Quiz 4 Flashcards
According to A&J, what is exposure therapy?
direct confrontation with a feared stimulus with the aim of facilitating fear extinction.
According to A&J, what disorders were moved to OCD and Related disorders and why?
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”
According to A&J, what is the rationale for behavior therapy with OCD?
weaken the associations between obsessional stimuli and excessive anxiety
and compulsive rituals and relief from anxiety
A&J Types of Exposure
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
A&J: What is Mower’s two stage learning theory of anxiety disorders?
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)
A&J: What is Foa and Kozak’s Emotional Processing Theory?
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
A&J: According to Foa and Kozak what is the key to long-term fear extinction (success of exposure therapy)?
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
A&J: What is Exposure and response prevention (ERP)?
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
A&J: What does the client learn during exposure and response prevention (ERP)?
- anxiety, uncertainty, and obsessional thoughts are manageable.
- these experiences usually decline over time even in the absence of rituals
- fear cues are not as dangerous as we predicted
A&J: What is Neziroglu, Roberts, and Yaryura-Tobias CB model of BDD?
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
A&J: Implementation of exposure for BDD?
Going out without make up
wearing pants that accentuate body shape
looking in distorted mirror and then regular mirror
A&J: Conceptualization of hair-pulling and skin picking
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
A&J: Hoarding conceptualization and treatment
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
A&J: More effective treatments for hoarding?
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
Exposure session structure
conduct exposure
debrief exposure
assign homework and plan next session
Review exposure homework
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?”
How to start an exposure task
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!
What’s the biggest barrier to an exposure?
Clinician’s fear of the feared outcome coming true
What to do during an exposure
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
What NOT to do during an exposure
Express shock, disgust, or fear
Become a safety signal
Facilitate avoidance
When to stop an exposure task?
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
Debriefing an exposure task
provide positive feedback and reinforcement
share your own observations
encourage evaluation of beliefs that maintain anxiety and assess for corrective learning
Guidelines for assigning homework
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
How to address extreme anticipatory anxiety
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
How to address previous unsuccessful exposure
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
How to address the normal people fallacy
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
How to address arguments about risk
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?
Problem of overengagement
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
How to address overengagement
start with tasks <40 SUDs
Modify exposure tasks to make them less distressing
allow skill use during exposure
offer more praise, reassurance, coaching, prompting
Why increase intensity of in vivo and interoceptive exposures?
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
Problem of underengagement
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
Potential solutions to underengagement
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
What are other exposure avoidance strategies?
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
Problem of relapse
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?
Inhibitory learning experience
deepened extinction - mismatch between expectancy and outcome for more than one stimulus
Internal vs. external contexts for exposure
Internal - medications taken, mod state, amount of sleep, hunger level
External - location, time of day, presence of others
more varied contexts –> less relapse
Variability of stimuli
Adjusting retrieval cues –> stimulus is in fact safe
Random and variable practice enhances retrievability
Variability in fear
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
Key factor for the long-term success of exposure therapy
strength and retrievability of inhibitory associations
