Quiz 4

Question 1

According to A&J, what is exposure therapy?

Answer 1

direct confrontation with a feared stimulus with the aim of facilitating fear extinction.

Question 2

According to A&J, what disorders were moved to OCD and Related disorders and why?

Answer 2

body dysmorphic disorder, hoarding disorder, hair pulling disorder (trichotillomania), skin picking disorder (excoriation)

Defines OCD as putatively similar disorders based on endophenotypes and apparent overlaps in etiologically relevant factors
Because OCRDs have similar response profiles to “anti-obsessional behavioral therapies”

Question 3

According to A&J, what is the rationale for behavior therapy with OCD?

Answer 3

weaken the associations between obsessional stimuli and excessive anxiety
and compulsive rituals and relief from anxiety

Question 4

A&J Types of Exposure

Answer 4

situational/in vivo - confronting external stimuli
imaginal - confronting unwanted obsessional thoughts and doubts that are not easily accessible to real life situations
interoceptive - feared bodily sensations

Question 5

A&J: What is Mower’s two stage learning theory of anxiety disorders?

Answer 5

Fear is acquired through classical conditioning (neutral stimulus paired with an anxiety-provoking stimuli)
and maintained through operant conditioning (avoidant/ritualistic behavior results in immediate reduction in fear, negatively reinforcing the ritual/avoidance)

Question 6

A&J: What is Foa and Kozak’s Emotional Processing Theory?

Answer 6

Fear structure to create a model of understanding the mechanisms involved in exposure therapy.
Exposure achieves effects via emotional processing - where pathological threat associations from part of the fear structure are modified by the incorporation of corrective information

Question 7

A&J: According to Foa and Kozak what is the key to long-term fear extinction (success of exposure therapy)?

Answer 7

Inhibitory learning - the non-danger associations successfully impeding access to and retrieval of the threat associations
Degree to which threat-based vs. non-threat based associations are expressed after finishing exposure therapy depends on the strength of this learning

Question 8

A&J: What is Exposure and response prevention (ERP)?

Answer 8

Requires individual to resist the urge to perform rituals in response to obsessions.
Repeated confrontation with feared stimulus occurs and client confronts the fear cues and resultant anxiety without trying to reduce it by withdrawing or performing compulsive rituals in varying contexts

Question 9

A&J: What does the client learn during exposure and response prevention (ERP)?

Answer 9

1. anxiety, uncertainty, and obsessional thoughts are manageable.
2. these experiences usually decline over time even in the absence of rituals
3. fear cues are not as dangerous as we predicted

Question 10

A&J: What is Neziroglu, Roberts, and Yaryura-Tobias CB model of BDD?

Answer 10

Classical conditioning occurs when, during puberty, a person is teased for changes in their body
Shame/disgust/etc. become associated with these events and become associated with particular body parts
Maintained via a cognitive perspective - triggered by defective mental image of their own reflection
Engages in negative appraisal based on assumptions of importance of physical appearance
safety behaviors - analyzing face/body in mirror or avoiding mirrors

Question 11

A&J: Implementation of exposure for BDD?

Answer 11

Going out without make up
wearing pants that accentuate body shape
looking in distorted mirror and then regular mirror

Question 12

A&J: Conceptualization of hair-pulling and skin picking

Answer 12

Do not have distressing intrusive thoughts
doing so is unpleasant yet necessary to reduce anxiety
*not good to lump with OCD because it’s NOT a feared-based avoidance behavior
better off altering antecedents instead –> possibly habit reversal training

Question 13

A&J: Hoarding conceptualization and treatment

Answer 13

Individuals assign greater instrumental, sentimental, and intrinsic value to possessions, feel greater responsibility and need to control them, and have deficits in information processing and memory
Proposed that it’s an impulse control disorder
Not good for ERP because
1. no pathological fear or fear-induced ritualistic behavior
2. individuals do not resist their urges to collect objects
3. individuals have poor insight into the senselessness of their symptoms
4. they have excessive emotional attachments to objects
5. have information processing deficits that maintain hoarding behaviors - poor organizational skills, deficits in decision making, difficulties with memory, over-importance assigned to remembering

Question 14

A&J: More effective treatments for hoarding?

Answer 14

Emphasize mtoivational interviewing
Development of attention, organization, decision-making, and problem-solving skills
helping patient organize and discard materials - helping client understand why they save possessions as a process of discovery
Going to places where acquisition is a particular problem to increase tolerance of urges to acquire possessions

Question 15

Exposure session structure

Answer 15

conduct exposure
debrief exposure
assign homework and plan next session

Question 16

Review exposure homework

Answer 16

reinforce homework completion
assess experience
ask about corrective learning
identify and troubleshoot problems
“What was it like for you? Did anything surprise you? What do you make of that?”

Question 17

How to start an exposure task

Answer 17

Describe procedures and give instructions - duration, repetitions and/or behavioral goals, note modifications from previous repetitions, model when appropriate
Discuss feared outcomes and misbeliefs
Provide rationale as needed
Assess pre-exposure SUDs and likelihood of feared outcome
Don’t delay start!

Question 18

What’s the biggest barrier to an exposure?

Answer 18

Clinician’s fear of the feared outcome coming true

Question 19

What to do during an exposure

Answer 19

Assess % chance of feared outcome occurring and SUDs about every 5 mins
Appear calm and confident
provide reinforcement and encouragement
be directive
watch for avoidance and block it
note important themes that come up

Question 20

What NOT to do during an exposure

Answer 20

Express shock, disgust, or fear
Become a safety signal
Facilitate avoidance

Question 21

When to stop an exposure task?

Answer 21

When maximum learning has occurred
Set achievable behavioral goals and stop when they are met
Remember habituation is not necessary for corrective learning to occur

Question 22

Debriefing an exposure task

Answer 22

provide positive feedback and reinforcement
share your own observations
encourage evaluation of beliefs that maintain anxiety and assess for corrective learning

Question 23

Guidelines for assigning homework

Answer 23

select the type, number, and frequency of tasks
provide relevant instructions
use homework forms for tracking SUDs
Troubleshoot any factors that might interfere with homework completion

Question 24

How to address extreme anticipatory anxiety

Answer 24

notice and disobey anxiety
validate fear
put them in the driver’s seat of the exposure
describe habituation to remind them that anxiety is usually temporary
anxiety is not harmful and can be tolerated

Question 25

How to address previous unsuccessful exposure

Answer 25

goal to see discrepancy between prediction and outcome
wrong focus - did the dog bite me rather than how was I able to tolerate being around a dog
assess ways in which previous exposure was done and tailor response to this analysis

Question 26

How to address the normal people fallacy

Answer 26

goal is to decrease anxiety not to act like “normal” people - might require exposures to push the envelope
reassure that they will never be asked to do anything dangerous

Question 27

How to address arguments about risk

Answer 27

Parents might not be considering long-term risk of not letting their child take the subway
acknowledge minimal risk
part of the exposure is to learn how to manage everyday risks
is it worth testing to see if it is less dangerous than they think?

Question 28

Problem of overengagement

Answer 28

excessive distress that interferes with processing and learning new information
dissociative type - spacing out, prolonged flashbacks
emotionally overwhelmed type - extreme anxiety before and after, sobbing, severe physical reactions

Question 29

How to address overengagement

Answer 29

start with tasks <40 SUDs
Modify exposure tasks to make them less distressing
allow skill use during exposure
offer more praise, reassurance, coaching, prompting

Question 30

Why increase intensity of in vivo and interoceptive exposures?

Answer 30

Ex. by drinking extra caffeine and going to the subway
Decontextualizes - if I can take the subway under these conditions, I can take them under any conditions

Question 31

Problem of underengagement

Answer 31

unable to achieve high SUDs levels
Engages with exposure but with flat affect
May be due to - extreme arousal and emotional numbing, efforts to suppress or avoid emotions, negative beliefs about consequences of experiencing intense emotions, problems with the exposure task

Question 32

Potential solutions to underengagement

Answer 32

validate urges to suppress emotions
reiterate rationale
assess beliefs about emotional experiencing
encourage them to test accuracy via exposure
modify the exposure task as needed

Question 33

What are other exposure avoidance strategies?

Answer 33

avoiding certain words or details from trauma narrative
leaving exposure sessions early
coming to sessions high
avoiding eye contact
rituals and safety behaviors
distraction
focusing on secondary behaviors like anger
refusal to do exposure task

Question 34

Problem of relapse

Answer 34

do not focus on within session fear reduction during exposure
vary stimuli and setting
don’t move up the hierarchy too slowly
have cognitive restructuring and diaphragmatic breathing become safety behaviors?

Question 35

Inhibitory learning experience

Answer 35

deepened extinction - mismatch between expectancy and outcome for more than one stimulus

Question 36

Internal vs. external contexts for exposure

Answer 36

Internal - medications taken, mod state, amount of sleep, hunger level
External - location, time of day, presence of others
more varied contexts –> less relapse

Question 37

Variability of stimuli

Answer 37

Adjusting retrieval cues –> stimulus is in fact safe
Random and variable practice enhances retrievability

Question 38

Variability in fear

Answer 38

Variability in fear throughout exposure may enhance long-term outcome because
teaches clients they don’t have to approach fear carefully
emotional state as retrieval cue for non-fear responding

Question 39

Key factor for the long-term success of exposure therapy

Answer 39

strength and retrievability of inhibitory associations