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BEHV7027 > 7) Interoceptive Exposure > Flashcards

7) Interoceptive Exposure Flashcards

1
Q

For which cases can you use interoceptive exposure?

A
  • Avoidance of internal sensations e.g., panic disorder
  • Avoidance of covert thoughts and images e.g., OCD
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2
Q

Explain how hyperventilation work.

A
  • Panic clients: breathe rapidly, breathe more heavily – they’re flooding their brains with oxygen
  • The thought is that they’re not getting enough air so they’re breathing more rapidly, and breathing more heavily – even though that’s not the case
  • Brain responds to both extremes in the same way
    o Low levels of oxygen: feel out of breath
    o High levels of oxygen: feel out of breath
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3
Q

What are some safety behaviours that clients may engage with to not think certain thoughts or experience certain behaviours

A
  • Alternative sensations (snap a rubber-band, pinch self, wet towel, ice-water on face)
  • Alternative cognitions (reading materials, joke-books, counting games, games on phone, sudoku)
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4
Q

Who came up with Interoceptive Exposure?

A
  • Goldstein and Chambless (1978): first to formally suggest that IE may be an effective way of reducing fear of physical sensations in panic disorder
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5
Q

Define high anxiety sensitivity

A

Elevated fear of arousal sensations

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6
Q

What is the objective of IE assessment

A

Identify sensations/thoughts/images that provoke anxiety in client

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7
Q

What are the 3 main clusters of panic sensations in Panic Disorder and identify sensations within each cluster? (3; 5; 3)

A

Heart cluster
* Palpitations, pumping HR, irregular HR
* Chest tightness
* Breathing problems

Head cluster
* Dizziness
* Derealisation
* Paresthesias = burning or prickling sensation that is usually felt in the hands, arms, legs, or feet
* Chest tightness
* Breathing problems

Abdominal = cluster most likely to lead to agoraphobia (terrified of having a bowel accident; embarrassing)
* Abdominal discomfort
* Nausea
* Vomiting
* Bowel problems

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8
Q

For the heart cluster of panic symptoms (3), what exposure tasks would you do?

A
  • Palpitations or irregular heart beat = aerobic exercise
  • Chest tightness = pressure on chest
  • Breathing problems = hyperventilation
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9
Q

What are the fear cognitions underlying the heart cluster of panic symptoms? (3)

A

Heart attack, cardiac arrest, stroke

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10
Q

For the head cluster of panic symptoms (5), what exposure tasks would you do? (3)

A
  • Spinning on chair = dizziness
  • Hyperventilation = derealisation, chest tightness, Paraesthesia
  • Breathing through straw = breathing problems,
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11
Q

What are the fear cognitions underlying the head cluster of panic symptoms? (3)

A
  • fainting
  • going crazy
  • losing control
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12
Q

For the abdominal cluster of panic symptoms (4), what exposure tasks would you do? (1)

A
  • Certain foods and drinks followed by progressive toilet delays
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13
Q

What are the fear cognitions underlying the abdominal symptoms of Panic/Agoraphobia? (1)

A

Bowel accident

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14
Q

What should be covered in the assessment before undertaking IE?

A
  • identify sensations/thoughts/images that provoke anxiety in client
  • ensure that there are no medical contraindications - consult/refer to a GP
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15
Q

What should therapist do once anxiety is trigger? (3)

A
  • Validity check: How similar is the feeling to panicky feelings in real life?
  • Severity check: How high was anxiety? Would it increase with prolonged exposure?
  • Cognitions check: Automatic thoughts and conditional beliefs (what if….)
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16
Q

What should be considered before provoking anxiety? (4)

A
  • Have a method for client to signal anxiety levels
  • Try to keep anxiety to tolerable levels (20-60)
  • Remember very brief exposure can trigger high levels of anxiety
  • Always do exposure in clinic first as a demo experience, before giving exposure task as homework
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17
Q

How should we prepare clients for IE? (5)

A
  • Explain rationale briefly in lay terms
  • Examine expectations of client - some anxiety is expected
  • Reassure client that they can terminate exposure if it becomes excessive
  • Prep client’s expecations - IE can trigger anxiety very quickly. Stop IE when it gets too much. BUT need to repeat - Exposure therapy often doesn’t work when it is too brief as it ends up reinforcing the anxiety and panic and makes it worse.
  • Won’t be waiting to repeat until SUDs go to 0 as it could take a day/week - need to do multiple repetitions within a single session of exposure
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18
Q

How should we conduct IE using principles of desensitisation? (6)

A
  • Graduated program
  • Duration of exposure: Often brief exposures (seconds, high SUDS are reached quickly) – but need to be repeated multiple times.
  • Prolonged exposure may be contraindicated - Be familiar with physiological effects
     E.g., Prolonged hyperventilation can cause fainting in rare instances
     Prolonged aerobic activity may be excessive for an unfit client
  • Use an appropriate coping strategy or just rest in the intervening period
  • Several exposure-relaxation/rest cycles are administered during the same session.
  • Number of cycles depend on client motivation and likely outcomes
     Can squeeze 6-12 cycles within each session.
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19
Q

What questions can therapists ask to facilitate reappraisal of negative beliefs? (4)

A
  • What is your appraisal of the event now?
  • What does this tell you about yourself?
    What does it tell you about what you can and cannot do?
    What does this tell you about your heart palpitations?
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20
Q

Outline some guidelines for IE. (8)
What is the best strategy?

A
  • Best strategy = keep SUDS within manageable limits at all times
  • Good range for beginners = 20-60
  • If more confident of controlling client’s anxiety = 20-80
  • Be collaborative. coping threshold vary between individuals and between therapy stages (lower levels initially) within same individual.
  • High levels of distress can lead to panic –> can have negative consequences on motivation, confidence
  • Don’t push the anxiety too high for too long.
  • IE is typically conducted under therapist supervision initially before these tasks are prescribed for homework.
  • Extinction/habituation: Typically quicker than situational exposure therapy (sometimes within 2- 3 weeks).
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21
Q

What occurs during the debriefing and reappraisal stage of IE? (3)

A
  • Examine client’s appraisal of events
  • Enhance awareness of how anxiety is triggered and maintained. Excellent opportunity for psychoeducation.
  • Excellent opportunity to target key beliefs that underlie client’s anxiety and avoidance
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22
Q

Why should panic attacks be avoided (especially in clinics)? (2;1)

A
  • False alarms can have conditioning properties
  • Panic attacks can be very demoralising for clients
  • Panic attacks can form new links for conditioning – so try to avoid having panics attacks in clinic
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23
Q

What are some common beliefs help by clients with PD? (6)

A
  • This sensation is dangerous – NOW
  • This sensation if not controlled now, will become dangerous SOON
  • Emotional reasoning: Because I feel so bad, it must be dangerous
  • Panic attacks may be harmful, why take the risk
  • The negative state will last forever
  • I’ll be unable to cope. I’ll deteriorate rapidly
24
Q

What are some types of simulations used for exposure programs? (1;3;1;1)

A
  • Imaginal (Systematic Desensitisation)
  • Specially designed simulations
    o Flight-simulation
    o Air-towers for sky-diving
    o Toast-masters
  • Virtual reality (need specialised equipment)
  • Role plays
    o Small groups (e.g., social phobia)
25
Q

What are some advantages to doing individual sessions for Social Phobia? (2)

A
  • Tailored to individual
  • less distressing to client initially
26
Q

What are some advantages to doing group sessions for Social Phobia? (10)

A
  • Enables simulation exercises which can be a powerful intervention
  • Economical - although getting adequate numbers to run a group may sometimes by difficult
  • Members can make lasting friendships if group runs its course
  • Vicarious learning: coping models vs fearless model
  • Learning through helping others
  • Enhances motivation
     Improvement in others; recovered persons revisiting gp
     Group commitment to change
  • Sense of being understood for the first time
     effect of this on appraisal of problem
  • Availability of role-play options
  • Use of group members to challenge distorted thinking
  • Fostering independence
27
Q

Describe group sessions for Social Phobia CBT programs. (3)

A
  • Closed format usually preferred
  • Homogenous groups are typical
  • Basic commitment & communication
28
Q

When are group formats for CBT social phobia not ideal for? (3)

A

 PD clusters a & b
 Angry & overcritical persons
 Very severe cases of social anxiety may require individual therapy first

29
Q

Describe Heimber’s CBT group programme for Social Phobia.
How many therapist, clients?
Age/gender/functioning?
Therapy stages? (4)

A
  • 2 therapists
  • 6 clients
  • Age/gender/functioning: at least 2 similar

Therapy stages
* Assessment and preliminary interview
* Acute treatment phase: 12 X 2.5 hrs, weekly
* Intensive continuation phase: 12 X 2.5 hrs, weekly
* Maintenance phase: 8 X 2.5 hrs, fortnightly, monthly

30
Q

What are some issues related to exposure programs in social phobia? (2;1

A
  • Unlike exposure situations in other phobias, exposure tasks are less controllable in terms of
    o distress levels (less predictable because they depend upon others’ responses)
    o durations are dependent on others so not controllable; often limited to brief interactions
  • Several programs use simulated exposure
31
Q

Describe how exposure simulation would look like and when it would be introduced into the sessions?

A
  • selection of role-play by negotiations
  • SUDs rating ~ 50
  • as early as 3rd session
32
Q

What would the role-plays in exposure simulations entail? (5)

A
  • As real as possible including characters, furniture arrangements
  • Behaviour of others in interactions discussed and role-played
  • Physical sensations may be provoked during exposure
  • Use additional props/persons if the role play demands this.
  • Speeches are sometimes included as exposure therapy
33
Q

What are advantages of exposure simulation (group)? (7)

A
  • Easy access
  • Easy to organise
  • Controllable by instructions
  • Observable exercises so less biased than S’s reports
  • Group members’ responses can be a powerful impact on changing processing biases and reducing performance disparagement
  • Enhances compliance
  • Facilitates in-vivo exposure in real world situations
34
Q

What model is utilised in the treatment of OCD?

A

The Stepped Care Model

35
Q

What are the principles for treating obsessional thoughts in OCD?

A
  • The same principles governing overt behaviours are used
  • Combine exposure and response prevention (ERP)
  • Principles of effective desensitisation must be followed as far as feasible e.g., duration, regularity, repetition, maintain SUDs in moderate range
36
Q

What is the procedure for treating obsessional thoughts in OCD? (3)

A
  • Client exposed to obsessional thoughts/images AND instructed to prevent neutralising behaviour
  • Exposure can be by: loop-tape, imagery (via instructions to client), repeated writing down of obsessive thoughts
  • if there are multiple thoughts, you can commence with thoughts lower on the hierarchy
37
Q

What are some challenges in assessment of CBT of OCD?

A
  • may be difficult to identify/discriminate obsessions from compulsions
  • may be difficult to identify ALL obsessions/compulsions
38
Q

Define obsessions (2)

A
  • Anxiogenic
  • Push increased anxiety
39
Q

Define compulsions (2)

A
  • Anxiolytic
  • Decrease anxiety
40
Q

What are some challenges when conducting CBT interventions of OCD? (4)

A
  • Higher levels of defensiveness/secrecy and distress
  • more subtle avoidance behaviours so challenges to enforce RP
  • Ethical and religious values may interfere with initial readiness to comply with intervention
  • Treatment may take longer and often involves others (family, other professionals)
41
Q

Should we use cognitive therapy when ERP works for OCD? Why/why not? (4)

A

Yes, should use CT.

  • Cient engagement in exposure requires psychoeducation
  • Need to discriminate between avoidance of contamination that is “healthy” and “exceissive”
  • Need to identify and re-appraise unhelpful beliefs concerning symptoms and maintenance.
    o Especially true for mental rituals. For e.g., all experience “bad or harmful” thoughts/images. Clients with OCD attribute excessive responsibility/guilt to them.
  • Thought-action fusion = relates to belief in power and influence of mental phenomena
    o Having an unwanted thought is as bad/evil/dangerous as an intention, plan, course of action
    o Thinking things can make them come true
42
Q

Is it common for OCD clients to be prescribed medication? Why/why not? (7)

A
  • Yes - usually high doses of SSRIs
  • Pharmacotherpay is an evidece-based treatment for OCD
  • Many clients receive both CBT and medication
  • Therapists need to be both be scientist-practitioners and ethical practitioners, so use effective treatments
  • Benzodiazepines are not good - they sit on the neurons like a glove, so they prevent them from firing.
    o Defeats the whole purpose of exposure therapy – ET wants the neurons to fire
  • Alcohol also does not work with ET – also sit on the neurons like a glove
43
Q

What medications/substances should we be aware of when administering ET?

A
44
Q

What medications/substances should we be aware of when administering ET?

A
  • Benzodiazepines are not good - they sit on the neurons like a glove, so they prevent them from firing.
    o Defeats the whole purpose of exposure therapy – ET wants the neurons to fire
    o Turn off the anxiety - habituation requires some anxiety to work
  • Alcohol also does not work with ET – also sit on the neurons like a glove
45
Q

What body response gets triggered for Blood Injury Phobia? Describe what happens.

A
  • Freeze response
  • HR drops, system shuts down etc.
  • Blood gets withdrawn from the brain - then they faint
  • Has strong genetic disposition
46
Q

How does the freeze response manifest in animals (2) and in humans (5)? Describe what it does and why it happens.

A
  • Common in animals
    o Response to predators
    o Can increase/decrease survival chances
  • In humans:
    o Altered state of reality
    o Time slows down
    o Feel numb; immobility
    o Calm outside; not inside
    o Part of dissociative disorders
  • Form of behavioural inhibition in response to threat
  • Occurs in large number of animals
  • Different from fight-flight response
  • Hardwired individual differences in how they respond to threat. Difficult to control
  • Associated with parasympathetic deceleration of HR (bradycardia), lower BP, fainting
47
Q

What are some treatment implications for Blood-injury-injection phobia given the freeze response? (5)

A
  • Relaxation techniques to drop ANS activity are not indicated
  • Fainting is a real possibility
  • Interventions need to differentiate between:
    o Procedures to decrease anticipatory anxiety, distress about symptoms and problem
    o Procedures to prevent fainting
  • Exposure by imaginal and in-vivo procedures
  • Need to teach Tension-induction (in-lieu of tension reduction) to use during exposure exercises.
     E.g., tense muscles, increase activity
48
Q

Why whould we teach tension-induction for Blood-Injury-Injection Phobia? (1)
What should we do when doing tension-induction? (2)

A
  • Blood gets withdrawn from the brain (because of freeze response - HR, BP drop etc) so clients faint
  • Instead, get clients to tense muscles, so that blood doesn’t drawin from their head, and blood is moving around
  • OR get clients to increase activity - facilitates blood supply to head & peripheral muscles
49
Q

Identify 5 best practice guidelines to conduct exposure therapies

A
  • 1) use scientific principles of effective desensitisation
  • 2) manage compliance and maintain/enhance motivation
  • 3) supervise exposure programs if necessary
  • 4) address common problems in exposure therapy
  • 5) effective use of exposure tasks as homework
50
Q

Describe and outline the scientific principles of effective desensitisation. (17)

A
  • Use science-based principles i.e., using empirically-supported procedures, conduct ET consistent with empirically and theoretically supported protocols
  • Prolonged exposure is better than brief exposure - More exposure, quicker the outcome, although the client’s capacity to tolerate exposure is a critical mediating factor
  • If exposure is very brief, repeat it several times, preferably within the same session (e.g., interoceptive exposure; social anxiety)
  • Regularity: More regular, better outcome (daily or several times weeks rather than once a week or month)
  • In-vivo exposure is usually better than imaginal exposure (when both modalities are accessible and feasible)
  • Graduated exposure is usually preferred to “Flooding therapies” (esp. when drop out rates are considered)
  • Terminate exposure when anxiety is low rather than high (to counter appraisal of failure)
  • Identify and phase out safety behaviours during the exposure program – informed by knowledge of mechanisms involved (e.g., conditioning/cognitive)
  • Combination of in-vivo and imaginal exposure may be required in certain conditions (e.g., for mental rituals in OCD)
  • In certain situations, exposure must be combined with response prevention to produce desired effects (e.g., OCD)
  • Exposure must be tailored to fit the motivational status of clients.
  • Intervene to down-regulate anxiety if levels are extremely high (e.g., client on verge of panic) as exposure can lead to sensitisation and panic attacks have classical conditioning propensities
  • Some medications (benzos) & alcohol interfere with learning so should be avoided during exposure
  • Safety cues/supports must be phased out before/during the programme
  • Test generalisation (practice in different situations/circumstances) before exposure is terminated.
  • Use supervision as necessary (e.g., to overcome reluctance to tackle items high on hierarchy)
  • Facilitate appropriate cognitive (re)appraisals as necessary) towards feared stimuli and towards self (efficacy)
51
Q

What does assessment of motivation include for ET? (2)

A
  • Consideration of current motivational status and expectations
  • Ability to maintenance motivation over the course of the exposure program (Client should not run out of steam before completion)
52
Q

When should we intervene to down-regulate anxiety during ET? (1)

Why? (2)

A

When?
* If levels are extremely high (e.g., client on verge of panic)

Why?
* Exposure can lead to sensitisation
* Panic attacks have classical conditioning propensities

53
Q

What contextual factors does effective outcomes of ET depend on? (4; 1; 3)

A
  • Client = readiness to tolerate exposure, stage of therapy, expected duration of exposure, nature of problem
  • Disorder: Sometimes you have little control over SUDs level (e.g., flashbacks; OCD mental obsessions)
  • Therapist: Therapist’s experience, ability to regulate client’s/one’s own anxiety
54
Q

What is a good SUDs level for ET?

A
  • A mean of 40-60 SUDs (averaged across session) works well for most clients
  • Brief elevations over this threshold are likely and are not a problem (use regulation of affect through appropriate instructions)
55
Q

What sort of ET can you expect from beginner therapists?

A

Typically overly cautious and therefore less efficient. Slower is not necessarily the best or most efficient (e.g., slow and prolonged surgery!).

BEHV7027 (15 decks)

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