Lecture 10 - Exposure Therapy for Anxiety Disorders Flashcards
Explain the History of Exposure Therapy. What is systematic desensitization?
*Developed in the 1950s
*Joseph Wolpe: developed systematic desensitization after being dissatisfied with existing treatments for PTSD
▫Reciprocal inhibition
The experience of fear is incompatible with the experience of pleasure or relaxation
If you pair a fear stimulus with something else, it brings the fear down
Exposure with relaxation techniques
▫Also developed Subjective Units of Distress Scale (o-100 scale to rate distress during exposure)
How does a fear develop?
*Neutral stimulus evokes fear response
▫Avoidance/safety behaviour maintains fear
*Trauma/bad experience
▫Generalize from one specific instance so that similar stimuli come to evoke fear
E.g., Get bit by dog, come to fear all dogs
▫Benign stimuli associated with the event begin to evoke fear response
E.g., After car accident, fear response to cars, location where accident happened, individuals who were present, etc.
What is exposure therapy? What are its goals?
Set of therapeutic techniques used to teach clients to approach feared stimuli
*May be paired with relaxation techniques and/or prevention of compulsions or safety behaviours
Goals:
*Allow client to learn that fear response diminishes over time
*Help client learn corrective information about the feared stimulus
What are the 2 mechanisms of change?
Learning of corrective information
*Over repeated trials, clients learn that feared outcome does not happen, or is very unlikely
Increased self-efficacy
*Even if fear response is not completely extinguished, client learns that he/she can handle feeling
What are the 4 types of exposure?
Graded exposure
*Client slowly exposed to increasingly difficult stimuli
▫E.g., fear of heights: start on 5th floor of building, move up to rooftop
Systematic Desensitization
*Like graded exposure, but with the addition of relaxation techniques
❑Cannot be relaxed and anxious at the same time
❑Not everyone likes relaxation techniques
Prolonged Exposure
*Designed to treat PTSD
*Repeated revisiting of traumatic event ▫Client recounts experience in great detail
*Exposure to situations/objects/individuals that are reminders of the traumatic event, but that do not pose a threat
*Facilitates emotional processing of event
One-session
*One extended session (up to 3hrs)
*Includes instruction, modelling, exposure, cognitive challenge
*Shown to be efficacious in adult populations, some evidence supporting use in child/adolescent populations
What are the 5 modes of delivery?
In vivo: exposure to actual feared stimulus, or some approximation
*Sometimes requires creativity
Imaginal: client imagines feared stimulus when it isn’t feasible to do in vivo exposure
*Frequently used for PTSD, GAD, phobias of uncommon stimuli
*Not all clients will be able to engage in this –need to have good visualization skills
Virtual reality:used when in vivo isn’t feasible
*Good alternative to imaginal for clients who have difficulty with visualization
*Becoming more accessible, but still not widely used
Interoceptive: exposure to physical sensations
*Especially useful for panic disorder or for clients who find physical anxiety symptoms to be unacceptable
*Clients learn that symptoms are not dangerous
Modelling
*Not primary intervention –used as adjunct
*Can help to ease client into exposure
*Shows client that feared outcome is unlikely/impossible
*Shouldn’t ask client to do anything that you wouldn’t do!
▫In fact, good idea to try out everything that clients will be doing, to know what their experience will be like
Typical Course of Therapy: Exposure and Response Prevention for OCD
Caroline (Himle& Franklin, 2009)
*Obsessions about causing harm to others through ”bad energy” or illness
*Engages in several compulsions to reduce her anxiety
*Goals for therapy:
▫Teach Caroline to face feared situations
▫Prevent her from engaging in compulsions
▫Work on her maladaptive thinking
Typical course of therapy: What are the early sessions like?
*Assessment of symptoms and interference
▫Caroline reports several obsessions related to causing harm to others and compulsions aimed at reducing the anxiety they cause
▫Her symptoms are interfering in her daily life
Time consuming
Avoidance of people/situations
*Psychoeducation
▫Describe nature of OCD
▫Explain how compulsions maintain anxiety
*Provide rationale for exposure
▫Extinction: stop “feeding” obsessions by engaging in compulsions
▫Improvement will take time –will actually experience more distress in the short-term
▫Describe empirical findings that support the use of exposure
▫Can also use example from client’s life (e.g., going on a first date with husband)
*Introduce symptom monitoring and SUDS ratings
▫Shows pattern of anxiety (e.g., triggers, thoughts, distress, responses)
▫SUDS = Subjective Units of Distress Scale
*Construct fear hierarchy
▫Use SUDS ratings from monitoring to create hierarchy
▫Start with moderately easy items (SUDS <30), but not too easy!
*Plan exposure exercises, prevention of rituals
▫Create one for each obsession/compulsion
▫Example: Caroline visits someone ill, shakes their hand, and does not engage in wiping, washing, cleaning, or showering
*Build rapport
▫Exposure will be difficult -important for client to trust therapist and feel comfortable with him/he
Typical course of therapy: What are the middle sessions like?
*In-session exposure
▫Therapist-guided
▫Prevention of compulsions
▫Client asked for SUDS ratings throughout
Can graph to have visual representation of progress
▫Do not move up hierarchy until client can complete item with little effort and without engaging in compulsions
*Homework:
▫Out-of-session exposure
Helps with generalizability and self-efficacy
▫Continue symptom monitoring
*Keys to successful exposure:
▫Manageable
▫Refrain from compulsions
▫Master one step before moving to next ▫Repeated
*Modify as needed
▫Adjust according to changes in symptoms, new behaviours, reactions to exposure exercises (e.g., moving too fast), etc.▫Provides opportunity for client to practice being own therapist
*Periodically assess overall symptoms to track progress
Cognitive restructuring??
*Debate about when to do it
*Can help clients engage in therapy more readily
▫Is more appealing (i.e., subjectively safe) to clients
*But,some clients might use cognitive restructuring techniques to neutralize anxiety during exposure
▫Some therapists prefer to save until exposure is mostly complete
Typical course of therapy: What are the late sessions like?
*Generalization/maintenance
▫Likely won’t have time to go through every obsession/compulsion in therapy, so important for client to continue on their own after termination
▫Have client develop additional hierarchies and response prevention strategies
*Relapse prevention
▫Predict future challenges, come up withplans to address them
▫Normal to have flare-ups –doesn’t mean progress is undone
What are the advantages of exposure therapy?
*Highly efficacious for various problems
▫E.g., OCD: 60-90% of individuals show a 50-80% reduction in symptoms
▫Often superior to pharmacological treatment
*Relatively brief
▫Typicallyunder 15 sessions (although some cases may require longer)
▫Important consideration in terms of cost
What are the disadvantages of exposure therapy?
*High dropout/refusal rate
▫Clients find it aversive
*Some therapists also find it aversive
*Several potential barriers to treatment:
▫Noncompliance
▫Subtle avoidance
▫Family involvement
▫Comorbidities
