Introduction to CBT - Exposures

CBT for Anxiety Disorders

Well-established.

• Moderate to large effect sizes (clinical significance) relative to both no treatment and to control conditions (e.g., supportive psychotherapy)

• Large pre-post effect sizes for panic disorder, seasonal affective disorder, PTSD, GAD, OCD

Anxiety Disorders - Characteristics

• Pervasive and persistent symptoms of anxiety and fear

• Involve excessive avoidance and/or escape behaviors that create functional impairment

• Cause clinically significant distress

• Fear/panic vs. anxiety/worry 

Fear/Panic

• Present-orientated mood state 

• Immediate fight or flight response to danger or threat

• Abrupt activation of the sympathetic nervous system

• Strong avoidance/ escapist tendencies

Anxiety/Worry

• Future-orientated mood state

• Apprehension about future danger or misfortune (“anticipatory fear”)

• Physical symptoms of tension/apprehension (e.g., muscle tension, etc.)

• Characterized as negative affect (manifests with physiological, behavioral, and cognitive components)

Nature of Fear and Anxiety

In the past, fear and anxiety have kept us safe. It is adaptive to fear real dangers and to be anxious about and avoid situations that place us in harms way.

Common Themes in Anxiety

• Trigger (current or in the future)

• Thoughts/interpretations that lead to elevated anxiety

• Behaviors

• Consequences

Common Themes in Anxiety - Thoughts/Interpretations

• Dysfunctional thoughts about likelihood of and catastrophic nature of situation, and

• Inability to cope if the expected catastrophe happens

Common Themes in Anxiety - Behaviors

Avoid, safety behavior, distract, ruminate

Common Themes in Anxiety - Consequences

Reduced anxiety in the short-term but prolonged and worsened anxiety in the long term.

Safety Behaviors

Coping mechanisms people use to reduce anxiety:

• Avoidance

  • avoiding eye contact, staying on the edge of social groups, or avoiding places associated with panic

• Impression management

  • rehearsing sentences or closely monitoring one's behavior

• Checking

  • checking locks or searching for symptoms online

• Neutralizing rituals

  • performing rituals to feel safe

Exposures (EXRP)

Type of psychological treatment that helps people face their fears by gradually exposing them to situations that cause distress.

• Used with CBT that can help with a range of anxiety disorders

Exposures - Types of Disorders

• Panic disorder

• Phobias

• Social anxiety disorder

• OCD

• PTSD

• GAD

Types of Exposure Therapy

• Imaginal exposure

• In vivo exposure

• Interoceptive

  • Feeling the physical sensations that cause the fear or anxiety

• Virtual reality

Pacing of Exposures

• Graded exposure

• Flooding

• Systematic desensitization

Targets Exposure is Thought to Help with

• Habituation and extinction

  • Used to be the main cause, old thinking

• Self-efficacy

  • Helps its development (they did it before, they can do it again)

• Emotional processing

  • Cease of avoidance of scary feelings

Learning Pathways in Exposures

Exposure works by creating new learned relationships.

• The old learning does not go away (hence risk for relapse in the future).

Why do Exposures Work?

• Old thinking: 

  • Extinction learning

  • Habituation

• New thinking:

• Inhibitory Learning Model

  • In order to be optimally effective, ERP needs to help people learn safety in such a way that it is strong enough to block out (or inhibit) the original fear — and this is where the term inhibitory learning gets its name.

  • Focusing on Anxiety Tolerance instead of Habituation

  • Disconfirming Expectations

  • The Element of Surprise

  • Combining Fear Cues

  • Variety

General Rules for Exposures

• Allow sufficient time in-session (ideally, with a 50-minute session, you’d spend ~30 minutes doing exposures)

  • The bulk of the session should be the exposure

• Assign similar exercises for homework

  • If they can do it in therapy, they can do it as homework.

• Within session anxiety reduction is great, but not necessary- between session is most important.

• Don’t do anything to decrease the anxiety!!

  • Safety behaviors, coping statements, relaxation training, distraction, etc. should be AVOIDED during exposures

    • Want to generalize learning, not create limits!

    • Want to “overlearn” safety

    • Be on the look out for “covert” examples

• Such strategies, including cognitive restructuring, may be helpful to prepare for exposures or to process afterwards

• Always over-correct

Panic Disorder 

Criteria include experiencing recurrent panic attacks, with one or more attacks followed by at least one month of fear of another panic attack or significant maladaptive behavior related to the attacks

• Can be treated with interoceptive exposures

Therapies for Panic Disorder

• Barlow’s Panic Control Therapy (PCT)

• 3 components: Physical, Cognitive, Behavioral

• Psychoeducation, particularly re fight-or-flight response

  • Normalizes physiological sensations

  • “Scanning”/”detecting” cognitive biases

• Cognitive treatment

• Psychoeducation

• Interoceptive exposure

• Build in exposure for agoraphobia throughout

Prolonged Exposure for PTSD

• Manualized versions range from 8-15 sessions, 90-120 minutes per session

  • Go through trauma exposure where they sit with it or possibly relive it.

• Psychoeducation

• Trauma assessment

• Breathing

• Imaginal Exposure

• In Vivo Exposure

• Cognitive Processing Therapy?

Imaginal Exposure for PTSD

Revisiting the trauma memory.

Instructions:

• Go back in your mind to the trauma

• Keep your eyes closed 

• Describe it as if it is happening now

• Engage in the feelings this elicits

Subjective Units of Distress Scale (SUDS)

0 to 100:

0 = Completely Calm

• No anxiety, totally relaxed

10–20 = Mild Anxiety

• Slight nervousness, manageable

30–40 = Noticeable Anxiety

• Some discomfort, but can still focus and function

50 = Moderate Anxiety

• Clearly anxious, hard to ignore, but still in control

60–70 = High Anxiety

-Distress is strong, difficult to concentrate, may want to avoid situation

80–90 = Very High Anxiety

-Almost overwhelming, may feel urge to escape or shut down

100 = Maximum Anxiety

-Worst imaginable, panic-level distress, feels unbearable

Anchors for what is the most, less or in the middle of the fear hierarchy. 

Creating a Fear Hierarchy

• Teach patients the SUDS scale

  • Provide anchor points

• Use info. obtained during intake + knowledge of typical triggers for that dx

• Be cognizant of what is realistic to do at home, office, etc.

  • Include imaginal, in-vivo, simulated, interoceptive types as needed

  • Make sure exposures are targeting primary fears

  • Be creative!

• Rate anxiety for scenarios when engaging in no avoidance behaviors

• Re-order list so highest scenario is at the top

Exposure and Response Prevention

• Strong evidence base

• Better than relaxation and anxiety management

• More effective than other CBT treatment