PSYCH 820 Quiz #5 Review PDF

Behavioral Analysis Quiz #5 Review Three questions in exposure- 1. How anxious are you? 2. How well can you tolerate it? 3. (idiographic question) what is the feared outcome of the exposure/what does the person think will happen? ○ We ask these before we start exposure, an...

Behavioral Analysis Quiz #5 Review Three questions in exposure- 1. How anxious are you? 2. How well can you tolerate it? 3. (idiographic question) what is the feared outcome of the exposure/what does the person think will happen? ○ We ask these before we start exposure, and then again during exposure When do we stop exposure? When we get maximum amount of corrective learning, usually when belief in feared outcome is about 5-10%, though sometimes we’ll stop when it’s higher (like when reduction plateaus and doesn’t change) How to make exposure work: Step #1- orienting clients to exposure treatment; first mistake people make is not explaining to client why they have to be doing something aversive to them, we discuss why we do the experiment, what the components are, what the questions are, what the framework is behind the therapy, tell them they’re in control ○ Also good to ask client if they can explain reasoning behind therapy ○ Explain how fear is maintained- Goal: for the client to understand how and why their anxiety is not going away and is likely getting worse over time Key points: Anxiety is maintained by avoidance and unhelpful beliefs, Unhelpful beliefs cause people to feel anxious about situations that are not actually dangerous, Avoidance decreases anxiety in the short-term, Avoidance increases anxiety in the long-term, because it prevents corrective learning. ○ Explain the rationale for exposure- explain how avoidance prevents unhelpful beliefs from being corrected, exposure blocks avoidance ○ Prepare clients to feel anxious- Things may get harder before they get easier, It is normal to feel anxious during exposure, Anxiety during exposure is a sign that it is being done correctly, Try not to resist or fight the anxiety, just allow the emotions to be there, Remember that anxiety is temporary We don’t want to be too reassuring, because then we reduce the corrective learning ○ Orient to the therapist’s role- Therapist’s role is as a coach or cheerleader, be supportive but not excessively Therapists do: Help to select and plan effective exposures, Provide instruction and encouragement as needed during exposures, Process exposures once they are done Therapists do not: Say much during exposures, Show intense emotional responses during exposures, Provide excessive reassurance and soothing ○ Orienting do’s- Provide a clear and detailed description of the treatment rationale, Spend sufficient time orienting, Avoid jargon, Engage the client in a collaborative discussion, Validate and normalize the client’s experience, Assess the client’s understanding ○ Orienting don’ts- Lecture or be overly didactic, Minimize the difficulty of exposure, Suggest their beliefs or behaviors are “bad”, Overemphasize  fear reduction (habituation) as the goal of exposure tasks, Guarantee safety or promise that feared outcomes will not occur during exposure tasks Step #2- assessment and hierarchy construction; we ask assessment questions, and formulate an exposure hierarchy ○ Exposure hierarchies- u A list of any internal or external stimuli that are avoided because they cause anxiety, Typically 10-20 items are included, Items must be things the client is willing to confront, Each item is rated using the Subjective Units of Distress (SUDs) scale (0-100), Can include in vivo, imaginal, and/or interoceptive exposure tasks, Clients may have more than one hierarchy. A hierarchy should be flexible Choose items with a ranger of SUD’s ○ Guidelines for constructing hierarchies: Be collaborative- Involve the client in identifying and selecting tasks Be specific- “Throw away clutter” vs. “Sort and throw away mail on the dining room table” Each item on the hierarchy should have a clear rationale. What belief is this item designed to test? Be creative- Do not limit yourself to tasks that can be done in the therapy office ○ Choose items that minimize the likelihood of relapse- Exposure should go beyond what most people would feel comfortable doing, “Push the envelope”, If it is harder than what is likely to be encountered in daily life, then daily life will seem easy. Always include the worst fear, If not confronted, clients may still believe some fears are justified, Include items that cover multiple fears, Whenever possible, choose in vivo over imaginal exposure Exposure therapy sessions- Review exposure homework (~5-10 mins.), Conduct exposure (~30 mins.), Debrief exposure (~15-20 mins.), Assign homework and plan next session (~5 mins.) ○ They don’t have to be as long when we know that habituation doesn’t work When a person seems skeptical of alternatives to their believes, then you, the clinician, can act as devil’s advocate Reviewing exposure homework- Reinforce homework completion, Assess the client’s experience of homework: “What was the homework like for you?”, Ask about corrective learning, “How likely does it seem to you now that you will get trapped if you ride on an elevator?”, Identify and troubleshoot problems (Not completing homework, avoidance, low fear activation) How to start an exposure task- Describe procedures and give instructions, Intended duration, repetitions, and/or behavioral goals, Note any modifications from previous repetitions, Model the task when appropriate, Discuss feared outcomes and (mis)beliefs, Provide rationale as needed, Assess pre-exposure SUDs & likelihood of feared outcome, Start – don’t delay It should be noted that in feared outcomes among panic patient, the endorsement/fear of  embarrassing oneself, was higher than fear of death What to do during an exposure task- Assess % chance of feared outcome occurring and SUDs about every 5 minutes, Do the exposure task with the client when appropriate (modeling) e.g., sit on bathroom floor and eat lunch together, Appear calm and confident, Reinforce the client and encourage to continue, Be directive, coach the client to stay in contact with the cue, Carefully observe: look for avoidance and block it, Note important themes/issues that come up e.g., new insights, comments indicative of corrective learning, slight changes in the imaginal narrative What not to do during an exposure task- Express shock, disgust, or fear, Become a safety signal, Provide excessive reassurance, Guarantee safety or promise habituation, Do things that make the exposure easier (unless done strategically) e.g., stand close by, physical touch, interact on client’s behalf, Facilitate avoidance e.g., engage in chit-chat, ask questions about unrelated ○ Rule: answer questions about risk only once When to stop an exposure task- Stop when maximum learning (expectancy violation) has occurred, Set achievable behavioral goals and stop when they are met: ○ Amount of time, Specific (observable) behavior that must be performed, Number of repetitions ○ Remember: habituation is not necessary for corrective learning to occur! Emphasize mastery (achieving goals) and fear tolerance, rather than fear reduction Debriefing an exposure task- Provide positive feedback and reinforcement, Ask the client about her experience, Use open-ended questions: “How was that for you?”, Share your own observations, Comment on aspects of the exposure that seemed particularly meaningful or important, Encourage evaluation of beliefs that maintain anxiety and assess for corrective learning. Guidelines for assigning HW- Select the type, number, and frequency of tasks, Choose tasks that can be easily repeated, Typically assign more than one task, Provide relevant instructions. e.g., minimize distractions, avoid interruptions, consider privacy, timing, Use homework forms for tracking SUDs, Troubleshoot any factors that might interfere with homework completion Addressing common client concerns: Extreme anticipatory anxiety- “Doing exposure will make me too anxious, I won’t be able to tolerate it!” ○ Validate that fear makes sense, Orient to exposure being under their control, gradual approach, Describe habituation to remind them that anxiety is usually temporary, Anxiety is not harmful and can be tolerated, “Invest anxiety now in order to have a calmer future” ○ With exposure there was a study done on clients with potential adverse outcomes with induced panic attacks, 99.98% of hyperventilation sessions had no negative outcomes Previous unsuccessful exposure- “I’ve exposed myself to this thing before and it hasn’t helped!” ○ Assess ways in which past “exposure” was done and tailor response to this analysis, Did they use avoidance behaviors?, White knuckle approach?,  Only confronted parts of feared situations?, Didn’t focus on new learning, Be careful not to invalidate their past experience or suggest that what they did was wrong The normal people fallacy- “Normal people wouldn‘t do that!” ○ Goal of treatment is not to act like “normal” people, but to decrease anxiety, This may require exposures that “push the envelope.”, Reassure that they will never be asked to do anything dangerous Arguments about risk- “It’s not safe!” ○ Acknowledge there is some risk involved, but the risk is minimal, Part of exposure is to learn to manage “normal” everyday risks, Is it worth testing to see if it is less dangerous than they think?, Do not reassure them that it is completely safe, or engage in debates about risk Common Problems in exposure treatment: Problem #1- Overengagement- Excessive distress that interferes with processing and learning new information. ○ Dissociative type- Dissociates and “spaces out”, Has repeated and prolonged flashbacks ○ Emotionally overwhelmed type- Extreme anxiety before and during exposure, Extended sobbing for long periods of time across multiple sessions, Intense physical reactions (e.g., shaking) General strategies for managing overengagement- Start with tasks that are < 40 SUDs, Modify exposure tasks to make them less distressing e.g., include safety signals, focus on less feared parts of the situation or memory, Allow skills use during exposure (e.g. diaphragmatic breathing), Allow controlled escape during exposure, Therapists get more active, More praising, reassuring, coaching, prompting Article Bullet Points OCD has been reclassified from an anxiety disorder to an obsessive compulsive and related disorder (OCRDs), a new diagnostic category This proposed category of OCRDs includes: body dysmorphic disorder, hoarding disorder, hair pulling disorder, and skin pulling disorder This change has garnered some criticism, but is based upon etiological factors such as neurotransmitter abnormalities, heritability, phenotypic similarities with other disorders, etc. Another reason it makes sense to remove OCD from the anxiety disorder category and into this new category, is that the various OCRD disorders, have similar response types to “anti-obsessional behavioral therapies” The article actually disagrees with the above claim and states that it indicates a misunderstand of behavioral therapies used to treat OCD (exposure and response prevention) They also believe that several of the OCRD categorized disorders should not be treated with exposure-based therapy When crafting a behavioral therapy the antecedents and consequences, must be  examined, this allows for proper intervention to be given for each patient In OCD, obsessional stimuli (e.g., contact with the floor) are associated with increases in anxiety, and compulsive rituals (e.g., hand washing), with reductions in anxiety The rituals create an escape from anxiety, and negatively reinforces the further use of these rituals Moreover, the immediate reduction in anxiety that is engendered by performing rituals prevents the natural extinction of the anxiety response and urge to perform rituals that would have otherwise occurred. In other words, rituals keep the individual from getting over his or her obsessional fear Effective behavior therapy for reducing OCD symptoms must therefore weaken the associations between: (a) obsessional stimuli and excessive anxiety, and (b) compulsive rituals and relief from anxiety The most effective behavioral techniques for accomplishing these goals are exposure and response prevention The use of exposure therapy for OCD is derived from Mowrer's two-stage learning theory of anxiety disorders; This model proposes that fear is acquired through classical conditioning, and that the conditioned fear response (and resulting avoidance and compulsive rituals) is maintained via operant conditioning The implication of Mowrer's two-factor model is that the treatment of OCD must foster extinction of the conditioned anxiety response Systematic exposure and response prevention are procedures that promote fear extinction via repeated confrontation with conditioned fear cues while resisting urges to avoid and perform compulsive rituals that would impede extinction learning. Mowrer’s model remains the basis of exposure therapy because it satisfactorily explains the maintenance of obsessional fear and rituals through operant conditioning Cognitive theories, however, have proven to provide a more empirically supported account than classical conditioning to explain the development of obsessions Foa and Kozak proposed emotional processing theory (EPT) and adopted Lang's concept of the fear structure to create a model for understanding the mechanisms involved in exposure therapy for anxiety disorders such as OCD, they asserted that exposure achieves its effects via “emotional processing,” a process by which the pathological threat associations which form part of the fear structure are modified by the incorporation of corrective information Craske et al. noted inconsistencies in EPT and specified that during exposure new non-threat associations are formed that compete with existing threat associations. Long-term fear extinction therefore hinges on inhibitory learning that is, the non-danger associations successfully impeding access to and retrieval of the threat associations. The degree to which threat-based versus non-threat based associations are expressed after finishing exposure therapy depends on the strength of inhibitory learning across time and context - rather than, as espoused by EPT, the habituation of anxiety within and between exposure sessions Situational and imaginal exposure are typically applied together in the treatment of OCD because OCD involves fear-provoking obsessional thoughts that are usually triggered by tangible environmental cues Response prevention is also a crucial aspect to exposure therapy with OCD, exposure forces the client to face their feared stimuli and thoughts, in order to instill corrective  learning, we can’t allow them to reduce their sense of harm The delivery of ERP for OCD can vary widely. One format found to be very effective is a few hours of assessment and treatment planning, followed by between twelve and twenty twice-weekly exposure sessions, lasting 60 to 90 minutes each A hierarchy of fears is not necessary to follow in exposure, and in fact randomness in exposure seems to enhance extinction OCD was considered unresponsive to therapy until the 1960’s, however when ERP (exposure and response prevention) the prognosis increased manifold The reason that exposure therapy works so well for OCD, is because the obsessions and fears of the individual are inherently not dangerous, and the rituals are really just redundant, as the fear levels of the individual would naturally decrease if they didn’t do them, exposure helps teach that these behaviors aren’t necessary to ensure safety BDD (body dysmorphic disorder) also has a compulsive aspect to it, as people become preoccupied with a particular feature and compulsively act to check, hide, disguise, “fix”, etc. the feature Typically, this occurs when a negative emotion like, fear, disgust, or shame becomes linked with a person’s features, fearing scorn the person engages in safety behavior to avoid ridicule or others noticing their “flaw”, in their compulsive avoidance/looking/overall behavior they prevent the corrective learning about negative outcomes In BDD, exposure helps the patient to learn that (a) the fear that others will notice and respond negatively to the imagined physical defect are excessive and unrealistic, and (b) that anxiety and feelings of embarrassment are temporary and tolerable ERP has been proven to be effective to treat BDD, when they examined ERP with cognitive therapy, they did not notice a significant improvement in therapy with the added cognitive element Trichotillomania/hair-pulling (TTM) is defined as an impulse control disorder, some people experience focused-pulling, some unfocused-pulling, and some both, it is also notable that to be diagnosed, this pulling must cause distress, skin-picking on the other hand, must cause lesions on the skin and must cause distress to be diagnosed Whether TTM and skin picking disorder should be conceptualized as impulse control disorders or as OCRDs is a matter of disagreement. Many have associated TTM and skin picking with OCD on the basis of seeming topographical similarities between the recurring and perceived irrepressible nature of hair pulling and skin picking, and that of compulsions in OCD. The functions of repetitive behaviors in OCD and TTM/skin picking, are typically different, skin and hair pulling are often outside of a person’s awareness, and don’t cause the unpleasantness of OCD rituals, they are often described in the opposite way, as satisfying, they’re maintained by positive reinforcement As there are no obsessions/fears driving TTM/skin picking, the same type of exposure wouldn’t apply Exposure is a treatment for fear-based avoidance and compulsive behavior, not for any type of compulsive behavior. Unfortunately, lumping TTM and skin picking disorder with OCD in the new OCRD diagnostic category is likely to lead to further confusion and the improper use of exposure ERP is not sufficient for treating TTM/skin picking disorders, rather, individuals with TTM  and skin picking are best served by implementing techniques that alter the antecedents (i.e., cues) of the target behaviors Though not in the DSM, In the proposed DSM-5 definition, hoarding behavior must result in extreme clutter that prevents the use of living spaces, as well as significant distress Hoarding is a behavior pattern not exclusive to OCRD’s and can be found with dementia, schizophrenia, and more Again with hoarding, there is no specific fear that leads to this behavior, ERP would therefore not work and has poor treatment outcomes, also ERP is not effective as often, the person does not view their behavior as hoarding, they don’t resist their urge to collect and find it comforting (in contrast to the unwantedness of compulsions), they also don’t find their hoarding senseless, they deem it important and attach emotional significance to objects, there are also a number of cognitive deficits associated with hoarding (problems with organizing, with memory, with numbers, etc.), and finally the traits that are commonly associated with hoarding are also traits that are likely to interfere with therapy Motivational interviewing techniques are far better suited for treating hoarding All this information considered, the OCRD category in the DSM is ill-suited for most of these disorders. While OCD and BDD have similar patterns that can be treated the same way, the same cannot be said for the other three disorders In order to avoid the misuse of exposure therapy in the era of the OCRD diagnostic category, it will be important for clinicians to understand the conceptual basis for exposure, as well as the psychological mechanisms involved in the various conditions classified as OCRDs