Summary Introduction to cognitive behavioral therapies – all the articles – by CD3V
This summary contains the following articles:
- The more you do it, the easier it gets: exposure and response prevention for OCD
- Maximizing exposure therapy: An inhibitory learning approach
- How does EMDR work? Journal of experimental Psychopathology
- Cognitive restructuring and graded behavioral for delusional appraisals of auditory
hallucinations and comorbid anxiety in paranoid schizophrenia
- Cognitive behavioral therapy for psychosis in clinical practice
- From lab to clinic: Extinction of cued cravings to reduce overeating
- Schema Therapy for Borderline Personality Disorder
- Results of a multicenter randomized controlled trial of the clinical effectiveness of schema
therapy for personality disorders.
- Schema Therapy for Personality Disorders: A Qualitative Study of Patients’ and Therapists’
Perspective
- Mindfulness decouples the relation between automatic alcohol motivation and heavy
drinking
- Principles and clinical application of schema therapy for patients with borderline personality
disorder
- Mindfulness meditation in clinical practice
- Acceptance and commitment therapy for anxiety disorders: three case studies exemplifying a
unified treatment protocol
,Summary Introduction to cognitive behavioral therapies – all the articles – by CD3V
The more you do it, the easier it gets: exposure and response prevention for
OCD
Michael B. Himle & Martin E. Franklin, (2009). Cognitive and Behavioral Practice 16, 29–39
The most thoroughly researched and most effective psychosocial treatment modality is CBT,
involving exposure and reaction prevention (EX/RP). EX/RP has consistently been shown to be
effective for reducing symptoms of both adult and pediatric OCD. One of the primary goals of CBT is
to teach the patient the persistent and consistent skills needed to directly confront fear-evoking
stimuli without engaging in fear-neutralizing rituals.
Introduction to EX/RP for OCD
EX/RP is a collection of therapeutic techniques aimed at teaching an individual to approach, rather
than avoid, fear-producing stimuli (exposure) coupled with the prevention of fear-neutralizing rituals
(response prevention). EX/RP together with other treatment techniques is frequently referred to as
CBT. No single model or theory yet proposed, including behavioral theory, can fully explain how or
why OCD develops. One can be reasonably certain that the underlying cause of OCD is multifactorial.
CBT has risen from our understanding of underlying behavioral processes involved in OCD.
Theoretical rationale for EX/RP
Early learning models of OCD were based largely on a two-factor theory of fear. The two-factor
model proposes that when an individual is faced with a situation that elicits a physiological fear or
anxiety state, an unconditioned (i.e., unlearned) behavioral reaction to escape that state is initiated.
If the action is successful in reducing the anxiety, it is strengthened, through negative reinforcement.
EX/RP assumes that if an individual is systematically exposed to stimuli that elicit obsessional
thoughts and associated anxiety and is prevented from escaping or otherwise neutralizing the
anxiety (ritual prevention), the anxiety will diminish over time through the process of extinction and
the person will be better able to function in his/her daily life.
A behavioral conceptualization focuses on the here-and-now functional relationship between an
individual’s obsessions and compulsions, with the assumption that this relationship can be modified
in treatment without necessarily understanding the “cause” of the obsessions, and the specific
content of the obsessions/compulsions is irrelevant. An example might include ‘frequent checking
in’, with a common underlying theme of repetitive performance of one or more rituals to avoid or
remove the distress associated with obsessional thoughts. Analyzing the nature and cause of one’s
obsessions is actively discouraged as this often makes them worse.
Empirical support for EX/RP for OCD
Several literature reviews have concluded that CBT is an effective treatment for reducing OCD in
60%-90% of adults and children with 50%-80% symptom reduction common. The treatment gains are
maintained at two-year-follow-up. Behavior therapy not only provides longer-lasting gains, but also
greater short-term improvement in symptoms.
Case conceptualization – the case of Caroline
The goal of EX/RP would be to teach Caroline to confront feared situations, in a graduated manner,
while simultaneously and voluntarily refraining from performing her rituals.
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, Summary Introduction to cognitive behavioral therapies – all the articles – by CD3V
Although the “meat” of treatment would focus on exposure and ritual prevention, maladaptive OCD-
specific cognitions would be identified, and cognitive therapy (CT) techniques could be also included
to target these symptoms. The focus of treatment is to teach Caroline to directly confront the feared
stimulus and deliberately elaborate or focus upon the fears in the moment, rather than to engage in
attempts to stop obsessions and discomfort from occurring. There is emphasis on trying to change
the behavior instead of her thoughts. It is often the case that individuals with OCD fail to understand
that although their rituals are effective for reducing discomfort in the short term, they are
maintaining (or even worsening) OCD in the long-term. To help Caroline understand how this relates
to EX/RP, we would help her to understand that the only way for her to overcome her fears is to
refrain from ritualizing and directly experience the outcome. Two “commandments” of successful
EX/RP are that patients should (a) expect to feel uncomfortable and (b) should not try to fight the
discomfort.
Implementation of EX/RP
The number and length of EX/RP sessions will vary individually, depending on the severity, availability
and other factors. Most individuals will respond well to 12 to 15 weekly treatment sessions that last
60 to 90 minutes. The primary components of EX/RP include assessment of OCD symptoms,
psychoeducation and treatment rationale, symptom monitoring, developing fear hierarchies, in-
session and out-of-session exposure work, relapse prevention, and generalization training. A sample
session structure for EX/RP can be found in table 2 below.
Assessment and review of OCD symptoms
Caroline was assessed using the Yale-Brown Obsessive Compulsive Scale, the result suggested that
the symptoms were of moderate severity.
Psychoeducation
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