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Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20

Symptom Discrimination and Habituation: A Case Study of Behavioral Treatment for Postural Orthostatic Tachycardia Syndrome (POTS) a

b

Timothy E. Ralston & Kathryn E. Kanzler a

Mental Health Clinic, Minot Air Force Base

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Clinical Health Psychology Clinic, Malcolm Grow Medical Clinics and Surgery Center Accepted author version posted online: 22 Oct 2014.Published online: 29 Jan 2015.

Click for updates To cite this article: Timothy E. Ralston & Kathryn E. Kanzler (2014): Symptom Discrimination and Habituation: A Case Study of Behavioral Treatment for Postural Orthostatic Tachycardia Syndrome (POTS), Behavioral Medicine, DOI: 10.1080/08964289.2014.977765 To link to this article: http://dx.doi.org/10.1080/08964289.2014.977765

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BEHAVIORAL MEDICINE, 0: 1–6, 2015 ISSN: 0896-4289 print / 1940-4026 online DOI: 10.1080/08964289.2014.977765

Symptom Discrimination and Habituation: A Case Study of Behavioral Treatment for Postural Orthostatic Tachycardia Syndrome (POTS) Timothy E. Ralston Mental Health Clinic, Minot Air Force Base

Kathryn E. Kanzler

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Clinical Health Psychology Clinic, Malcolm Grow Medical Clinics and Surgery Center

Postural orthostatic tachycardia syndrome (POTS) is a multifaceted disorder of the autonomic nervous system that profoundly impacts physical functioning. In addition to physical consequences, many patients develop situational anxiety that causes reduced activity level, which may impede functional recovery from POTS. Despite links with anxiety, to date there have been no reports of psychological intervention for POTS. Here we report a case study of POTS in a 40-year-old female serving on active duty in the US military. Because there are no established guidelines for the psychological treatment of POTS, intervention techniques were adapted for use with the patient. Elements of cognitive behavioral therapy, including in-vivo exposure and symptom discrimination, were used to target avoidance of feared situations. Over the course of treatment, the patient learned to discriminate her POTS symptoms from anxiety and displayed a significant decrease in POTS-related functional impairment. Implications for future care are discussed.

Keywords: case study, exposure therapy, health psychology, POTS INTRODUCTION Postural orthostatic tachycardia syndrome (POTS) is a disorder of the autonomic nervous system (ANS) characterized by rapid heart rate without hypotension during orthostasis (ie, standing upright).1 The actual prevalence of POTS is difficult to estimate, but it appears to occur approximately 5–10 times as often as orthostatic hypotension alone.2 Individuals with POTS often experience a variety of symptoms, including cerebral hypoperfusion (ie, lightheadedness, presyncope, or weakness), autonomic overactivity (ie, heart palpitations, tremulousness, shortness of breath This article not subject to U.S. Copyright law. The opinions and statements in this article are the responsibility of the authors and do not necessarily represent the policies or opinions of the Department of Defense, Department of the Air Force, the United States, or their agencies. Correspondence should be addressed to Timothy E. Ralston, Chief, Mental Health Clinic, Minot Air Force Base; Address: 194 Missile Ave, Minot AFB, ND 58705 USA. E-mail: [email protected]

[SoB], and chest pain), sudomotor symptoms (ie, decreased sweating or hyperhidrosis), dysautonomia (ie, gastrointestinal complaints and papillary dysfunction), and generalized somatic complaints (ie, fatigue, insomnia, headaches, and pain).3 These symptoms result in significant decrements in the patient’s quality of life.4 The etiology of POTS is poorly understood and is described as a heterogeneous disorder that may be triggered by a variety of factors, such as viral infection or prolonged bed rest.5 Approximately 50% of patients with POTS recover in two to five years, although for some the symptoms persist and become a chronic disorder.6 One proposal for the perpetuation of POTS symptoms suggests a strong psychological contribution, whereby learning and conditioned fear, somatic hypervigilance, and behavioral changes entrench symptoms partially though dysfunctional sympathetic arousal.5 Mental stress has been documented to significantly increase heart rate, main arterial pressure, and forearm vascular conductance in both healthy and POTS patients.7 It is understandable that such physiological

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changes could be misinterpreted as physical POTS symptoms rather than normal physiological responses to stress. Benarroch5 proposes that the impact from behavioral arousal (anterior cingulated cortex action), interoceptive awareness (insular cortex involvement), and emotional interpretation of sensations (amydgala contribution) are involved in maintaining POTS over time. This proposed mechanism seems plausible, particularly since POTS symptoms may be unpredictable or uncontrollable. Based on this proposed mechanism, patients may develop avoidant behaviors in an attempt to circumvent triggers for POTS episodes. Some types of avoidance are adaptive and necessary to manage the condition (eg, drinking water to avoid the negative consequences of dehydration), but inappropriate or superstitious avoidant behaviors may develop, whereby individuals evade perceived triggers that are coincidentally related to symptom episodes. Indeed, POTS patients may display significantly greater anxiety sensitivity, body vigilance, and catastrophizing than healthy persons, cultivating the context for maladaptive avoidance.7 In fact, a study of 94 patients with POTS revealed that functional disability was most strongly associated with catastrophic thinking, which likely promotes associated avoidance, rather than actual POTS symptoms.8 Typical treatment protocols for POTS involve medication, as well as increased sodium and fluid intake, exercise, support garments, and physical counter-maneuvers (eg, frequent crossing of legs).1,5,6 Treatment recommendations target the physical symptoms of POTS, and such interventions are well-established with a good evidence base. Benrud-Larson and colleagues8 additionally recommend a cognitive-behavioral therapy (CBT) approach, but no treatment studies to date have included CBT for POTS. This is surprising considering the devastating impact of POTS symptoms on quality of life over the course of the syndrome, and the documented detrimental nature of catastrophic thinking and maladaptive behavioral responding that can perpetuate the symptoms over time.8 Although no psychological treatment protocols or studies have emerged for POTS, there are well-established CBT approaches that complement multidisciplinary treatment of other medical conditions (eg, COPD).9 Typically such interventions include psychoeducation from a biopsychosocial perspective, behavioral and cognitive training to help discriminate between condition-related symptoms versus false alarms of anxiety-induced sympathetic nervous system arousal, relaxation training to increase self-efficacy and manage anxiety symptoms, and exposure therapy to facilitate extinction of avoidant responding through habituation to feared situations and physiological stimuli.9 Due to the similarity of exacerbating factors in POTS, adapting and applying such treatment concepts could lead to improvements in quality of life and a reduced likelihood of condition chronicity.

METHODS Clinical Case Description A patient with recently diagnosed POTS was referred to the Clinical Health Psychology (CHP) clinic at an east coast military treatment facility. The patient was assigned to the first author (T.E.R.) during his predoctoral clinical psychology internship under the supervision of the second author (K.E.K.), a board-certified Clinical Health Psychologist. The patient was a 40-year-old, married, female active duty Senior Non-Commissioned Officer in the military with 18 years in service, who will be referred to as Sergeant (SGT) Jones. She worked within the personnel section of a busy military installation, and had been married for nearly two decades with two adolescent children. She was referred by her treating neurologist for support in accepting the limitations of her new medical condition. SGT Jones reported a rapid onset of POTS symptoms following her return from a humanitarian deployment approximately three months ago. Her first symptomatic episode occurred while shopping on the military installation, at which time she experienced tachycardia, dizziness, and trembling. She had a syncopal episode while in the store and was taken for emergency treatment. Although there may have been prodromal symptoms leading up to this episode, she was not aware of them, and the precipitating event was a surprise and was an extremely upsetting experience for SGT Jones. Following this episode, the patient remained symptomatic as medical providers attempted to determine the cause of her symptoms. Her activity level greatly decreased because she would experience tachycardia and extreme dizziness when standing for brief periods of time. She spent five days as a medical inpatient due to unrelenting symptoms and was placed on steroid medication for 10 days. She was formally diagnosed with POTS approximately 1 month after the initial episode. Between her diagnosis and her initial appointment in the CHP clinic, SGT Jones remained symptomatic, with episodes of tachycardia and dizziness several times per day lasting for 20 minutes to two hours. Because these episodes were associated with periods of physical activity, the patient was not leaving her home and spent most of her time recumbent on her couch. This decreased activity level was facilitated by her husband and children, who adopted more responsibility in and out of the home. She was placed on convalescent leave following the onset of symptoms and thus had not been working for approximately 4 months. At her initial visit, SGT Jones’ symptoms were being managed with medications (ie, fludrocortisone, pseudoephedrine, diazepam, and magnesium supplements) and increased fluid intake of at least two liters of water per day. In addition, she had visited the emergency department 4 times in the past month for infusions of fluids and electrolytes.

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CASE STUDY OF BEHAVIORAL TREATMENT FOR POTS

SGT Jones’ physical symptoms were accompanied by several key psychosocial factors. She reported significant anxiety and worry associated with her future functionality and the impact that POTS would have on her military career. These concerns were not unwarranted due to her vague prognosis and a pending Medical Evaluation Board (ie, an official medical inquiry into a service member’s fitness for duty which may result in medical separation or retirement from service) that was initiated shortly after her initial CHP appointment. She also reported cognitions reflecting her concerns and decreased functioning (eg, “I can’t do anything”). The patient endorsed fear of public spaces and driving because she believed she would have another episode of syncope. She was able to avoid such situations due to her convalescent leave and the efforts of her family. While this allowed her to avoid feared situations, she expressed dissatisfaction with her life and a desire to become more active again. Despite drastic changes in her life, SGT Jones did not evidence symptoms of depression. Her goals at intake were to “be able to function again” and to return to work. Based on her presentation at intake, it appeared that SGT Jones was managing her POTS appropriately from a medical perspective. However, her anxiety was clearly preventing her from being able to re-engage in day-to-day tasks and valued activities. Without facing uncomfortable situations, she was unlikely to recover quickly and would continue to be functionally limited with potential long-term negative consequences. She was diagnosed with Psychological Symptoms Affecting a General Medical Condition (ie, POTS) and Adjustment Disorder with Anxiety. Intervention Approach While SGT Jones’ POTS symptoms certainly appeared to be negatively influencing her activity level, it was crucial for her to learn to distinguish between symptoms of POTS and symptoms of anxiety as she began to increase her activity level. Such an approach rooted in CBT would allow her to more accurately appraise her physical sensations, reduce catastrophic thinking, and gain self-efficacy. This cognitive component of treatment was geared towards enhancing SGT Jones’ ability to engage in feared situations as she began exposure therapy. Before commencing exposure therapy, she first required psychoeducation on the nature of avoidance and how it can reinforce anxiety. A hierarchy of feared situations needed to be constructed, similar to procedures in exposure therapy for other anxiety disorders,10,11,12 and in vivo exposure would later begin with a situation eliciting moderate distress. The patient’s progress in therapy was tracked using the Beck Anxiety Inventory (BAI).13 This measure has solid psychometric properties and assesses a combination of cognitive and somatic symptoms associated with anxiety. In addition, SGT Jones was given the 36-item version of the well-validated Short Form Health

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Survey (SF-36)14 at initiation and termination of treatment. This instrument provides a measure of the patient’s perceived functioning in physical and mental domains compared to a general sample in the United States. Course of Treatment Session 1: Understanding Cognitions SGT Jones presented to her first appointment with a friend who drove her and remained in the waiting room. She stated that this was a precaution in the event she had “an episode” while she was outside of the home. SGT Jones explained that she only left her home to attend medical appointments, and that she always had someone with her (usually her husband). She provided more detail on her perceptions of POTS, and it became evident that she was attempting to find patterns and explanations for her symptoms. For example, she expressed a belief that fluorescent lights exacerbated her symptoms because her initial episode occurred in a store with bright fluorescent lighting. She also felt that she could prevent or minimize symptoms by drinking excessive amounts of water throughout the day (ie, beyond recommendations). These cognitions were not challenged immediately, as initial goals were to collect additional information and provide her with a framework for treatment. The therapist discussed the nature of anxiety and provided SGT Jones with an explanation of how anxiety induces physiological arousal that could exacerbate or mimic POTS symptoms. Although she expressed understanding that anxiety symptoms could be misinterpreted as POTS, SGT Jones was hesitant to accept that anxiety could be contributing to her level of distress. Her assignment between sessions was to begin monitoring her symptoms and cognitions throughout the day. The assignment was chosen so she could gather data on her symptoms and appraisals depending on the location (eg, outside in a parking lot vs inside a convenience store) and other contextual factors (eg, length of time standing, accompanied by her husband versus others). Sessions 2 and 3: Making Symptom Distinctions SGT Jones experienced fluctuation in her POTS symptoms during the early treatment sessions, worsening following influenza infection. She was adherent to her assignment from Session 1 by observing her reactions in various situations. In particular, she had accompanied her husband to nearby stores on several occasions. She noticed that she began to experience tachycardia, dizziness, hot flashes, and shakiness upon entering these locations. These symptoms became worse the farther she ventured into the store and would dissipate as she approached the exit; she said her symptoms would disappear upon leaving the store. Based on these experiences, SGT Jones concluded that being

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outdoors in open space was beneficial to her POTS symptoms, and that indoor spaces exacerbated symptoms. In Sessions 2 and 3 the therapist used these examples to highlight the distinction between anxiety symptoms and POTS symptoms. Using Socratic questioning and psychoeducation, the therapist helped SGT Jones to expand her understanding of POTS and anxiety as seen in her increasingly more insightful statements that there was no medical connection between a particular physical environment and POTS symptoms. The therapist pointed out that these environments had been reinforced as feared stimuli, so they engendered an automatic physiological response. In addition, the gradation of physiological responding appeared to be associated with ease of escape from the feared environment. This work on reframing the patient’s attributions during these sessions allowed her to have confidence in the rationale for exposure therapy. In addition, it became clear that SGT Jones would benefit from more tools to manage physiological responses, in order to build self-efficacy in her ability to tolerate uncomfortable situations. As a result, the therapist instructed her in the methods of diaphragmatic breathing. Her assignments following Session 3 were to (1) continue monitoring her cognitions to determine how they influence avoidance, and (2) identify valued activities that have been avoided due to POTS. Sessions 4 and 5: Beginning In Vivo Exposure SGT Jones described improvement in her POTS symptoms such that her predominant symptoms were dizziness and fluid retention. She noted success with her behavioral experiments (ie, spending more time in the store) and was able to utilize diaphragmatic breathing to decrease physiological arousal. She also returned to successfully working on a half-time basis by Session 5. Due to SGT Jones’ increasing insight, self-efficacy, and new coping tools, the therapist decided to engage in exposure therapy in earnest, so that remaining symptoms would cease to impair her functioning. At this point, SGT Jones needed evidence for the distinction between POTS and anxiety symptoms in order to discard her remaining avoidant/unhelpful coping strategies. Modification of evidence-based anxiety disorder protocols occurred predominantly in these sessions. A list of feared situations was constructed during Session 5, which was then organized into an exposure hierarchy, as is commonly done with CTB treatment of other anxiety disorders.10 A Subjective Units of Distress Scale (SUDS) was defined from 0 to 100 and used as anchor points for SGT Jones’ hierarchy. SGT Jones rated driving on the interstate as her most distressing event, with varying public scenarios lower on her hierarchy. The therapist explained how repeated exposure to feared situations would allow SGT Jones to habituate to the cues that generate anxiety and perpetuate avoidance. A situation in the middle of her hierarchy was chosen as a first in vivo exposure

assignment so that SGT Jones would be successful during the exposure exercise while also experiencing distress. Thus, the patient agreed to begin driving herself on the installation, and to and from work. Sessions 6, 7, and 8: Strengthening Behavioral Changes During Sessions 6 through 8, SGT Jones noted continued improvement in POTS and anxiety symptoms. She was successful with driving on base and found that she quickly habituated to driving. She had also returned to work fulltime by Session 6 without incident. The remaining items on her exposure hierarchy were shopping in a retail store, completing a full grocery shopping visit, and driving on the highway. It also became evident during these sessions that SGT Jones was relying on her water bottle as a safety signal and was consuming approximately twice as much water as indicated. To address the over-reliance on water, the therapist encouraged her to not bring her water bottle to sessions and to ration her water on a schedule throughout the day. Her assignments during these sessions also involved spending progressively longer periods of time in stores, first with her husband, and then by herself. In addition to exposure progress, SGT Jones expressed less dissatisfaction with her condition, and acceptance of her new physical limitations during these sessions. The therapist facilitated SGT Jones’ new contentment through discussions of acceptance and exploration of personallyheld values, which were informed by techniques from Acceptance and Commitment Therapy (ACT).15 SGT Jones reflected that she had adjusted to her “new normal” and was surprisingly happy with the relatively slower pace of her life. She still wanted to run and hike again, but she reported that she could be content if such activities were forever out of her grasp. By Session 8, she no longer met criteria for Adjustment Disorder with Anxiety due to the emerging acceptance of her condition and resulting dissolution of anxiety symptoms. While her functioning improved, SGT Jones’ motivation to overcome all items on her hierarchy strengthened. Sessions 9 and 10: Maintaining Gains By Session 9, SGT Jones had met all of her exposure goals except for an independent full grocery-shopping trip. Her progress was attributable to diligent work between sessions to engage in exposures on a daily basis; the concept of graduated exposure from sessions had generalized, and she was able to successfully manipulate her exposure exercises so that she could continue to be challenged. SGT Jones was now able to shop in the base retail shop and other large stores in the community without avoidance or a safety signal. She was also successfully driving on the interstate and did not feel functionally limited aside from her ability to exercise or stand for long periods of time. At Session 9,

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it was collaboratively decided that she was no longer in need of psychological treatment. SGT Jones wanted to meet her final exposure goal, so a final termination visit was scheduled. When she attended Session 10, the patient reported that she had been able to complete a full 60-minute grocery shopping trip by herself. She reflected on her progress and expressed happiness in the day-to-day functionality that she had regained. Prior to terminating, the therapist focused on relapse prevention by reviewing successful coping strategies and planning ahead to overcome possible future POTS-related concerns.

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RESULTS Over the course of 10 sessions, this patient was able to dramatically increase her activity level to a point that was close to her baseline. In addition, she showed a shift in her acceptance of her medical condition and her ability to have a high quality of life despite any remaining physical constraints. The patient showed a reduction in BAI scores at each assessment time point (Figure 1), improving from a severe level of anxiety symptoms at baseline to a minimal/ absent level of symptoms at termination. The patient’s SF36 data suggest that while she still perceived herself as below average physically compared to the U.S. population, her mental well-being improved from low average to above average (Figure 2). These data are consistent with her selfreport and indicate that her increased daily functioning and quality of life were due in part to a reduction in her anxiety symptoms. Perhaps most importantly, the patient’s Medical Evaluation Board results were returned with a recommendation for her to remain on active duty military status, thus allowing her to remain employed and giving her the opportunity to retire in another two years; this result would not have been possible without the rapid increase in functioning that occurred during treatment.

FIGURE 2 SF-36 scores at baseline and post-treatment. SF36-P refers to the patient’s perceived physical functioning, while SF36-M is a measure of the patient’s perceived mental well-being. Data are presented as t scores in comparison to a general U.S. population.

DISCUSSION This is the first published case study reporting on the success of CBT applied to a patient with POTS. The case of SGT Jones demonstrates the application of nomothetic knowledge (ie, the existing scientific literature) to the idiographic presentation of a particular patient. The process described herein of developing a treatment approach using evidence-based elements, testing hypotheses, and tracking outcomes over time represents the scientist-practitioner model in clinical practice. Because there was not a standardized protocol or manualized treatment for managing the psychological components of POTS, a scientific approach was utilized to assess the relationship between symptoms and behavior via functional analysis. It became clear that avoidance was driving psychopathology for SGT Jones, leading to the adaptation of treatment elements from evidence-based interventions targeting avoidance in anxiety disorders. Specific interventions proved successful in treating functional impairment secondary to POTS. The following is a list of the intervention components for the behavioral treatment of POTS: 1. 2. 3. 4. 5. 6. 7.

FIGURE 1 Beck Anxiety Inventory (BAI) scores over the course of treatment. BAI scores correspond with the following levels of anxiety symptoms: 0–7, minimal; 8–15, mild; 16–25, moderate; and 26–63, severe.

Psychoeducation Self-monitoring Symptom discrimination and skill building In vivo hierarchy construction Graduated in vivo exposure Acceptance of limitations and new lifestyle Relapse prevention

These intervention elements combine components of treatment for Panic Disorder (eg, symptom discrimination), Social Anxiety Disorder (eg, constructing an exposure hierarchy), Obsessive-Compulsive Disorder (eg, stopping

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compulsive water intake), and more ubiquitous CBT techniques (eg, cognitive reappraisal, graduated exposure), as well as ACT-based interventions (eg, values clarification and acceptance strategies). Each of these components was included in treatment to help the patient reduce her avoidance and become re-engaged in valued aspects of her life. SGT Jones was at high risk for losing her career and cementing functional impairment, but she was able to accurately appraise her symptoms and habituated to previously feared situations, thus mastering the psychosocial impact of POTS. Although the patient’s progress in therapy was significant, it is important to note potential methodological limitations and the unique circumstances of her case. Because this case study represents standard clinical care in an outpatient treatment facility, we did not employ any experimental design conditions. There were no controls for the influence of other therapeutic or external factors on the patient’s improvement; therefore, we cannot say with certainty which aspects of the therapeutic intervention “package” best account for her improvement, or if placebo effects may have been responsible for change over time. A better understanding of the mechanisms of action could be tested in future research using variants of single case design and case series research, such as ABA or ABAB designs.16 Observing treatment gains in only the active condition would help to bolster confidence that the intervention components were responsible for change. Regarding patient characteristics, SGT Jones displayed a high level of motivation during treatment that may not be typical of most patients. She was an accomplished and high ranking enlisted member who was motivated to not only increase her daily functioning, but also to show her medical providers that her condition would not interfere with her ability to remain in the military. In addition, the patient had access to a variety of medical providers due to her geographical location, allowing for multidisciplinary care that may not be typical for others with POTS. CONCLUSIONS Despite these unique characteristics, results of this case study suggest that medical providers should consider psychological treatment a valuable adjunct to medical care for POTS patients. It is possible that such intervention would help other patients to progress more rapidly and reduce symptom-related impairment. While POTS is not a common diagnosis, the scientist-practitioner process described herein can be readily applied to other medical conditions where avoidance may be perpetuating symptom-related anxiety and contributing to functional impairment in excess

of the medical condition itself. This case study highlights the universality of CBT intervention components and suggests that impairment due to uncommon medical conditions can benefit from a background in clinical health psychology coupled with a scientist-practitioner approach.

REFERENCES [1] Raj SR. The postural tachycardia syndrome (POTS): pathophysiology, diagnosis and management. Indian Pacing Electrophys J. 2006;6:84–99. [2] Low PA, Sandroni P, Joyner M, Shen W. Postural tachycardia syndrome (POTS). J Cardiovasc Electrophysiol. 2009;20:352– 358. [3] Thieben MJ, Sandroni P, Sletten DM, et al. Postural orthostatic tachycardia syndrome: the Mayo Clinic experience. Mayo Clinic Proc. 2007;82:308–313. [4] Benrud-Larson LM, Dewar MS, Sandroni P, Rummans TA, Haythornthwaite JA, Low PA. Quality of life in patients with postural tachycardia syndrome. Mayo Clinic Proc. 2002;77:531– 537. [5] Benarroch EE. Postural tachycardia syndrome: a heterogeneous and multifactorial disorder. Mayo Clinic Proc. 2012;87:1214– 1225. [6] Grubb BP. Postural tachycardia syndrome. Circulation. 2008;117:2814–2817. [7] Masuki S, Eisenach JH, Johnson CP, et al. Excessive heart rate response to orthostatic stress in postural tachycardia syndrome is not caused by anxiety. J Applied Physiol. 2007;102:896–903. [8] Benrud-Larson LM, Sandroni P, Haythornthwaite JA, Rummans TA, Low PA. Correlates of functional disability in patients with postural tachycardia syndrome: Preliminary cross-sectional findings. Health Psychol. 2003;22:643–648. [9] Kunik ME, Braun U, Stanley MA, et al. One session cognitive behavioral therapy for elderly patients with chronic obstructive pulmonary disease. Psychol Med. 2001;31:717–723. [10] Craske MG, Antony MM, Barlow DH. Mastering Your Fears and Phobias: Therapist Guide (2nd ed.). New York, NY: Oxford University Press; 2006. [11] Fang A, Sawyer AT, Asnaani A, Hofmann SG. Social mishap exposures for social anxiety disorder: an important treatment ingredient. Cogn Behav Pract. 2013;20:213–220. [12] Foa EB, Hembree EA, Rothbaum BO. Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences: A Therapist Guide. New York, NY: Oxford University Press; 2007. [13] Beck AT, Steer RA. Manual for the Beck Anxiety Inventory. San Antonio, TX: The Psychological Corporation; 1990. [14] Ware JE, Kosinski M, Keller S. SF-36 Physical and Mental Health Summary Scales: A User’s Manual. Boston, MA: The Health Institute; 1994. [15] Hayes SC, Strosahl K, Wilson KG. Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York, NY: Guilford Press; 1999. [16] Kazdin AE. Single-Case Research Designs: Methods for Clinical and Applied Settings (2nd ed.). New York, NY: Oxford University Press; 2011.

Symptom Discrimination and Habituation: A Case Study of Behavioral Treatment for Postural Orthostatic Tachycardia Syndrome (POTS).

Postural orthostatic tachycardia syndrome (POTS) is a multifaceted disorder of the autonomic nervous system that profoundly impacts physical functioni...
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