Treatment of Agoraphobia in a Pregnant Woman

Abstract

A combination of exposure therapy techniques and Acceptance and Commitment Therapy (ACT) strategies were used to treat a 23-year-old pregnant female who was housebound due to symptoms of agoraphobia. The client in this case study had not left her family home in 10 months when she sought treatment for her anxiety. The client was successfully treated over a year, such that she was able to receive prenatal care at an obstetrician’s office and to deliver her infant at a hospital. Neither the client nor her fetus suffered any complications due to treatment. Post-treatment and 1-year follow-up data indicated that the client continued to show significant functional improvements following the birth of her child. Recommendations for integrating ACT strategies into exposure therapy for severe agoraphobia and for anxious pregnant women are provided.

Keywords

agoraphobia exposure Acceptance and Commitment Therapy pregnancy

1 Theoretical and Research Basis for Treatment

Agoraphobia (AG) is a disorder characterized by fear about being in situations where escape might be difficult (American Psychiatric Association [APA], 2000). The fear of experiencing panic-like symptoms or other potentially embarrassing physiological sensations leads to avoidance of these situations. For the person struggling with AG, anxiety-provoking situations commonly include being outside the home alone, being in a crowd or standing in a line, being on a bridge, or traveling in a bus, train, or automobile. AG is associated with serious functional impairment, and, in serious cases, can result in the agoraphobic being unable to leave his or her home.

AG is a much-debated diagnostic category that has undergone several revisions in the Diagnostic and Statistical Manual of Mental Disorders (DSM; Wittchen, Gloster, Beesdo-Baum, Fava, & Craske, 2010). At the time the subject of this case study was receiving treatment, the treating clinician worked under the diagnostic structure of DSM (4th ed., text rev.; DSM-IV-TR; APA, 2000). However, there have been recent changes in the diagnoses of both Panic Disorder (PD) and AG that address the very issues that have troubled experts about the former diagnostic category AG without a history of PD (DSM [5th ed.; DSM-5; APA, 2013]). Due to concerns about the underdiagnosis of AG without a history of PD, the authors of DSM-5 have separated the diagnoses of PD and AG completely, and AG currently stands as an independent diagnosis with its own separate diagnostic criteria (APA, 2013). This change reflects the growing number of cases in which the affected person experiences fear in AG-related situations but does not experience recurrent, unexpected panic attacks or even panic-like symptoms.

From a behavioral perspective, anxiety is maintained and exacerbated by negative reinforcement—escape and avoidance. Contemporary behavioral research suggests that verbally competent humans not only escape and avoid stimuli that have been directly paired with negative outcomes or that share common physical features with stimuli that have predicted negative outcomes but also may avoid verbally derived (e.g., imagined) negative outcomes and escape from the anxiety produced by transformation of stimulus functions via verbal relations (Dymond & Roche, 2009). Each time avoidance/escape behavior prohibits contact with perceived threatening stimuli, removes direct or derived signs of threat, and produces an immediate (albeit temporary) reduction in anxiety, it is reinforced—strengthened. As this contingency repeats, ther is a progressive strengthening of escape/avoidance responding and a corresponding narrowing of the client’s behavioral repertoire to which it is more and more subsumed by escape and avoidance responding. Perhaps the most striking outcome of this process is apparent in severe AG, when individuals become completely homebound and reliant on others for provision of basic necessities. At this point in the process, such a client may not experience intense anxiety symptoms on a day-to-day basis because he or she does not have to face, or anticipate facing, feared situations. As long as avoidance is high and life is small, anxiety is low. There are few, if any, degrees of freedom in this calculation. Such psychological inflexibility is the hallmark of psychopathology from a contemporary behavioral perspective (Hayes, Luoma, Bond, Masuda, & Lillis, 2006).

Treatment Options

There is little empirical evidence specific to the treatment AG, especially in pregnant women. Cognitive-behavioral therapy (CBT) has strong empirical support as a treatment for anxiety disorders and particularly for PD with and without AG (Craske, DeCola, Sachs, & Pontillo, 2003; Landon & Barlow, 2004). Traditional CBT involves use of (a) cognitive restructuring strategies to alter catastrophic thoughts about the meaning of bodily sensations or overestimation of risk/danger and (b) in vivo and interoceptive exposure exercises where feared environmental and bodily stimuli are directly encountered without escape and avoidance (Craske, Rowe, Lewin, & Noriega-Dimitri, 1997). The necessity of cognitive restructuring has been called into question and some recent CBT approaches, such as Acceptance and Commitment Therapy (ACT), combine mindfulness-skills, rather than cognitive restructuring, with exposure exercises (Eifert et al., 2009). Exposure remains central to treatment in acceptance-based behavioral approaches, but with an emphasis on willingness/acceptance of anxious emotions during exposure, rather than on reduction in anxiety. Indeed, in a randomized clinical trial comparing CBT and ACT for anxiety (Arch, Eifert, et al., 2012), the same exposure exercises were used in both conditions, with the difference being the rationale—opportunities to practice willingness versus to pursue anxiety reduction (Eifert et al., 2009). Both treatments were equally efficacious, suggesting the viability of an acceptance-framed exposure therapy. That said, there remains active debate about the exact nature of the similarities and differences in concepts, techniques, and mechanisms of action across the various approaches that fall under the cognitive-behavioral umbrella (Arch & Craske, 2008; Grayson, 2013; Hayes, 2008).

Exposure-based treatment may be appropriate for women who are pregnant as it does not involve pharmaceutical intervention, but there is little research about the effects of exposure therapy on the health of pregnant women or their developing fetuses. Available data do not suggest that exposure therapy produces harmful elevations of stress hormones (e.g., cortisol) in non-pregnant individuals, but we cannot necessarily generalize these findings to pregnant women (Siegmund et al., 2011). Thus, a recent review of the literature called for additional research to establish the efficacy of exposure therapy during pregnancy, but suggested that the small existing literature indicates that exposure therapy appears safe during pregnancy (Arch, Dimidjian, & Chessick, 2012).

In the present case, the client experienced high levels of fear when imagining or engaging in an activity that would take her any distance from her home or from a bathroom. In such situations, the client reported that she would experience intense anxiety-related bodily sensations (e.g., gastrointestinal [GI] symptoms such as stomach cramping, nausea, sensations associated with diarrhea, etc.). She sought not only to escape and avoid these sensations but also what they meant. That is, her social environment provided a context where anxious symptoms were viewed as bad, a sign that something is wrong with her. Her avoidance behavior further contributed to maintenance of verbal rules (e.g., the presence of anxious bodily sensations means that a GI incident is highly likely) that did not correspond to environmental contingencies (there was only one isolated GI incident).

Given that the symptoms of pregnancy (e.g., nausea, upset stomach, a sensitive bladder, increased GI distress) overlapped with, mimicked, and/or amplified the client’s bodily sensations related to anxiety, we decided to deemphasize reduction or elimination of such sensations, instead of focusing on an acceptance-based exposure treatment plan, grounded in ACT (Hayes, Strosahl, & Wilson, 1999). As noted above, exposure remained central to treatment, but was not presented as a way to reduce anxiety but to practice willingness to experience anxiety in the service of being able to engage in committed action (e.g., driving to the obstetrician’s [OB] office) based chosen values (e.g., being a loving mother). When anxiety is given more freedom to vary, avoidance can move and life can expand. When private events, such as bodily sensations, are removed as barriers to valued action and one can behave while experiencing them, this is what is described in ACT as evincing psychological flexibility. To promote psychological flexibility, ACT employs strategies drawing from six core processes: acceptance, defusion, self-as-context, contact with the present moment, values, and committed action.

In the context of the present case study, exposure work then is actually means of practicing psychological flexibility. Within an ACT framework, exposure challenges the client to accept and defuse from negative private events while behaving toward a valued direction.

Therefore, while exposure was the main treatment mechanism used in the present case study, all six core ACT processes were incorporated throughout to facilitate progress and decrease experiential avoidance.

2 Case Introduction

The client, KJ, was a 23-year-old Caucasian female. At the time of treatment, KJ was living at home with her 2-year-old son, her boyfriend of 3 years, and her mother. The client sought psychological services as she was “housebound” due to symptoms of AG, and she suspected that she may be in the early stages of a second pregnancy. At the time of her intake session, she thought that she may be 9 or 10 weeks pregnant, and she had yet not seen or made an appointment with an obstetrician . The client had been taking 50 mg of Zoloft twice daily for 2 years prior to the intake session. Zoloft was prescribed following the birth of her first child, as KJ reported an increase in anxiety symptoms during the postpartum period. KJ denied a history of major depressive symptoms prior to and during her first pregnancy, but she did experience some mild depressive symptoms during the postpartum period. The introduction of the medication seemed to be linked to KJ’s ability to overcome her symptoms of AG and mild depression, and KJ was unwilling to stop taking Zoloft during her second pregnancy. She remained on the same dose of Zoloft medication throughout treatment. In addition to pharmacological treatment, KJ also had a history of receiving counseling on and off in the past for anxiety. At the time of her intake, however, she was not currently receiving any such psychotherapeutic services. Past psychological care had been “supportive,” but it had not decreased KJ’s anxiety-related symptoms. The client reported that she had no previous experience with any sort of cognitive-behavioral or exposure-based treatment.

3 Presenting Complaints

KJ reported that she frequently experienced intense anxiety-related bodily sensations (e.g., GI symptoms such as stomach cramping, nausea, sensations associated with diarrhea, etc.) when she was at great distance from her home or from a bathroom. She explained that she would experience high levels of fear when leaving home, riding in a car, or driving a car, and she would engage in many behaviors to make herself feel safer and to avoid these specific situations. KJ would alter her diet to consume more or less foods or drinks associated with using the bathroom, so that she could control her GI symptoms (e.g., drinking coffee to elicit bladder and bowel movements at specific times). She would also attempt to use the bathroom multiple times a day, and she would wear clothes that made her feel more “held in” when she was not attempting to use the bathroom. At the time of her intake, KJ had not left her family home for approximately 10 months.

It is important to note that at the time of intake, much of KJ’s time was dedicated to the avoidance of anxiety and situations associated with anxiety. KJ was able to maintain a homebound existence with the help of her boyfriend and her family members. KJ’s boyfriend worked two jobs to contribute to KJ and KJ’s son’s well-being, and KJ’s mother and sisters would run errands for KJ (e.g., buy food, snacks, and other supplies for KJ). KJ relied heavily upon her family members for financial support as well as access to the world outside of her home. In return, KJ cared for her young son and the upkeep of the family home. KJ also used the Internet to prevent social isolation and anhedonia. At the time she presented for treatment, KJ was enrolled in two online graphic design courses, and she was a part of several online crafting communities. KJ’s skillfulness in soliciting social support and connection from her family and through the Internet served as a means of coping, however, this ability to garner support was key to the maintenance of her symptoms of AG. During her intake, KJ reported that she needed her family members help and support, but she also acknowledged that she wished she did not need to rely on them so heavily.

4 History

KJ reported that first significantly impairing problems with anxiety appeared during high school when she was 15 years old. She stopped attending school because of the intense anxiety that she experienced riding the bus to school. KJ did not go to school for a few weeks, but eventually resumed attendance as her father “forced” her to go. When KJ was 20 years old, she became pregnant with her first child. KJ reported that she experienced heightened anxiety during her pregnancy, and she was especially sensitive to GI symptoms during the postpartum period following her pregnancy. She explained that in the months following the birth of her son, KJ experienced symptoms of depression and anxiety (e.g., worry, restlessness, irritability, feeling down, anhedonia), and she became housebound again during this period. KJ reported that this episode of AG ended naturally after a few months. The episode of AG that constituted KJ’s most serious episode began 10 months prior to KJ seeking treatment. She was driving in the car with her son, and she suddenly had the urge to use the bathroom while she was driving on a busy road. KJ reported that she nearly had a GI “accident” in the car, but she was able to pull into a fast food restaurant and use the bathroom. She reported that she was very ill in the bathroom, and she felt scared to return to her vehicle. KJ did drive home with her son, but she has identified this incident as the event that triggered a period of being housebound for approximately 10 months.

Although KJ reported that her symptoms of AG could be traced back to high school, she also explained that she had been sensitive to sensations associated with anxiety for her entire life. KJ described a family history of anxiety where her mother displayed symptoms of intense worry, and her twin sister experienced recurrent panic attacks. KJ also reported that she and her twin sister were sexually molested in childhood by a family friend. While KJ did not endorse a lifetime history of posttraumatic stress disorder, she reported that she did likely experience some symptoms of acute stress immediately following the abuse.

It is likely that because of this history of anxiety sensitivity and sexual abuse, KJ went to great lengths to avoid sensations associated with anxiety. At the time of her intake, KJ was avoiding any stimuli that may elicit GI symptoms (e.g., certain foods such as chili), and she was never leaving her home, not even to go on short walks with her family. She reported that her fear and anxiety were interfering with her life in many ways, and she anticipated issues taking care of an infant as well as her 2-year-old son while being housebound. She no longer went places with her son, and she did not attend any family events outside the home which she had greatly enjoyed in the past. KJ stopped participating in many other activities as a result of anxiety such as going to the library, shopping for quilting supplies, and going to the movies. KJ’s experience of AG also affected her relationships with her boyfriend and her family members. KJ reported that she did not feel emotionally supported by her family, and she often felt that they were irritated with her. She wanted treatment, so that she could confirm her pregnancy, attend prenatal care appointments, deliver her child in a hospital, and have improved relationships with her family and her children as well as attain greater independence overall. KJ had aspirations to return to school to complete an undergraduate degree in graphic design, to work part-time to help support her family financially, and to take her children to appointments and activities outside the home.

5 Assessment

All assessments were performed in KJ’s home. Three graduate student clinicians conducted the intake: one met with KJ, one met with KJ’s boyfriend, and one met with KJ’s mother. These three clinicians were doctoral-level clinical psychology graduate students who were receiving supervision from a licensed clinical psychologist trained in behavior therapies, including exposure-based therapies and ACT. During this session, histories were taken from KJ and her family. KJ completed the Multimodal Life History Inventory (Lazarus & Lazarus, 1991), which was administered as a semi-structured interview. Over the next four sessions, it was determined that KJ met DSM (4th ed.; APA, 1994) criteria for a diagnosis of AG without a history of PD. She reported that she experienced some symptoms of PD (e.g., GI symptoms), but she had never experienced full panic attacks. In addition, her symptoms did not appear “out of the blue,” but rather KJ’s symptoms were evoked when she was away from home, away from a bathroom, driving, or riding in a car. At the time of the initial assessment, KJ did not meet criteria for any other anxiety or mood disorder. KJ did not present with any other serious medical concerns apart from her suspected pregnancy.

As initial assessments were taking place, the assessing clinicians solicited information regarding KJ’s history of anxiety and AG, physiological symptoms, patterns of avoidant behavior, catastrophic thinking, interpersonal functioning, values, and motivation to undergo treatment. KJ reported that she felt significant pressure from her family and her boyfriend to receive treatment. KJ’s mother and boyfriend confirmed their strong desire for KJ to receive treatment. However, KJ’s mother did make several statements during her interview about the dangers of driving in the country and her own fears about driving on the highway or driving in congested areas. During these initial assessment sessions, KJ reported that she would likely not have sought treatment for her symptoms had she not suspected that she was pregnant. Her primary reason for agreeing to treatment was to appease her family and to deliver her baby in a hospital. As assessment progressed, KJ also admitted that she was also unhappy with the interpersonal dynamics with her boyfriend and family members, and she wished she could do things and go places without them. She also reported that above all else, she highly valued her role as a mother and wanted to be able to care for her children.

Over the course of assessment, KJ participated in the Anxiety Disorders Interview Schedule for DSM-IV–Lifetime Version (ADIS-IV-L; Di Nardo, Brown, & Barlow, 1994), and she also completed four self-report measures: the Beck Anxiety Inventory (BAI; Beck & Steer, 1993), the Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996), the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986), and the Brief Symptom Index (BSI; Derogatis, 1993).

The ADIS-IV-L is a semi-structured interview that provides information about current and lifetime disorders of anxiety as well as a broad range of commonly comorbid conditions (e.g., substance use disorders). Inter-rater reliability is sufficiently high for the diagnostic categories of PD and PD with and without AG. Specifically for the diagnosis of AG, apprehension and avoidance ratings yield a kappa coefficient of .86 (Brown, Di Nardo, Lehman, & Campbell, 2001).

The BAI is a 21-item self-report questionnaire that assesses the severity of emotional, physiological, and cognitive symptoms of anxiety. Responses vary by how much the symptom described in the item bothered the respondent in the last week. The response for each item could range in score from 0 (not at all) to 3 (severely). The values for each item are summed yielding an overall score ranging between 0 and 63 points. A total score of 0 to 7 is interpreted as a “minimal” level of anxiety, 8 to 15 as “mild,” 16 to 25 as “moderate,” and 26 to 63 as “severe.” Internal consistency ranges from .92 to .94 (Beck & Steer, 1993).

The BDI-II is also a 21-item self-report measure that assesses cognitive and behavioral symptoms of depression. The response for each item could range in score from 0 to 3. The values for each item are summed yielding an overall score ranging between 0 and 63 points. A total score of 0 to 13 indicates a “minimal” level of depression, 14 to 19 indicates “mild” depression, 20 to 28 indicates “moderate” depression, and 29 to 63 indicates “severe” depression. Internal consistency is adequate.

The ASI is a 16-item self-report measure that assesses the degree to which individuals fear particular sensations associated with anxiety. Elevated scores on the ASI are typically associated with anxiety disorders in general, but are particularly correlated with PD (Blais et al., 2001). Coefficient alpha ranges from .80 to .90.

The BSI is a 53-item self-report symptom scale, which assesses levels of psychopathology. The BSI scores the following nine dimensions: Somatization (SOM), Obsessive–Compulsive (OC), Interpersonal Sensitivity (INT), Depression (DEP), Anxiety (ANX), Hostility (HOS), Phobic Anxiety (PHOB), Paranoid Ideation (PAR), and Psychoticism (PSY). Internal consistency for the BSI is adequate (DeRogatis, 1993).

The ADIS-IV-L AG rating scales, BAI, BDI-II, ASI, and BSI, were used as repeated measures, being administered several times over the course of treatment and at follow-up. Specifically, these assessments were given prior to the start of treatment, at 2, 5, and 8 months into treatment, following treatment, and 1-year following the termination of treatment services. In addition to these self-report and interview assessments, mileage data were taken based on the distances KJ was able to travel during in-session exposures. KJ participated in an interview during the 1-year follow-up assessment, which allowed her to reflect on treatment and post-treatment exposures and life events. Excerpts from this interview are interspersed throughout this article as relevant.

6 Case Conceptualization

KJ’s developmental history includes experiences that are established precursors to developing sensitivity to anxiety from childhood. She reported a strong family history of anxiety and long-standing sensitivity to bodily sensations. KJ was also the victim of sexual abuse in childhood at the hands of a family friend. Due to some of these experiences, KJ had learned to evaluate anxiety and related bodily sensations as “bad” or “dangerous” and as something that it was important from which to escape. Through messages communicated to her in family interactions, and consistent with the broader social-verbal community, KJ learned that psychological well-being is associated with self-control, self-confidence, and the absence of fear, worry, and related bodily sensations. KJ reported hearing and covertly saying to herself things such as “anxiety doesn’t help anything,” “having bodily symptoms is related to poor self-control,” “bodily sensations are dangerous,” “unless you feel confident or safe, don’t leave home,” “you must get rid of anxiety,” and “you have to be in control of your emotions.” Statements like these frame sensations associated with anxiety in opposition with competence, safety, and well-being. As a result of her family history and her experience with abuse, it is possible that KJ received more of these verbal messages than the average person, and it is probable that she was significantly more sensitive to such messages. Throughout KJ’s development, bodily sensations acquired aversive functions and became something she thought she must get rid of to have a healthy, normal life. In her own history with anxiety symptoms and AG, as well as the experiences of her mother and sister in responding to anxiety, it also appeared clear that in KJ’s family anxiety was viewed as a sufficient reason for behavioral avoidance.

This history helps make sense of the event that KJ reported as a precipitant to the 10-month episode of AG for which she presented for treatment. The GI “near miss” occurred in someone with an established sensitivity to similar or related bodily states, who evaluated them negatively, construed their absence as a key to psychological health, and for whom the avoidance was established as a reasonable response to anxiety. Thus, regardless of the ultimate cause of the GI distress in the precipitating event, thoughts of and actions that would take her away from home, away from a bathroom, or might contribute to GI states (eating or drinking shortly before leaving the home) now came to occasion anxiety and escape and avoidance behavior. Over time, KJ began avoiding more and more situations which were associated with GI symptoms or which she thought might elicit them or place in a circumstance where she would not be able to respond it they occurred (e.g., consuming certain foods, driving/riding in cars, etc.). Avoiding these situations would provide relief in the short term, but this avoidance also served to maintain and exacerbate her symptoms of AG. By continuing to avoid these situations she also failed to engage in adaptive behaviors (e.g., going places with her son, finding employment), and this failure provided her with more unpleasant thoughts, worries, feelings of guilt, and negative self-evaluations fueling increased problems with anxiety and her interpersonal relationships. Her current context also continued to support this behavior as, despite their frustrations, KJ’s mother and boyfriend exempted her from leaving the home because doing so made her anxious. At the time of intake, she had not left her family home in 10 months. Avoidance was high and life was small. Those in her environment were growing weary of her behavior, but there was also an important kernel of self-motivation—she genuinely wanted the best for the fetus and recognized that this entailed seeing her OB/GYN.

In short, our assessment and corresponding case conceptualization identified an important personal value (i.e., being a good mother). KJ could identify behaviors in the service of that value she would like to pursue—both for her fetus and for her other child—but for the barriers erected by escape and avoidance. The identification of a relevant personal value provided a motivational variable for doing the challenging work of exposure. In addition, because aspects of her pregnancy (e.g., nausea, upset stomach, a sensitive bladder, increased GI distress) overlapped with, mimicked, and/or amplified the client’s bodily sensations related to anxiety, the decision was made to deemphasize reduction or elimination of such sensations, instead of focusing on acceptance/willingness. Thus, an ACT-based intervention appeared appropriate. Treatment consisting of acceptance strategies and exposure exercises would seek to establish a context, wherein anxiety was not a sufficient reason for avoidance. Therapy would emphasize exposure to feared situations and bodily sensations, done in the service of committed action toward values, and during which acceptance of anxiety-related bodily states and defusion from catastrophic thoughts could be practiced.

7 Course of Treatment and Assessment of Progress

All treatment sessions took place at KJ’s home. Exposures were conducted in the therapist’s vehicle or in KJ’s family vehicles. Treatment consisted of 50 therapy sessions, 5 formal assessment sessions, and 4 family sessions over the course of 12 months. Every session, the distance traveled (in miles) from KJ’s home was measured (see Figure 1 for distance data). Therapy sessions included two imaginal exposure sessions, 43 in vivo exposure sessions, and 5 interoceptive exposures followed by in vivo exposures. ACT processes and strategies were applied throughout treatment. The ACT hexaflex was used consistently to guide intervention development and selection. Figure 2 provides a graphic representation of how core ACT processes were used across sessions to guide treatment. Early in treatment, the ACT processes of values, committed action, and self-as-context received the most attention in sessions to facilitate exposure work and actively reduce experiential avoidance. After the delivery of KJ’s child, undermining experiential control and fusion as well as promoting willingness were the focus of most sessions.

Figure 1.

The client’s mileage from home during in-session exposures.

Figure 2.

How the hexaflex (which depicts the core processes of ACT) was used throughout treatment.

The treating clinician in this case was different from the three initial assessors. This treating clinician was a doctoral-level graduate student in clinical psychology. This clinician had graduate coursework and training in contemporary behavioral therapies, and she attended a 2-day ACT workshop prior to beginning work on this case. The treating clinician also received weekly group and individual supervision from a licensed clinical psychologist with specialized clinical training and research experience in ACT.

Sessions 1 Through 5

During the first five sessions, formal assessments were conducted, family members were interviewed, psychoeducation about AG and anxiety was provided to KJ and to her family, and KJ’s values were informally evaluated and incorporated into the treatment plan. Exposure therapy was explained to the client within an ACT framework. Drawing from KJ’s stated values and goals, the therapist discussed the importance of committed actions in the direction of KJ’s values (e.g., engaging in graded exposures for the purpose of getting prenatal care for her fetus and being a “good mother”). During these sessions, the therapist helped the client build an action plan based on values and encouraged the client to move with barriers rather than against them. In Sessions 4 and 5, imaginal exposures were conducted where KJ sat in the car and imagined riding in the car as a passenger. In her follow-up assessment interview, KJ reported,

At first we just did visualizations of what would be happening and how I would feel or what I would see as I was leaving the driveway. I really had to get into the mindset of it. We practiced just sitting in the car, and then to the top of the driveway, and then to the end of the road. I would get nervous about all those things. My heart would race, I would feel sweaty, and my legs would feel numb.

Sessions 6 Through 35

KJ received consent from her OB/GYN over the phone to participate in in vivo exposure therapy. In Session 6, a loose hierarchy was developed for in-session in vivo exposures. This hierarchy broke down exposures based on major landmarks on the way to KJ’s OB/GYN’s office (located approximately 6.4 miles from KJ’s home). The hierarchy was not strictly followed, as KJ’s willingness to participate and her desire toward committed action were intended to guide exposures. Typical exposure sessions involved setting tentative goals, discussing the importance of values, committed action, and self-as-context, and then having KJ ride in the car while the therapist or occasionally the client’s boyfriend or family members drove. KJ recalled,

I felt really nervous about them, apprehensive even getting ready the whole day before them because we usually met in the evening. When we’d go down to the end of the road, we’d stop there at one point and I was so nervous to even move. We then went out to the main road and we stopped half way down the hill and we just sat there. I was so afraid to just leave that spot. I felt like throwing up because of my nerves and the pregnancy. Eventually we turned around and then we went back to the house, but it was so nerve-racking. But during that day we made a lot of trips back and forth from the end of the road to the house to get used to that. We did that, and it was scary just sitting there and having the thought that we would have to head back to the house. The thought of just going up that very short hill and down, for like one minute, and then back to the house was just terrifying. I felt so numb, I felt nauseous, I felt really hot, and my legs felt just numb.

KJ made it to her first OB/GYN appointment during the 15th session. The therapist drove KJ to this appointment, but drivers varied for most exposures (e.g., KJ’s boyfriend, mother, or sister also served as drivers for exposures). KJ attended four additional OB/GYN appointments with her boyfriend. Once prenatal care appointments were being attended with regularity, exposures continued to center around valued living (e.g., going to the public library, going to the grocery to pick out treats for KJ’s son, etc.). Starting at Session 21, KJ began driving as one of her stated goals was to be able to transport herself and her children around town. Sessions 30 through 35 focused on practicing going to the hospital for the delivery. After Session 35, KJ rode with her boyfriend driving to the hospital located approximately 15 miles from KJ’s home where labor was induced as previously arranged by KJ and her OB/GYN. KJ reported no complications to her health or the health of her infant during delivery.

Sessions 36 Through 59

KJ began exposure work again 1 week following the delivery of her infant. The therapist chose to begin exposure work again quickly, so as to counteract any risk of relapse during the postpartum period. KJ agreed that it was best to continue exposures soon after delivery as she had experienced anxiety and some depressive symptoms during postpartum in the past. Post-pregnancy, KJ reported a decline in GI symptoms while engaging in exposure work. During these sessions, typical therapy began with tentative goal planning (with a focus on going places that facilitated valued living) followed by in vivo exposure. Therapy after pregnancy focused more on undermining fusion and avoidance as well as promoting willingness. The therapist worked with KJ to realize the unworkability of control efforts and the paradoxical effect of emotional control strategies. KJ also used defusion strategies by incorporating language such as “I’m having the thought or feeling that . . . ” when experiencing bodily sensations and talking about the actions of her mind (e.g., “My mind is telling me . . . ”). She also learned to speak about her anxiety with willingness and acceptance. KJ explained during her interview,

I realized that, even though it’s a depressing thought, I’ll always have to live with this and I needed to learn to cope with it so I wouldn’t live in this bubble I was surrounded in. Even when I was anxious, I would live above what I had available to me. I was depending on people to pick up stuff for me, to do this or do that, and it really was difficult trying to do that. So I wanted to live above what I could do in my own little bubble. The next step was really just getting out there and working on it and realizing what I needed to do, how I needed to think, and to know that before I left the house my anxiety was always really high and then after I started driving it really dropped down at least 3 points. It dropped down a bunch, so it was more manageable. I’d be fine once I got to the location. It might spike again before I left, but it would go down again when I was driving. It was really just keeping that in my head as I was getting ready to leave the house or leave a location, really focusing on that part. I don’t know exactly when it was that it clicked, probably after I delivered my baby. It really just clicked, and it really helped. And it helped when I finally started driving myself, I didn’t have to depend on other people.

KJ drove herself during later exposures as values-consistent behavior for her involved being able to take her children places and do her own independent activities. During Sessions 55 through 59, therapy sessions also incorporated interoceptive exposure in addition to in vivo exposure. Specifically, KJ would eat or drink certain foods before doing a driving exposure. Before these sessions, KJ would purposefully restrict food and beverage intake prior to in vivo exposures. For the final session, KJ drove with the therapist to a local diner to have breakfast, including coffee, a beverage she had strictly avoided before treatment. KJ spoke about her feelings toward the end of treatment and how her understanding of anxiety had changed in her follow-up interview:

For me, anxiety took form when [my therapist] told me it was kind of like a monster, and if you just keep feeding it, it’s going to stay there. So I really just kind of think about that. For anxiety, if you fight it, it’s always going to stay with you, it’s always going to be there. You have to, not ignore it, but know what it is and work around it so that it can become smaller and smaller and not such a huge force that’s right in your way . . . With anxiety, you don’t give into it when it’s really up there in front of you.

KJ completed the ADIS-IV interview, the ASI, the BAI, the BDI, and the BSI 5 times over the course of treatment, and she completed these assessments again approximately 1 year following termination of services. During her pre-treatment ADIS-IV interview, KJ rated her apprehension and avoidance of situations involving driving or riding as “very severe” (or an 8 on a scale of 0-8). Across treatment, KJ’s apprehension ratings of driving situations fluctuated. Generally KJ’s apprehension ratings decreased as treatment progressed (with apprehension ratings dropping from an 8 to a 3 for “local driving”), but some of her ratings remained high even at post-treatment (“long distance driving” rated as a 7) and follow-up (“long distance driving” and “riding in a car” both rated as a 6). KJ’s ratings for avoidance, however, decreased consistently across treatment and at follow-up for all three driving categories (and dropped down to “0” at follow-up for “local driving”). This disparity between persistently moderate to high apprehension ratings and low avoidance ratings at post-treatment is consistent with an ACT-based intervention. According to an ACT perspective, feelings of anxiety or apprehension may not decrease with successful ACT treatment, but experiential and behavioral avoidance should decrease markedly. This very pattern is present in KJ’s ADIS-IV apprehension and avoidance data. While KJ’s feelings of apprehension related to driving situations changed only slightly as a result of treatment, her avoidance of the experience of symptoms of anxiety changed markedly. Figure 3 depicts this steady change in behavioral avoidance of driving situations.

Figure 3.

The client’s ADIS-IV-L agoraphobia avoidance ratings.

KJ’s ASI, BAI, BDI, and BSI data also fluctuated throughout her pregnancy and following her delivery. Table 1 displays these data. KJ’s ASI, BAI, and BDI all indicated mild symptoms of anxiety and minimal symptoms of depression at the time of pre-treatment assessment. At pre-treatment assessment, KJ’s BSI was approaching clinical elevation in the domains of ANX (T = 60) and PHOB (T = 65). It is interesting that KJ reported mild symptoms of anxiety, given her extremely high level of functional impairment prior to receiving treatment. However, KJ’s symptom reports again make sense in the context of an ACT conceptualization. Changes in KJ’s self-reported symptoms of anxiety and depression varied over the course of her pregnancy and during the postpartum period. By post-treatment assessment, approximately 1 year after beginning exposure and ACT therapy, KJ’s BAI, BDI, and BSI scores declined, but these declines were small. KJ’s ASI score actually increased from pre- to post-treatment, but this increase was not clinically significant. Again it is key to note that an ACT-based treatment plan would not demand a dramatic decrease in the client’s experience of anxiety or depressive symptoms. Rather, an ACT model would predict that successful treatment would be associated with marked increase in behaviors associated with value-consistent living rather than the reduction or elimination of unpleasant symptoms.

Table 1.

Self-Report Measure Scores Across Treatment.

Measure	Pre-treatment	2 months	5 months	8 months	Post-treatment	Difference pre to post	Follow-up
ASI	8	10	8	14	9	+1	13
BAI	10	16	9	10	7	−3	17
BDI	7	7	17	7	3	−4	2
BSI ANX	60	65	60	60	38	−22	63
BSI PHOB	65	70	62	63	60	−5	63

Note. ASI = Anxiety Sensitivity Index; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BSI ANX = Brief Symptom Index Anxiety; BSI PHOB = Brief Symptom Index Phobic Anxiety.

This reduction of behavioral avoidance instead of a reduction in reported symptoms is exactly what is seen in KJ’s case. During treatment, the therapist recorded the miles KJ rode in the car with the therapist, drove in the car with the therapist, and participated in interoceptive (eating or drinking) exposures before driving. Figure 1 depicts the number of miles from home KJ rode in or drove a car for each exposure session. Using a multiple baseline across situations graphic representation, it is clear that KJ was able to quickly increase distances riding in the car, driving the car, and driving the car following interoceptive exposure exercises.

KJ remained healthy throughout treatment. She was monitored by her OB/GYN physician at his office and over the phone, and he expressed no concerns about KJ’s health over the course of treatment. KJ had a vaginal delivery, and both mother and fetus were healthy immediately following the delivery. Neither mother nor child had experienced any known health complications at the 1-year follow-up assessment.

Following the birth of her child, KJ reported that her symptoms of anxiety and depression improved markedly. She also reported improvements in her level of activity and her relationships with her children, her boyfriend, and her family. In her follow-up interview, KJ explained,

I could even go from [one town to another] which is about a half-hour away without stopping anywhere. I could go to an appointment and not feel too nervous about it. It was really liberating that I could plan to do things. I could drop my son off and it wouldn’t matter if my anxiety increased. I was making a lot more plans, doing more, and I felt less anxiety about doing things. Since I started driving my son more and doing more stuff by myself I felt more freedom. I could plan things and not have to worry about other people and how it would fit into their schedule and that was nice.

8 Complicating Factors

The client in this case presented when she was 9 or 10 weeks pregnant, and the therapist saw her for 1 year following her intake sessions. Treating KJ throughout her pregnancy and during the postpartum period posed several concerns for the therapist. Medically, the research findings about exposure therapy and pregnancy are extremely limited. However, the client was requesting services specifically because she was pregnant and requiring prenatal care and OB/GYN monitoring. A literature search was conducted to determine a course of treatment that would be both empirically supported and fast-acting. The treatment rationale was presented to KJ, and she chose to participate in treatment to protect her health and the health of her fetus. The therapist in this case worked closely with a supervision team, the client’s supervising physician, and the client’s family to tailor treatment to be as safe and effective as possible.

9 Access and Barriers to Treatment

The treatment in this case was unique because the therapist traveled to client’s home to do exposure therapy in the client’s car, with the client’s family, and to those locations most pertinent to the client (e.g., the doctor’s office). Home-based therapy was necessary, given the severity of KJ’s agoraphobic symptomatology; however, this type of intensive therapy may be difficult for some providers to administer. While the client in this case was very motivated to seek treatment, she required home-based visits to get her treatment started. The frequency of home-visits declined as treatment progressed, and by the end of therapy the client was meeting the therapist outside the home and was traveling to other appointments on her own (therapy, dentist, medical). While home-based care may be complicated, it may also be necessary for clients who have severe anxiety symptoms and medical considerations.

10 Follow-Up

KJ’s progress after treatment was assessed 1 year after termination of services. Several months after the conclusion of treatment, KJ reported that she was engaging in many values-based activities including driving her son to preschool everyday, visiting the local library, driving to see her extended family, and attending medical appointments for herself and her children. She also traveled to a psychology clinic weekly with her boyfriend to continue to improve her relationship with him (this clinic was located about 20 miles from KJ’s home). KJ described the period following treatment in her follow-up interview:

About the time [treatment] stopped, my boyfriend and I went to couples’ counseling. I would drop the kids off at my dad’s house and then we would go to the counseling sessions and then pick the kids up. So I got practice stopping somewhere and not going to the bathroom and then going to somewhere else. That really did help. I also took my son to school. It was pretty big for me to be able to do that. I was pretty excited, I felt like it was such a huge accomplishment. I was able to also focus on driving places locally by myself and being able to feel comfortable doing that. I was planning ahead, and driving places with people. One of them was going to an expo center for a big sale for new mothers. I was able to do that which was exciting because that was a huge source of anxiety going down [a particular road], and being able to do that even with a passenger. It was nice being able to know that I could do it, and that I could plan ahead to do things like that. We went to a few things as a family in neighboring towns. It was nice to know that I could do it, that I had a foundation to know how to deal with the sensations should they arise.

Nine months after the conclusion of treatment, KJ discovered that she was pregnant again. Despite the resumption of several anxiety symptoms (see Table 1), KJ did not relapse back into agoraphobic, avoidant behaviors. She continued to drive her son to school, participate in other valued activities, and schedule and attend prenatal OB/GYN appointments. She reported that she had scheduled all of her prenatal appointments, and she has not missed one since discovering her pregnancy. This response to a new onset of anxiety is easily predicted by an ACT conceptualization. When KJ’s symptoms of anxiety resurfaced, KJ was still capable of engaging in her life according to her values. KJ compared her new pregnancy with her last one during her follow-up interview:

With this pregnancy my anxiety is pretty much the same. I feel very nervous about things. The difference between this one and the last one is I know how to deal with it. I know what I’m feeling, how to interpret the feelings, how to move past them in order to accomplish the things I need to get done. I know how not to think so negatively about them, just to know what they are, and how to proceed. I’ve got the foundation of knowing that it’s going to happen and I’m going to feel bad, but it’s going to feel better when I get to my destination. It will probably feel bad coming home, but nothing’s going to happen and if it does it’s not a big deal. So that’s another positive, I didn’t have that last time. I just always thought something horrible was going to happen and it would be the worst ever, but now I realize it’s not and it’s going to be okay. Eventually you understand that it’s not the end of the world.

KJ reported that even with an increase in anxiety symptoms, she has felt confident in her ability to continue to make progress with her life goals. It is clear that her psychological flexibility has increased from her second pregnancy to her third. She is planning to move out of her family’s home to a house with her boyfriend, which was an important goal for her. KJ reflected on her treatment goals and successes in her interview:

My goals for treatment were to get out and do driving by myself, with my kids, and to go to further places and eventually move out and live on my own. I feel I’m doing pretty well with them. With the help of the therapy, I drove my son to school every day and picked him up. It’s only a half-day but still, it could be trying at times. I have made it farther places. I’m moving out soon. Just overall in general I feel that the goals were met and exceeded for the most part. I’m able to function normally. I’m able to go out and do things, to plan ahead, to keep my plans, to be able to live life and get things done and do things by myself and with people. It’s one of the major pluses of treatment is that I was able to focus and move ahead and find what I needed to do in order to continue on like that, in order to set myself up for future success.

11 Treatment Implications of the Case

While exposure therapy is the most effective treatment for anxiety disorders, there is limited evidence about the specific treatment of AG without a history of PD. There is even less empirical evidence about the effects of exposure therapy on pregnant women and developing fetuses. This case study represents an addition to the literature because it provides support for using aggressive exposure therapy combined with ACT processes in a pregnant woman struggling with severe AG symptoms. Exposure therapy supplemented by ACT strategies was used to treat the client throughout her pregnancy and 6 months following her delivery. During this treatment period and at the 1-year follow-up assessment, the client did not report any negative effects to the progression of her pregnancy, the fetus’s health, or the child’s subsequent development. The client carried her fetus full-term, and she had no problems with delivery or care of the infant after birth. In fact, the client’s psychological well-being was much improved during the postpartum period.

This case study is important because AG is an anxiety disorder that may particularly affect women during their childbearing years. In addition, there is reason to believe that many pregnant women struggling with anxiety disorders, in particular AG, do not receive adequate prenatal care. Information about pregnant women and the treatment of severe anxiety is greatly needed, and this case study provides initial evidence that the use of exposure therapy and ACT processes during pregnancy is not only harmless, but it may also be very effective.

12 Recommendations to Clinicians and Students

CBT is frequently recommended for the treatment of severe anxiety disorders. However, with particularly treatment-resistant cases, it may not be beneficial to focus on changing negative cognitions or the experience of negative sensations (Ost, Thulin, & Ramnero, 2004). Especially in the case of a pregnant woman, it may not be advantageous to focus on goals such as the complete elimination of any physiological or cognitive symptoms of anxiety. An ACT conceptualization and treatment plan may be particularly effective for clients with longstanding, treatment-resistant anxiety or for clients whose experience of physiological anxiety symptoms is inevitable. ACT encourages the client to willingly experience physiological symptoms of anxiety in the service of living according to one’s personal values. For KJ, it was much more realistic to teach her to accept rather than challenge her experience of the physiological symptoms that must accompany pregnancy and that had been a part of her long history with anxiety. Working with KJ from an ACT perspective allowed exposures to flow naturally and to be guided by KJ’s values (e.g., being a loving mother, being an independent and achieving woman) rather than by arbitrary benchmarks. This contributed to quick treatment progress, and values-based exposures allowed KJ to feel a sense of mastery and confidence when she met her goals. It is recommended that clinicians consider ACT strategies as a supplement to exposure therapy in the treatment of individuals with severe AG symptoms and certain medical complications (e.g., pregnancy).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Colleen C. Cullinan, M.A., is a doctoral student in the clinical psychology department at Western Michigan University. Her research focuses integrated behavioral healthcare and pediatric psychology.

Scott T. Gaynor, Ph.D., is an associate professor of psychology at Western Michigan University. His research focuses on treatment process and outcome in behavior therapies.

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