Lecture 1 & Article - Exposure & Behavioral Activation

Question 1

How is pathological anxiety developed in the first place?

Answer 1

conditioning

Question 2

Social Fear is Acquired through..

Answer 2

– Classical Conditioning

Question 3

Social Fear is maintained through..

Answer 3

– Operant Conditioning
-Negative reinforcement plays a big role (if I escape/avoid situation, I won’t feel anxious

Question 4

Fear structures

Answer 4

refers to the way in which anxiety / fear is programmed in our mind => a program to escape danger

contains info about:
-fear stimuli (dog)
- fear responses: verbal, behavioral, physiological (shortness of breath)
- meaning of the stimuli and responses (means that the dog is dangerous and it will bite me)

-> The fear structure is activated by inputs that match part of the structure

Question 5

Emotional processing theory (Kozak & Foa):

Answer 5

• effective exposure therapy = corrects fear-structure
• fear-structure has to be activated first (patient must be experience anxiety)
• new info has to be introduced in fear-structure that is incompatible with old info
• correction of fear structure (so if therapy is working) is indicated by habituation -> anxiety is decreasing
• if anxiety is lower > we can stop with exposing

Question 6

Criticism emotional processing theory

Answer 6

research showed that HABITUATION IS NOT PREDICTIVE OF EXPOSURE THERAPY OUTCOMES

Question 7

Alternative theory- Inhibitory learning theory:

Answer 7

• effective exposure therapy = the old fear structure is not changed but we form a new fear structure that is competing with the old fear structure
• habituation is not necessary anymore
• fear toleration as key concept => experiencing anxiety is tolerable
• having a new structure in which feat is tolerable
• learning that the stimulus itself but also your own response is not that dangerous
• after exposure: the fear structure and the non-threatening structure compete for retrieval
• empirical evidence about this theory is not conclusive

Question 8

Do we know how exposure really works? Through which mechanisms?

Answer 8

NO - we know that exposure works, but not how it actually works

Question 9

Behavioral activation – Treatment for Depression:

Answer 9

• the structured scheduling of specific activities for the client to complete in their daily life, that increase contact with !positive reinforcements!
• Function: Increase contact with positive reinforcement, which can generate/change/maintain behavior
• Reinforcement & mood: are entangled, hard to sperate > when reinforcers are lost, people feel bad
• We try to target behavior in order to change mood and depression > suggest activation as a tool to break this cycle and support problem solving

Question 10

Study results about the components of CBT

Answer 10

 Only behavior activation was as useful as the full package

Question 11

Grading Tasks - Behavioral activation

Answer 11

breaking down activities into parts
> assign simple to more complex tasks in a stepwise fashion

Question 12

How to make exposure most effective?

Answer 12

1. Do cognitive restructuring only after the exposure to not minimize violation of expectancy
2. Vary stimuli (e.g., videos, written info) and contexts (e.g., different places)
3. Pair the stimuli to deepen the extinction
4. Don’t stick to a hierarchy of feared stimuli – vary it randomly (Although usually beginning with least anxiety producing item to avoid attrition.)
5. Remove safety behaviors
6. Use affect labeling during exposure – “how are you feeling?”
7. Mental reinstatement – imaginably reinstate successful exposures
   9.expectancy violation= design exposures that maximally violate expectancies regarding the frequency or intensity of aversive outcomes.

Question 13

Occasional reinforced extinction

Answer 13

Pairing CS with US during the exposure at times. Face the fear to enhance learning by violation of expectancy.

Question 14

Reinstatement vs reacquisition

Answer 14

Reinstatement of fear occurs when unpaired US is presented (e.g., one experiences bullying). Reacquisition is when fear is renewed upon encountering CS+US (e.g., being in school + being bullied)

Question 15

Challenges for exposure therapy

Answer 15

-after a successful exposure therapy, if you don’t expose yourself to the feared stimuli (e.g. flying in an airplane) > you will likely return to being feared when you fly again, because you avoided this stimulus for a while

-fear extinction is specific to context (so its not good if you do exposure always only in therapy session with the therapist)

-Reinstatement of conditional fear occurs if unsignaled (or unpaired) US presentations occur in between extinction and retest. &raquo_space; hard to control what happens between sessions

• Rapid reacquisition of the CR is seen if the CS-US pairings are repeated following extinction

Question 16

Pair the stimuli to deepen the extinction

Answer 16

either multiple fear CSs are first extinguished separately before being combined during extinction or a previously extinguished cue is paired with a novel CS.

For example: drinking coffee in a shopping mall for social anxiety disorder and panic disorder because you enhance and combine the bodily symptoms with the feared stimulus (large crowds)

Question 17

Exposure Therapy for OCD

Answer 17

Session 1: detailed discussion regarding the nature of associative learning and how avoidance can interfere with new learning by preventing any violation in expectancy

Session 2-5: focused on in vivo exposure

Session 6-11: continued with in vivo exposure whilst incorporating several extinction enhancement strategies in order to maximize extinction learning

Question 18

Exposure Therapy for PTSD

Answer 18

Session 1: detailed discussion regarding nature of associative learning and how avoidance and safety behaviors can interfere with exposure by preventing violation in expectancy

Session 2-4: focused on in vivo exposures centered on expectancy violation while decreasing safety behaviors

Session 5-12: continued with in vivo exposure while also incorporating imaginal exposure to trauma

Question 19

Exposure Therapy for Social Phobia

Answer 19

• Session 1: psychoeducation and treatment planning. Therapist discussed prevalence, origins and psychopathology of social phobia and foundations of exposure-based psychotherapies
• Session 2-5: devoted to creating an inventory of feared social situations, collaboratively engineering the corresponding exposure exercises and carrying out in- and between- session exposures.
• Session 6-12: therapist helps to design augmented exposures to enhance inhibitory learning

Question 20

Exposure Therapy to specific phobia

Answer 20

• Session1: thorough assessment of situational avoidance behaviors and discussion about how the exposure therapy model could help the person to regain the social and leisure activities that were affected by specific phobia.
• Session 2-5: repeated practice of in vivo-exposure
• Session 6-12: basic principles of exposure as well as specific inhibitory learning strategies could be communicated and rehearsed. Exposures with strategies drawn from inhibitory learning research.

Question 21

Exposure Therapy for Panic disorder

Answer 21

• Session 1: discussions about associative learning, how avoidance prevents extinction learning and importance of exposures for eventual (not immediate) fear reduction
• Session 2-7: focused on interoceptive exposure through induction of dizziness, shortness of breath and racing heart
• Session 8-14: focused on deepened extinction, which involved combining multiple feared stimuli that have been extinguished in isolation in order to enhance extinction learning

Question 22

Exposure for PTSD

Answer 22

1. Psychoeducation
2. Make a list of avoided situations and feared outcomes, rate them in severity
3. Exposure in vivo and reducing safety behaviors, e.g. going to feared places without taking pepper spray
4. Imaginal exposure of trauma (violating the expectation of having a mental breakdown if you talk about trauma). Use affective labeling throughout.

Question 23

mowrer 2 process model

Answer 23

classical conditioning - fear acquisition
operant conditioning - fear maintenance

Question 24

different components of CBT (4)

Answer 24

• facilitative startegies
  -automatic thought strategies
  -core beliefs strategies
  -behavioral activation strategies

Question 25

lewinsonhs theory - depression

Answer 25

-The essence of depression is inactivity (low rate of behavior)
-Inactivity is caused by loss of reinforcement for active/healthy behavior
-Inactivity leads to less opportunities to experience positive reinforcement, increasing
depressed mood

Question 26

treatment rational

Answer 26

-Emphasize relationships between environment, mood, and activity
-Highlight vicious cycle that can develop between depressed mood, withdrawal/inactivity, and worsened mood
- Suggest activation as a tool to break this cycle and support problem solving
-Emphasize an outside-in approach: act according to a plan or goal rather than a feeling or internal state

Question 27

How to maximize the chance of successful activity completion?

Answer 27

Grading Tasks
-Break down activities into parts
-Assign simple to more complex tasks in a stepwise
fashion
-Design assignments so that early success is guaranteed
-Because completing one component will increase likelihood of completing others
- Goal is not to accomplish all parts of the activity— rather, to get started, increase activation, disrupt avoidance

Question 28

behavioral activation - what to do, when obstacles arise?

Answer 28

-Problem Solving
-Back-up plans
-Imaginary rehearsal

Question 29

What to do when activities are not completed?

Answer 29

-Be empathetic and hopeful
-Discourage self-blame/self-hatred
-Analyze
-Different/smaller activity?
-Rationale