Clinical Case Studies

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Cognitive-Behavioral Treatment of Generalized Anxiety: Disorder and Vomiting

Phobia in an Elementary-Age Child
Sarah W. Whitton, James K. Luiselli and Deidre L. Donaldson
Clinical Case Studies 2006; 5; 477
DOI: 10.1177/1534650105284476

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http://ccs.sagepub.com/cgi/content/abstract/5/6/477

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CLINICAL
10.1177/1534650105284476
Whitton et al.
CASE
/ COGNITIVE-BEHAVIORAL
STUDIES / December 2006TREATMENT

Cognitive-Behavioral Treatment
of Generalized Anxiety
Disorder and Vomiting Phobia in an Elementary-Age Child

SARAH W. WHITTON
JAMES K. LUISELLI
DEIDRE L. DONALDSON
The May Institute

Abstract: This case report describes cognitive-behavioral treatment (CBT) with a 7-year-
old girl diagnosed with generalized anxiety disorder (GAD) and specific phobia (fear of
vomiting). Developmental history was significant for excessive worry, pervasive anxiety,
and complaints of stomach discomfort. Her fear of vomiting had resulted in eating inhibi-
tion and weight loss. Treatment focused on teaching behavioral skills to reduce anxiety (dis-
traction, relaxation), correcting misattributions about physiological sensations, reducing
anxiety-inducing self-statements, and eliminating reinforcement of somatic symptoms in
the family system. Self-report on the State-Trait Anxiety Inventory for Children (STAIC)
before and following CBT documented clinically significant changes in anxiety. At termi-
nation, the client no longer met diagnostic criteria for GAD or specific phobia. Over the
course of treatment, complaints of stomachaches were significantly reduced, and the client
demonstrated weight gain. A 5-month posttreatment evaluation revealed that clinical
improvement was maintained.

Keywords: generalized anxiety disorder; specific phobia; vomiting; cognitive-behavioral

treatment

1 THEORETICAL AND RESEARCH BASIS

Anxiety is one of the most common forms of psychological distress in children and
adolescents, reported by 10% to 20% of the school-age population (Garralda & Bailey,
1986; Kashani, Orvaschel, Rosenberg, & Reid, 1989; Pine, Cohen, Gurley, Brook, &
Ma, 1998; Shaffer et al., 1996). Anxiety disorders in childhood and adolescence are fre-
quently associated with impaired academic and social functioning (e.g., Chansky &

AUTHORS NOTE: Correspondence should be addressed to Sarah W. Whitton, Judge Baker Childrens Center, 53
Parker Hill Avenue, Boston, MA 02120; e-mail: swhitton@jbcc.harvard.edu or James K. Luiselli, The May Institute, One
Commerce Way, Norwood, MA 02062; e-mail: jluiselli@mayinstitute.org.
CLINICAL CASE STUDIES, Vol. 5 No. 6, December 2006 477-487
DOI: 10.1177/1534650105284476
2006 Sage Publications

477

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478 CLINICAL CASE STUDIES / December 2006

Kendall, 1997; Dweck & Wortman, 1982) and are risk factors for later substance abuse
(Rohde, Lewinsohn, & Seeley, 1996) and adult depressive and anxiety disorders (Pine
et al., 1998).
Cognitive-behavioral treatment (CBT) for childhood anxiety disorders has
received growing empirical support (Chambless & Ollendick, 2001), documented in
several randomized clinical trials (Barrett, Dadds, & Rapee, 1996; Kendall, 1994; Kend-
all et al., 1997). Importantly, gains achieved with CBT appear to be maintained follow-
ing treatment (Barrett, Duffy, Dadds, & Rapee, 2001; Kendall & Southam-Gerow,
1996). In addition, parent involvement can enhance the effectiveness of CBT for child-
hood anxiety disorders (Barrett et al., 1996).
As defined in the Diagnostic and Statistical Manual of Mental DisordersIV
(DSM-IV; American Psychiatric Association [APA], 1994), generalized anxiety disorder
(GAD) is characterized by excessive anxiety and worry that is difficult to control and is
accompanied by motor restlessness, poor concentration, fatigue, disturbed sleep, and
muscle tension. Among children, GAD frequently concerns worry about performance
at school, punctuality, and catastrophic events. Relative to empirically supported psy-
chological interventions, CBT is the only well-established and efficacious methodology
for children with GAD (Chambless & Ollendick, 2001). However, application of CBT
in clinical settings to treat children who are anxious often is complicated because fea-
tures of individual cases may differ substantively from the homogeneous, noncomorbid
samples studied in randomized clinical trials (Weisz, Donenberg, Han, & Weiss, 1995).
Many children with anxiety disorders, including GAD, have comorbid diagnoses and
other clinical problems that demand professional attention (APA, 1994). In such cases,
treatment may have to be more broadly focused than is typical of CBT as conducted in
research trials (Weisz et al., 1995). Accordingly, it would be valuable to evaluate how
comorbidity potentially moderates the impact of CBT and to inform clinicians about
how to treat co-occurring disorders. In addition, research on efficacy of CBT for child
anxiety disorders has focused on the age range of 9 to 13 years (Kendall, 1994; Kendall
et al., 1997). One pertinent question is whether therapeutic effectiveness extends to chil-
dren who are younger. The current case study describes CBT with an elementary-age
child who had GAD and a vomiting phobia. We incorporated several empirical mea-
sures to document the course of treatment and evaluated outcome using a standardized,
self-report assessment of anxiety and maternal ratings of phobia-related somatic
complaints.

2 CASE INTRODUCTION

Lucy (a fictitious name) was a 7-year-old female enrolled as a second-grade student

at a local elementary school at the time of treatment. She lived at home with her biologi-
cal parents and older brother. Lucy was referred to a behavioral health services clinic by

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 Whitton et al. / COGNITIVE-BEHAVIORAL TREATMENT 479

her primary care physician because he suspected she had an anxiety disorder. Based on
her mothers report, Lucy had many worries, became anxious in nonthreatening situa-
tions, and voiced somatic discomfort about having stomachaches.

3 PRESENTING COMPLAINTS

At intake, Lucy presented with worry and anxiety, especially about new people and
events, which tended to resolve after repeated exposure and familiarity. At the start of
each school year, she demonstrated distress, emotional outbursts, and attempts to avoid
school. Lucy also complained daily of stomachaches, which at times were associated
with her feeling nervous. She reported a fear of vomiting, particularly when con-
fronted with events such as a peer who vomited near her or hearing a discussion about a
bug going around. Perhaps in response to the apprehension about vomiting, Lucy had
periods of restricted food intake, leading to weight loss and health concerns.

4 HISTORY

Family history was significant for anxiety. Lucys father reported a lifelong anxiety
disorder, recently successfully treated with pharmacotherapy. Her developmental his-
tory was within normal limits, with no major illnesses, although she always had an anx-
ious and/or inhibited temperament. At ages 4 and 6 years, she experienced two separate
episodes of vomiting associated with illness. Both episodes were followed by periods of
restricted eating (lasting 1 to 6 months) and weight loss during which time Lucy
expressed the belief that If I dont eat, I wont throw up. Subsequently, she complained
of stomachaches at least daily. Frequent medical evaluations ruled out a physical basis
for stomachaches.

5 ASSESSMENT

The first author conducted diagnostic interviews with Lucy and her mother,
obtaining developmental, medical, and educational histories, as well as confirming clin-
ical presentation. Consistent with her excessive worry across topics, difficulty controlling
the worry, associated muscle tension, and sleep disturbance, Lucy met DSM-IV (APA,
2004) diagnostic criteria for GAD (300.02). She also qualified for a diagnosis of specific
phobia (300.29) given her persistent (approximately 3-year) fear of vomiting that was
excessive, cued by anticipation of having to vomit or exposure to stimuli related to vomit-
ing, endured with distress, and a cause of impaired school and social functioning.

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480 CLINICAL CASE STUDIES / December 2006

Several measures were recorded during a 2-week baseline phase and a 14-week
course of treatment. Each day, Lucys mother documented frequency of stomachache
complaints and the duration of each episode (estimated as total minutes). Maternal rat-
ings of the severity of each stomachache, based on behavioral indices such as perceived
pain, crying, and clinging, were made on a scale from 0 (no signs of distress) to 10 (maxi-
mum signs of distress).
Lucy completed the Trait Anxiety subscale of the State-Trait Anxiety Inventory for
Children (STAIC-T; Spielberger, 1973), 1 week before initiating treatment (baseline), 1
week after terminating treatment, and at 5-month follow-up. The Trait Anxiety subscale
contains 20 self-report items that assess general anxiety proneness. We note that
although the STAIC-T has demonstrated construct validity and reliability when used
with second graders (Papay & Spielberger, 1986) such as Lucy, the lowest published age
norms are for fourth-grade students.
The final dependent measure was Lucys body weight. Nursing staff at the clinic
recorded her weight on a calibrated scale at baseline and at approximately 3-week inter-
vals during and following treatment.

6 CASE CONCEPTUALIZATION

As noted previously, Lucys history was significant for early-onset anxiety and worry
that was evident in multiple contexts. Her profile was complicated further by stomach
discomfort, which at times was linked to anxiety but other times with eating or the per-
ception of being full. We conceptualized the relationship between her somatic symp-
toms and anxiety as bidirectional, with anxiety triggering stomachaches and resulting
from her irrational thoughts and beliefs about stomach sensations. The aversive experi-
ence of vomiting episodes was viewed as an unconditioned stimulus, setting the occa-
sion for physiological hypervigilance (e.g., attending cautiously to any stomach sensa-
tions), misattribution (e.g., Feeling full means Im going to throw up), and avoidance
(e.g., eating inhibition). Certain situations were highly correlated with anxiety about
vomiting, such as eating a meal or being close to a child who was ill. We judged that CBT
would be a potentially effective treatment for Lucy by teaching her what to think and do
when she experienced worry, anxiety, and stomachaches.

7 COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS

Lucy attended 14 weekly to biweekly sessions over 20 weeks with the first author as
primary therapist. Each session began by meeting briefly with Lucys mother and review-
ing behavioral measures recorded during the preceding week, followed by a discussion
about progress and future plans. The remainder of each session was devoted to individ-

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 Whitton et al. / COGNITIVE-BEHAVIORAL TREATMENT 481

ual therapy with Lucy. Her treatment included several components that were imple-
mented sequentially across three phases. The basis for changing phases was the thera-
pists judgment that Lucy understood the material covered in earlier sessions and was
using skills properly. Typically, sessions consisted of therapist-directed demonstration,
rehearsal, performance feedback, and clarification. At the end of each session, Lucy
informed her mother about what she had learned and what skills she should practice in
the upcoming week. The therapist used praise to reinforce Lucys compliance with
homework assignments, which consisted of practicing skills learned in the prior session.
In Phase 1, treatment comprised psychoeducation about anxiety. Lucy was taught
that although fear is a useful emotion because it helps us avoid real dangers, she was hav-
ing false alarms and, as a result, felt scared or worried without reason. She was taught to
accurately recognize and label physiological signs of anxiety. Finally, Lucy and her
mother were educated about the typical course of anxiety; the therapist used art and met-
aphor (anxiety grows like a snowball) to introduce how stopping anxiety early would
prevent it from building and causing distress.
Sessions in Phase 2 featured training in behavioral coping skills, including distrac-
tion and relaxation strategies. Lucy was taught to employ distraction by engaging in an
enjoyable activity in response to feelings of anxiety or fears of vomiting. The therapist
also taught her relaxation strategies, including simple breathing exercises and abbrevi-
ated progressive muscle relaxation, as techniques she could use when feeling worried or
experiencing a stomachache. Effort was made to facilitate application of these skills out-
side of sessions by creating plans that defined how she should respond to likely stressors
in the coming week.
Lucys parents were also taught behavioral strategies to help reduce Lucys anxiety-
related and stomachache-related distress. They were trained in active ignoring of Lucys
maladaptive behaviors (e.g., complaining of stomach pain, clinging to parents when
worried) and were helped to identify their own reactions that might reinforce the behav-
iors, such as talking at length with Lucy about the discomfort or soothing her. The
therapist then guided them in creating an alternative plan for responding to Lucys com-
plaints with simple prompts to use the coping strategies she had learned in therapy fol-
lowed by active ignoring. In addition, to avoid inadvertent reinforcement of stomach-
aches at bedtime by attention from her father (who often talked with or read to Lucy at
night if she was sick), periods of father-daughter time were scheduled at a set time each
evening, so that they were not contingent on Lucys reports of distress.
Phase 3 treatment emphasized cognitive coping strategies, including correcting
misinterpretations of bodily sensations, challenging unrealistic automatic thoughts, and
employing positive counterthoughts to replace her anxiety-provoking self-talk. Although
treatment progress was evident by this phase, Lucy continued to interpret normal stom-
ach sensations as painful and as signs that she would soon vomit, which frequently led to
fear and distress. To correct Lucys misinterpretation of normal stomach sensations, the
therapist helped Lucy create more accurate labels for her stomach feeling full,

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482 CLINICAL CASE STUDIES / December 2006

Baseline Treatment Post

20
Frequency of Stomachaches and Average Severity Rating (0-10)

18

Frequency
16
Phase II

14
Phase I
12

10

6
Phase III
4
Severity

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 40
Weeks

Figure 1. Frequency and Average Severity Rating of Stomachaches Each Week

empty, nervous, and so on. To make this cognitive treatment component develop-
mentally appropriate for her young age, artwork was used to represent each label and
parents were assigned to help her identify these sensations correctly at home. Next, the
therapist created a metaphor Lucy could use for challenging her negative and unrealis-
tic anxiety-producing thoughts. Specifically, Lucy was taught to be a detective finding
clues to solve the mystery: Is this worth worrying about? For example, in response to
worried thoughts that she might vomit because she felt full at a meal, Lucy would ask
herself, Have I ever thrown up before because I was full? Finally, she was taught to
replace unrealistic anxiety-provoking thoughts with positive, calming remarks such as
Im fine and I can deal with this.
The therapist also introduced graduated, imagined exposure during Phase 3 by
creating a fear-worry hierarchy. With direction, Lucy generated anxiety-provoking situa-
tions that would be easy, medium, and challenging for her to confront. These situ-
ations were specific to her fear of vomiting (e.g., imagining vomit coming up my
throat) and generalized contexts (e.g., singing at a recital). During sessions, Lucy imag-
ined exposure to the continuum of anxiety-provoking situations and was coached to
employ coping strategies to reduce her level of distress.
Lucys treatment progress is documented in Figures 1 and 2. Frequency of stom-
achaches (Figure 1) ranged from 18 to 20 each week at baseline but decreased steadily in
response to treatment, with only two incidents reported during the final month of ther-
apy sessions (Weeks 17 through 20). Figure 1 also shows that the severity of stomach-

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 Whitton et al. / COGNITIVE-BEHAVIORAL TREATMENT 483

Baseline Treatment Post

600

500
Duration (Minutes) of Stomachaches

400 Phase II

300

200

Phase I

100
Phase III

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 40
Weeks

Figure 2. Duration (Minutes) of Stomachaches Each Week

aches decreased contemporaneously with the reduction in frequency. The average

maternal rating of stomachache intensity was between 5.0 and 5.1 in the baseline phase
and 1 or less by the end of treatment. Duration of stomachaches, depicted in Figure 2,
exceeded 500 minutes on average each week at baseline. With treatment, duration
decreased progressively, excepting an increase recorded at Week 8, apparently caused by
anticipatory anxiety Lucy experienced for several hours preceding her birthday party. At
the end of treatment, she had less than 10 minutes of stomachaches each week.
Baseline and posttreatment percentile rankings on the STAIC-T indicated a signif-
icant decrease in self-reported anxiety symptoms. Lucy reported experiencing more anx-
iety than 34% of females before treatment, and 8% at posttreatment. At the last treatment
session, her mother indicated that Lucy was less anxious in a variety of situations. For
example, she explained how Lucy no longer expressed worry about being left with a
babysitteran event that consistently provoked significant anxiety and distress in the
past.
Lucys weight at the 1st week of the baseline phase was 41 pounds. At her final treat-
ment session, she weighed 43 pounds, indicating an increase of approximately 2 pounds.
Nursing staff indicated that this rate of weight gain was within normal limits for Lucys
age. Although we do not have objective measurement of Lucys food consumption, her
mother reported that as treatment progressed, Lucy began eating larger portions of food
at all meals and no longer complained about being full or being scared of vomiting
when directed to eat her meal.

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484 CLINICAL CASE STUDIES / December 2006

8 COMPLICATING FACTORS

Lucy and her mother were motivated to seek treatment, attended sessions as sched-
uled, and did not encounter major complications. However, Lucys young age made it
difficult for her to grasp self-recording procedures. For that reason, we relied on her
mother to document the frequency, severity, and duration of stomachache complaints.
We also were concerned that having Lucy record stomachache data might increase her
undesirable hypervigilance of bodily sensations, again endorsing a decision to rely on
maternal report. The only other complication was occasional lapses in weekly data col-
lection, at Week 3 of the baseline phase, and 2 weeks during Phase 3 of treatment that
coincided with winter holidays.

9 FOLLOW-UP

Follow-up measures were taken 20 weeks (just under 5 months) posttreatment.

Lucys weight had increased to 47 pounds, representing an increase of 5 pounds over
approximately 5 months, which exceeds age-normative expectations for weight gain.
According to her mother, she was eating like a pig and showing significantly more
energy at home and school. Stomachache frequency data that were recorded for 3 weeks
documented only two incidents (M = .66 per week), lasting less than 2 minutes on aver-
age, each of them with a 1 (mild) severity rating. Lucys self-report at follow-up was that
she felt happy because she did not have stomachaches all the time. This appraisal was
confirmed by her mother who stated, Stomachaches are simply not a problem any-
more. The decrease in Lucys self-reported anxiety immediately after treatment was
maintained at follow-up, when her score on the STAIC-T was again at the eighth
percentile.

10 TREATMENT IMPLICATIONS OF THE CASE

One conclusion from the current case study evaluation is that CBT can be an
effective treatment for GAD in children younger than age 9 years, and those presenting
with psychiatric comorbidity. Lucys self-report of anxiety decreased appreciably from
baseline to posttreatment, and at termination she no longer met diagnostic criteria for
GAD or specific phobia. Her anxiety-precipitated stomachaches were significantly
reduced, as demonstrated by maternal ratings of frequency, severity, and duration. These
gains were maintained 5 months posttreatment. Lucys increased weight from baseline
to follow-up was another positive change. The combination of parent documentation,
self-report, clinician ratings (diagnostic categorization), and objective measurement
(body weight) strengthens the interpretation that CBT was responsible for Lucys
clinical improvement.

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 Whitton et al. / COGNITIVE-BEHAVIORAL TREATMENT 485

Treatment with Lucy included individualized therapy, parent consultation, devel-

opmentally appropriate homework assignments, and data-based monitoring. Through
treatment, Lucy learned how to counter anxiety using behavioral techniques (distrac-
tion, relaxation) and cognitive strategies (challenging unrealistic anxiety-producing
thoughts and beliefs, using calming self-talk). She employed these skills in response to
anxiety associated uniquely to fear of vomiting and anxiety that reflected more pervasive
worry and apprehension.
As a case study, clinical outcome cannot be attributed conclusively to treatment.
The absence of data during the 3rd week of the baseline phase makes it difficult to deter-
mine whether the decrease in stomachache frequency and duration from Week 1 to
Week 2 would have continued without therapeutic intervention. The quasi-experimental
design also did not include withdrawal and replication of treatment as a control for inter-
nal validity. Despite these limitations, the clinical improvements that co-occurred with
treatment were rapid and were observed across reporters and across measures. In addi-
tion, follow-up results obtained with Lucy suggest that the immediate benefit of CBT for
GAD and specific phobia can be maintained following active treatment. In the current
case, this positive outcome was noteworthy given the relatively brief course of treatment.

11 RECOMMENDATIONS TO CLINICIANS AND STUDENTS

CBT for young children with GAD and related anxiety disorders should consider
techniques consistent with developmental level (cf. Albano, Miller, Zarate, Cote, &
Barlow, 1997). As described in this case, the therapist employed artwork, simple meta-
phor, gamelike exercises (e.g., detective thinking), and frequent demonstration to
impart information to Lucy, sustain her motivation, and assess skill acquisition. Where a
coexisting disorder such as vomiting phobia also is the focus of treatment, CBT with a
young child should emphasize techniques that are not complicated and can be general-
ized effectively to natural settings. We saw with Lucy, for example, that she found appeal-
ing the relabeling of stomachache sensations and distracting herself during high-anxiety
circumstances. Clearly, selection of techniques by a therapist should be individualized
to the unique presentation of each child.
This case also illustrates the importance of parent involvement in the treatment of
childhood anxiety disorders (Barrett et al., 1996). Meeting with Lucys mother before
each session enabled the therapist to review data from the preceding week, discuss prog-
ress, and problem solve any difficulties the family encountered in implementing the
coping strategies at home. End-of-session parent meetings allowed Lucys mother to sup-
port and reinforce her daughters practice of coping skills between sessions and to learn
parenting strategies to help reduce nondesired behaviors (e.g., active ignoring). Lucys
significant improvement over the course of a treatment that included these aspects of
parent consultation preliminarily suggests that when working with parents, it is impor-

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486 CLINICAL CASE STUDIES / December 2006

tant to involve them in data collection, supporting the completion of homework, and
the translation of skills learned in therapy to real-life situations.
A final recommendation is that professionals incorporate practical methods of
empirical efficacy evaluation. The maternal ratings of stomachaches, Lucys self-report,
and measurement of body weight provided objective support for her treatment and an
index for data-based decision making by the therapist. Certainly, ones approach to eval-
uation must be reasonable, allowing clients and significant others to record data effi-
ciently, while being sensitive to meaningful clinical change. Apropos to the current case,
these objectives can be realized by including repeated assessment on standardized
instruments, combined with individually tailored recording of symptom-reflective
target behaviors.

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Sarah W. Whitton, PhD, is currently a postdoctoral fellow at the Judge Baker Childrens Center, Harvard
Medical School, Boston. She completed the current clinical case study during her clinical internship at The
May Institute 2003-2004. Her interests include the interface between family functioning and the mental
health of individual family members, and cognitive behavior therapy with children.

James K. Luiselli, EdD, ABPP, BCBA, is senior vice president of Applied Research, Clinical Training, and
Peer Review and director of the Predoctoral Internship Program in Clinical Psychology, The May Institute,
Norwood, MA. His interests include behavior therapy, health-threatening behaviors, and the integration of
research and clinical practice.

Deidre L. Donaldson, PhD, is director of Pediatric Psychology Services, The May Institute, Norwood, MA.
Her interests include pediatric behavioral medicine, enhancement of childrens coping skills, and adoles-
cent suicide.

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