11. exposure therapy for anxiety disorders Flashcards
history of expo ther, overview of expo ther, typical course of ther, pros/cons
who developed exposure therapy?
joseph wolpe
what prompted the creation of exposure therapy?
wolpe wasn’t satisfied with current tx of PTSD, developed systematic desensitization
2 main contributions of wolpe
- reciprocal inhibition
- SUDS scale
what is reciprocal inhibition?
can’t have competing responses at same time
what is the SUDS, what is it used for?
subjective units of distress scale
0-100 scale of distress during exposure
how a fear develops?
2 things
neural stimulus paired w fear response
trauma/bad experience
what’s an indirect way that fear can be modeled?
through parental exposure
ex: parent is scared of dogs, child internalizes that dogs are dangerous
examples of benign events that can evoke fear responses
ex: after car accident
* cars
* location where accident happened
* people who were present
* etc
what is exposure therapy?
- therapy techniques used to teach clients to approach feared stimuli
- can be paired with relaxation techniques
- can be paired with preventions of compulsions/safety behaviours
what’s a safety behaviour?
behaviour used to cope from fear of initial stimulus
why should we prevent performance of safety behaviours?
client might attribute safety to the behaviour rather than reality
what are the two main goals of exposure therapy?
- teach client that anxiety leaves on its own
- help client learn corrective information about feared stimulus
exposure therapy
what are the 4 mechanisms of change?
- habituation
- extinction
- inhibitory learning
- increased self-efficacy
mechanisms of change
what’s a con of habituation?
not sustainable over time
mechanisms of change
explain extinction
- feared stimulus no longer paired with escape/avoidance behaviour
- stimulus may be paired with relaxation so that new association is learned
mechanisms of change
what is inhibitory learning?
client learns that feared outcomes don’t happen/v unlikely over repeated trials
mechanisms of change
how does increased self-efficacy work?
even if fear response isn’t completely gone, client learns that they can handle their own feelings
5 types of exposure GO!!!
- graded exposure
- systematic desensitization
- prolonged exposure
- flooding
- one-session
types of exposure
difference between graded exposure and systematic desensitization?
what’s an issue with systematic desensitization?
systematic desensitization is graded expoure but with relaxation techniques (deep breathing, etc)
* can’t be anxious + relaxed at the same time
* not everyone likes relaxing (ex: people with anxiety – it makes them hyperaware)
types of exposure
explain what prolonged exposure is and everything that comes with it
- PTSD – after 3 months
- repeatedly going through event in detail
- exposure to situations, objects, people that are reminders of event, but don’t pose a threat
- facilitate emotional processing of event (emotions)
types of exposure
flooding, talk about it – explain, rationale, cons
- starting at worst of the hierarchy
- why? can’t sustain intense fear for extended period of time, they’ll evnetually have to relax
- can backfire and traumatize again
types of exposure
one-session: what is it, what does it consist of, who’s the demographic?
- extended session (3hrs)
- teaching client, modelling, exposure, cognitive challenge (it’s kind of like an exposure therapy “class” - test their hypoethesis, challenging their cognition)
- works with adults (working with specific phobias)
- might not work as well for kids/teens
explain the paper on evidence for one-session tx for specific phobias in youth
- OST and education support tx (EST) superior to waitlist in terms of clinician rating and % of pts who were dx-free following tx but not behaviour approach tests BAT or self/parent-reports
- OST superior to EST for clinician ratings, % of dx-free pts, child rating of pre-BAT anx + tx satisf
- 6 month follow up: only superior on clinician ratings + % of dx-free pts
samples were US + Sweden lol
modes of delivery of exposure therapy
- in vivo
- imaginal
- VR
- interoceptive
- modelling
modes of delivery of exposure therapy
what’s in vivo exposure?
exposure to actual feared stimulus, or some approximation
can require field trips!
what’s a mode of delivery thats frequently used for PTSD, GAG, and phobias of uncommon stimuli?
imaginal
modes of delivery of exposure therapy
what’s interoceptive exposure?
what is it most often used for?
exposure to physical sensations
used mostly for panic disorder
learning that sx aren’t dangerous
modes of delivery of exposure therapy
what is modelling?
characteristics, etc
- you do the action
- used mostly as adjunt rather than primary mode of delivery
- show client that feared outcome is unlikely
- not always suitable (GAD, OCD – “you can do it and nothing bad will happen but if I do, something will go bad”)
typical course of exposure therapy
steps of early sessions (7)
- assessment of sx + interferences in daily life
- psychoeducation
- provide rationale for exposure
- introduce sx monitoring + SUDS
- build fear hierarchy
- plan exposure exercises, prevention rituals
- build rapport
typical course of exposure therapy
middle sessions (5)
- in session exposure
- homework
- SMART
- modify as needed
- periodically assess overall sx
typical course of exposure therapy: middle sessions
what does in-session exposure consist of? how can pt move up pyramid?
- therapist guided
- prevention of compulsions “let’s try”
- ask client SUDS
- can’t move up hierarchy until client can complete iten with little effort AND without engaging in compulsions
can jump up and down ladder as needed
typical course of exposure therapy: middle sessions
benefits of asking client to do homework
helps with generalizability to different stimuli + self efficacy (avoid associating therapist to safety)
typical course of exposure therapy
pros and cons of cognitive restructuring
- can help clients engage in therapy more readily
- some might use cog restr to neutralize anxiety during exposure
typical course of exposure therapy
late sessions
- generalization/maintenance
- relapse prevention
pros of exposure therapy
- high efficacy
- relatively brief (under 15 sessions)
cons of exposure therapy
- high dropout rate
- some therapists don’t like it
- several barriers to tx
cons of exp ther
what are some of the potential barriers to tx?
- noncompliance
- subtle avoidance
- family involvement
- comorbidities
