Exposure Therapy Flashcards
What is Exposure Therapy (ET)?
Part of Cognitive Behavior Therapy
Goals of Exposure Therapy
Exposing people to fear evoking stimuli
Learn that anxiety will naturally go down (habituation
Learn that the feared outcome does not occur
Learn that even if this will occur, they can handle it
ET isBased on classical conditioning
Conditioned Stimulus -> Unconditioned stimulus -> Conditioned Response
Habituation
Conditioned Stimulus -> X Unconditioned Stimulus -> Conditioned Response
Emotional processing theory
Inhibitory learning theory
(Bouton, 1993; Craske et al., 2014; Craske , 2015)
Instead of unlearning conditioned response one “builds”a new pathway from conditioned stimulus directly to no unconditioned stimulus (dog = no harm)
Types of Exposure
Exposure in vivo
Imaginal exposure (“in vitro”)
Introceptive exposure
Virtual reality exposure
Flooding
Inhibitory learing theory as opposed to emotional processing theory from ;
(Craske, M. (2015). Optimizing Exposure Therapy for Anxiety Disorders: An Inhibitory Learning and Inhibitory Regulation Approach. Verhaltenstherapie, 25(2), 134–143. doi:10.1159/000381574)
” Within a Pavlovian conditioning approach, the inhibitory learning models mean that the origi-nal CS-US (conditioned stimulus-unconditioned stimulus) associ-ation learned during threat conditioning is not erased during ex-tinction, but rather is left intact as a new, secondary inhibitory learning about the CS-US develops [e.g., Bouton and King, 1983; Bouton, 1993]. In other words, after extinction, the CS possesses 2 meanings; its original excitatory meaning (CS-US) as well as an ad-ditional inhibitory meaning (CS-noUS).”
Necessary conditions of TRADITIONAL Exposure Exercises
- Graded
- Prolonged
- Repeated
- Without distraction
Treatment components
- Fear Hierarchy (list)
- Exposure exercise
- Monitoring
- Evaluation
- Fear hierarchy (list)
from most difficult (e.g. to hold a spider in ones hand) to least difficult (watching a video of a spider moving)
- Pick an Exposure exercise
- Discuss THOROUGHLY with your patient: (where, how, why, when, who, what)
- Do the exposure exercise+ monitoring
a list of all the exposure sesssions with date, what they did, ratings of anxiety before, after and during etc.
- Evaluate
What happened?
Pick the next exposure exercise
Effectiveness
Exposure treatment efficacy:
Low Intensity Exposure
Well adaptable
Patient requirements:
- Low to medium symptoms severity
Therapist requirements:
- Knowledge of anxiety symptoms
- Competent working with highly structured protocols
Client therapist time requirements:
- unclear
Low Intensity Treatment key components
- Psycho education
- Collecting information
- Guidance: set realistic goal for treatment
- Monitor and review progress
- Psycho education
- Explain CBT model
- Explain Exposure Rationale
Anxiety: fight flight
Vicious cycle of fear and avoidance
CS US CR relationship
- Collecting information
Self monitoring
Symptoms - frequency and intensity
Behavior
Cognitions
Emotions
- Setting realistic goals
Don’t:
- “not feeling anxious anymore”
- “not getting a heart attack
Do:
- Acquiring knowledge
- Goals related to daily functioning
- Learning to manage anxiety
- Guidance + Monitor and review progress
no further infos on slides…
Effectiveness of Low intensity exposure therapies
Low intensity exposure treatment efficacy
- Self help compared with wait list and face to face (Haug et al., 2012)
- Self help >wait list
- Self help < face to face
Relapse…
19 62% of treatment responders show a return of fear (Craske and Mystkowski, 2006)
…room for improvement!
Strategies to improve Exposure
1) Expectancy violation
2) Deepened extinction
3) Removal of safety behaviour
4) Variability
5) Multiple contexts
6) Reconsolidation
When picking an Exposure Exercise:
test it out first:
Analyze “If….then belief”:
- What do you fear most? What would happen?
- Under what circumstances is it most likely that this will actually happen?
Design:
- An experiment that will test your expectation the best
- Determine the duration and frequency needed to violate the expectancy .
- Check whether the experiment is doable.
Expectancy violation
Determine
What result/response/outcome will confirm fear expectation?
What result/response/outcome will disconfirm fear expectation?
Important!!
Reduction of fear is not required
Do cognitive interventions afterwards, not before Exposure
Deepened (compound) extinction
COMBINE IT
Combination of CS-s (internal/external)
Removal of Safety Behavior
THROW IT OUT (distracting or numbing behaviours)
STAY WITH IT (Focus)
Variability
MIX IT UP
Random order and length of exposures
•…but: has to be doable
Multiple contexts
CHANGE IT UP
Consolidation
BRING IT BACK bringing it from short term to long term memory (e.g. rehearsal)
More extensive evaluation
What did you expect would happen? What actually happened? Were you surprised?
What did you learn?
Necessary conditions of non TRADITIONAL Exposure Exercises
Take home message
What is Exposure Therapy?
- An effective behavioral intervention for Anxiety and Related Disorders
How does Exposure work?
- Inhibitory learning (+habituation)
- How effective is Exposure Therapy? Highly effective, also in LIT
How can efficacy be improved?
- Test it out
- Combine it
- Throw it out
- Stay with it
- Change it up
- Bring it back
