continue providing in-home services. In this instance, the use of videoconference was critical to ensuring that Rachel had access to treatment.

10 Follow-Up

Rachel has continued to attend individual and couples treatment sessions at the psychology clinic. Rachel’s initial stated goal for individual therapy was to address anxiety experienced during thunderstorms, which she hoped would dissipate following treatment for PD/A as she frequently experienced panic symptoms during thunderstorms. Further querying over multiple sessions revealed that Rachel’s anxiety during thunderstorms was related to worries that she or her son would be struck by lightning. She reported additional worries related to her son, her finances, and her health. While some of these worries were present at initial assessment, the conceptualization at that time was that the worries were reflective of Rachel’s PD/A and its consequences rather than Major Depressive Disorder (MDD). Given that these worries did not remit with treatment for PD/A and Rachel reported other symptoms of PD/A (i.e., difficulty controlling such worries and the associated symptoms of feeling keyed up, difficulty concentrating, irritability, and sleep disturbance), a diagnosis of Generalized Anxiety Disorder (GAD) was warranted. Rachel will continue individual therapy for GAD. This will also ensure that potential signs of PD/A relapse are addressed quickly using CBT.

11 Treatment Implications of the Case

PD/A is unlikely to remit without treatment, but severe Agoraphobia symptoms can limit a patient’s ability to seek traditional face-to-face psychotherapy in an outpatient clinic. The case of Rachel demonstrated that PD/A can be successfully treated using IE delivered via videoconference in conjunction with in vivo exposure. This case study extends the body of literature regarding IE delivered via videoconference by showing that this treatment can be delivered not only to individuals in rural outpatient clinics (e.g., Bouchard et al., 2004; Bouchard et al., 2000), but also to those whose symptom severity prevents them to visit an outpatient clinic.

Though videoconference was immensely helpful in this case, it is not a panacea. Several factors contributed to the success of this particular case. First, Rachel presented with extremely high motivation for treatment and a willingness to experience the discomfort that accompanies exposure-based therapies. This willingness was especially important when Rachel needed to persist with IE exercises without a therapist physically present in the room or when she needed to complete exposures as homework assignments. Second, Rachel demonstrated understanding of behavioral principles and readily applied them during planned homework exercises and by designing extra challenges for herself (e.g., going to her sister’s house and remaining there until habituation occurred because she felt ready after practicing assigned exercises in her neighborhood). Third, the treating providers conducted Rachel’s assessment and initial exposure sessions in the home. This allowed the providers to more directly observe Rachel’s symptoms (e.g., shakiness that was visible during the assessment would not have been visible over videoconference) and to become familiar with Rachel’s environment which aided in later construction of in vivo exposure hierarchies.

Regarding telehealth in general, there are numerous potential advantages. These include the ability to reach those who may not otherwise be able to access care, including those whose psychiatric or physical disabilities prevent them from leaving home, those in rural areas, those in dangerous or underserved areas, or those who feel stigmatized when visiting mental health clinics (Reger & Gahm, 2009). Telehealth can also reduce costs for patients (e.g., travel time, missed work, transportation costs) and may facilitate continuity of care (e.g., the ability for a patient to attend a session when transportation is unavailable or for providers to hold a treatment team meeting). In addition, telehealth can offer great flexibility with regard to the frequency and duration of sessions, as in Rachel’s case where shorter, more frequent sessions were conducted. In general, patients who have received services via videoconference have rated it favorably and concerns that videoconferencing may adversely impact the therapeutic alliance have been unfounded (Gros et al., 2013; Thorp, Fidler, Moreno, Floto, & Agha, 2012)

Despite the potential advantages of telehealth, there are also several potential limitations. Patient safety is a primary concern, particularly when patients receive their services at a private location where there are no staff present. While steps can be taken to minimize risk (e.g., knowing a client’s physical address and their local emergency contacts, having multiple ways to contact a client to ensure safety, asking the client to seek a medical opinion regarding the proposed treatment plan if needed), this risk cannot be eliminated (Gros, Veronee, Strachan, Ruggiero, & Acierno, 2011). Technology problems can be stressful for the client and therapist and can also result in the client missing important information (e.g., being unable to see or hear the therapist clearly) or the therapist missing clinically relevant information (e.g., inability to see psychomotor agitation or detect the smell of alcohol on a client’s breath). Last, there are a number of confidentiality issues ranging from the security features of phone or videoconferencing software to the inability of the provider to control a patient’s environment in ways that ensure confidentiality (e.g., a family member could overhear the session from a nearby room; Gros et al., 2013).

Despite the move toward utilizing telehealth within medicine and psychology, very few states or professional organizations have issued clear guidelines about the provision of telehealth. At present, the American Psychological Association has no official policy regarding the provision of telehealth services by psychologists or trainees, and refers those interested in providing such services to the American Psychological Association (APA) Code of Ethics (Baker & Bufka, 2011). Although the APA Code of Ethics (APA, 2010) also does not offer specific guidance for telehealth, all of the guiding principles and ethical standards apply.

In the absence of clear guidance from professional organizations, several authors have provided recommendations about the ethical provision of telehealth services. Harris and Younggren (2011) suggested that a risk–benefit analysis must be conducted for each client, examining the relative benefits of providing services through videoconference or other means versus referring the client to another type of treatment. Risks and benefits will vary depending on the severity of the client’s symptoms, the presence or absence of high-risk behaviors (e.g., previous suicide attempts), the availability of other suitable treatment providers, and the amount of contact required to appropriately treat the client. They also advocated some face-to-face contact, such as an initial evaluation, to facilitate the development of a strong therapeutic alliance. Baker and Bufka (2011) highlighted the importance of adequately protecting client confidentiality, potentially requiring consultation with software developers or information technology professionals. Obtaining informed consent from clients means educating them about the potential risks and benefits of telehealth, ensuring their understanding, documenting the conversation, and maintaining an ongoing dialogue, the impact of technology on treatment, and the therapeutic alliance (Maheu, 2003). Competence in telehealth requires familiarity with technology being used and understanding of how that technology may impact care. According to Gros and colleagues (2013), this includes ensuring that backup procedures are in place in the event of equipment failures (e.g., having a phone number for a client who is seen by videoconference), making arrangements to provide clients with handouts, assessments, and other materials necessary for treatment (e.g., mailing handouts rather than drawing on a whiteboard, asking clients to have a straw on hand for IE), and modifying communication styles based on technology (e.g., asking direct questions, because body language and gestures can be difficult to observe via videoconference).

12 Recommendations to Clinicians and Students

Although there is an implicit assumption that in-person services would be superior to services delivered via videoconference or other means like Internet-delivered self-help, there is a growing body of literature to suggest that these types of treatments hold promise for many clients (e.g., Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010; Bouchard et al., 2004). It is important for those providing mental health treatment to seek out education and supervision regarding this method of service delivery and be familiar with the emerging guidelines regarding ethical and legal issues related to providing such services even if they do not wish to provide these types of services themselves to that they can make appropriate treatment recommendations.

Given the ways that telehealth may benefit those seeking mental health treatment, continued research in this area is very important. Additional research is needed to determine which types of treatments or which types of presenting concerns are most amenable to telehealth applications as well as therapist or client factors that may impact treatment outcome. Development of ethical and legal guidelines for the provision of telehealth services in the field of psychology will also be important as the provision of treatment via telehealth becomes more common.