Phobia cbt

CBT for Phobia
Dr. Preeti Singh
Assistant Professor
Dept. of Clinical Psychology
Institute of Mental Health and
Hospital, Agra
©Dr. Preeti Singh, Asst. Prof of Clinical
Psychology, IMHH, Agra
16 May 2017

Points to covered
• Targets of CBT intervention
• Exposure based intervention
• Behavioural experiment
• Cognitive therapy techniques
• Cognitive restructuring
• Eye movement
desensitization
• Other techniques
1. Distraction
2. Paradoxical intention
3. Social skill training
4. Modelling
5. Vicarious extinction
• Recent therapeutic advances
1. Virtual reality therapy
2. Applied tension therapy
3. Breathing retraining
4. Neuro-linguistic
programming
5. Play, story, art etc.
• Cognitive Drill Therapy
• CBT for different types of
phobia
16 May 2017

Targets of CBT intervention in phobia
•Real Traumatic experience
•Observed Traumatic experience
•Information transmission
Precipitating
•Avoidance
•Attentional bias- hyper attention to threatening material
•Overestimation of threat
•Underestimation of self coping ability
•Hyper-vigilance about physical sensations
•Sick role
•Substance abuse
Perpetuating
•Genetic loading of anxiety disorders
•Harsh parental training
•High anxiety sensitivity
•Heightened separation anxiety
Predisposing
©Dr. Preeti Singh, Asst. Prof of Clinical Psychology, IMHH, Agra
16 May 2017

Assessment of fear
• Define the
goal of
treatment
• Identify the
appropriate
measure for a
Precise nature of phobia Define the goal of treatment Identify the appropriate
measure for phobia
Physical symptoms Primary vs. secondary Easy to use
Behavioural symptoms More severe vs. less severe Sensitive to required change
Subjective symptoms Level of functional
interference
Graded hierarchy (1-10 or 10-
100)
Severity of phobia Level of danger Behavioural tests-real situation
(0-100)
Functional interference Self monitoring
Pattern of avoidance Cognitive distortion
Cognitive interpretation
of symptoms
Rating scales ( fear
questionnaire – Marks , 1979;
fear survey schedule – Wolpe,
1964; Mobility inventory for
agoraphobia – Chambless,
1985)
Existing coping skills
Internal and external
resources
16 May 2017

EXPOSURE BASED
INTERVENTION
16 May 2017

Exposure Therapy
The principle behind ET is that avoidance of a
feared stimulus reinforces the fear while exposure
diminishes it.
By slowly exposing the client to the stimulus in a
safe and controlled environment, their cognitive
distortions are challenged and eventually diminish
(Scharfstein, 2011).
16 May 2017

Principle
• Graded
• Repeated
• Prolonged
• Task should be clearly specified in advance
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Types
• In-vivo exposure
• Imaginal exposure
• Graded exposure
• Prolonged exposure
• Systematic desensitization
Equal effectiveness with
less pain in graded
Richard William, 2011
16 May 2017

In-vivo exposure – assisted or without
assisted (what)
16 May 2017

Imaginal exposure (what)
Starts with vivid imagination,
think as much detail as
possible of phobic object or
situation until anxiety
subsides. (relaxation
sometime)
16 May 2017

Graded exposure (How)
• Make a hierarchy from high to low level fear
situation or objects
• Full range situations avoided by patient (separate
hierarchy)
• Starts from low to high (0-10, 10-100)
• The pass out criteria from one symptom to second
is three consecutive exposure doesn't produce fear
for prolonged real exposure of situation or object.
•
1 3 5 8 10
16 May 2017

Prolonged exposure (How)
• Synonymly used for flooding
• First experiment on phobia (Watson, 1971) but later
modified and frequently used for PTSD, OCD, abuse,
disaster, crisis (Edna B Foa).
• Studies suggests that rapid outcome with intense
pain/anxiety/fear during exposure can lead heart
attack, fainting, trauma etc.
• Reduced follow up, loss the faith in therapy (patient)
• Prolonged exposure primarily on Imaginal level
thereafter real.
16 May 2017

Therapeutic procedure
• Find out the major stimulus or situation to be targeted.
• Educate patient about fear curve, safety behaviour,
therapeutic procedure, mechanism of therapeutic
procedure and outcome.
• Educate and note down the level of fear on 0-10 or 10-100.
• Prolonged continues exposure of phobic objects in fantasy
first then in reality without avoidance.
• Wait to reduce the fear curve (as much time required
provide)- 4 to 5 hour
• Ask experiences and again explain the mechanism of
therapy
•
16 May 2017

Systematic desensitization
Reciprocal inhibition (Joseph Wolpe, 1958)
Imaginal exposure
Fear hierarchy
Relaxation
Relaxation
Fear
16 May 2017

Verbal exposure
COGNITIVE
DRILL
THERAPY
16 May 2017

Cognitive therapy techniques
• Downward arrow technique
• Reattribution
• Silver lining
• Labelling cognitive distortions
• Daily Thought Record
• Imagery replacement
• Survey method
• De-catastrophizing
16 May 2017

Downward arrow technique – Cockroach
If you touched the cockroach then what will
happen – I’ll get infected by bacteria
Then what happen – I’ll become ill or have
infection
Then what happen – I’ll become severely ill
Then what happen – I’ll be hospitalized
Then what happen – there will be minor or no
effect of medical treatment and I could be die.
16 May 2017

Reattribution
• A case of social phobia
Performance type – I wa‘nt able to speak a single
word in front of my boss or colleagues (stuttering).
1. Speak on demonetization for five minutes
2. How‘s your performance – 20%
3. How many components of a good speech
a. Material
b. Volume of voice
c. Body gesture
d. Speed of voice
16 May 2017

Volume of
voice
20%
Body gesture
15%
Speed of
voice
5%
Material
40%
Lets re-rate the performance
by dividing 100% into all these four components
(80%)
16 May 2017

Silver lining
• There is always some positive aspect of each
negative experiences.
• Useful for real traumatic experience
• Silver lining could be –
a. Coping strength
b. I can better understand the feelings or other
persons suffered for same trauma
c. I can help other peoples through self-disclosure of
self used coping techniques
d. I am lucky and have more strength than others
because I survived.
16 May 2017

Labelling cognitive distortions
• Overestimation of threat
• Emotional reasoning
• Personification
• Catastrophizing
• Magnification and minimization
• Overgeneralization
• Tunnel vision
• Jumping to the conclusion
16 May 2017

Daily Thought Record
Day/
Time
Situation -ve Automatic
thought
Emotion
(0-100)
Alternative thought Outcome
…….. Dog
following
me on
street
1. Dog will
attack me
and bite me
2. I’ll dead
Fear –
80-90%
1. Dog may be
normally walking
to reach near
about shadow in
this hot,
2. Dog may be
walking to reach
the food spreads
on the side of
street
Fear – 10-
20%
16 May 2017

Imagery replacement
• Faulty mental images about the negative or life
threatening consequences for having exposure
of phobic stimulus or situation.
• Replace that image with adaptive or extreme
opposite of faulty image and then exposed to
the phobic situation or stimulus (RFBT).
16 May 2017

Survey method
Dog phobia
I’ll be dead if dog will bite
How many peoples are dead in a month by dog bite
(hospital) or how many relatives dead by dog bite
Rarely or no
Is it possible that you will be die
after dog bite
16 May 2017

Decatastrophizing
• What worst could be happen?
• If it does happen, how will your life be different,
three months from now?
• Eg. Height phobia
a. I will fall from the roof
b. I may be lost my leg or hand but I could be
alive and survive
16 May 2017

Cognitive Restructuring
• Advantage and disadvantage
• Inducing dissonance – (how it affects your job,
personal, family responsibility, social
responsibility etc.)
• Socializing cognitive model
• Examining evidence of fantasised consequences
(points in favour and points in against)
• Finding alternative assumption
• Testing alternative assumption
• Consolidating alternative assumption
16 May 2017

Eye movement
desensitization
16 May 2017

Eye movement desensitization
The adaptive information processing (AIP) model—the
theoretical framework for EMDR therapy—explains that
some memories associated with adverse life
experiences may remain unprocessed due to the high
level of disturbance experienced at the time of the
event. The stored memory may be linked to emotions,
negative cognitions, and physical sensations
experienced during the event and the unprocessed
memory can affect the way a person responds to
subsequent similar adverse experiences. Through
EMDR therapy, these fragmented memories can be
reprocessed so that they become more coherent and
less disruptive.
16 May 2017

The eight phases of EMDR therapy
• History taking: The therapist and client review past events, current
concerns and future needs, and identify target events for processing.
• Preparation: To prepare for coping with any distress that may arise
during the desensitization phase, the person in therapy selects a safe-
place image that can provide stabilization and self-control as needed.
• Assessment: With the distressing event in mind, the client’s negative
beliefs about himself or herself are recorded, evaluated, and
measured. In contrast, a desirable positive belief is selected, and this
belief is measured to determine how true it feels to the client. Physical
symptoms are recorded as well.
• Desensitization: Bilateral stimulation, in the form of eye movements,
tones, or taps are used to reprocess the distressing event. The
therapist will break periodically to check in on the client‘s level of
disturbance.
• Installation: The selected positive cognition is the target of the
bilateral stimulation in this phase. The therapist will check in
periodically to see how true the desired belief feels to the client.
16 May 2017

Conti…….
• Body scan: Any residual physical tension or distress
indicates that the event is not fully processed, and the
bilateral stimulation continues, if necessary.
• Closure: This phase will occur at the end of a session,
regardless of whether or not the memory is fully
processed. A complete sequence of EMDR therapy can
take several sessions, and it is important to reach
stabilization before the session ends. Closure can include
discussion of the session.
• Re-evaluation: The next session begins here, in order to
evaluate and measure the level of disturbance and the
accuracy of the targeted positive belief. If the target
remains unresolved, the session will resume with
desensitization, phase 4.
16 May 2017

Other techniques
• Distraction – rehabilitating or supportive therapy
• Social skill training – relapse prevention (social
phobia)
• Paradoxical intention
• Vicarious extinction
16 May 2017

Paradoxical intention – Viktor Frankl
This technique intensifies the client's emotional
state in order to help the client understand the
irrationality of the emotional reaction.
Social phobia – performance type – in real class
imagine and repeat the all heightened negative
irrational thought‘s and emotions aloud till the fear
reduced. Repeat it several times till felt no fear or
anxiety symptoms while doing this.
16 May 2017

Vicarious extinction
• Information about what is dangerous and safe in
the environment is often transferred from other
individuals through social forms of learning, such
as observation.
• Vicarious extinction is a form of modelling in
which a previously reinforced behaviour is
eliminated by withdrawal of consequences
applied to a model.
16 May 2017

A recent study - Armita Golkar et al. 2013
• found that when vicarious extinction compared
with a standard extinction procedure, vicarious
extinction promoted better extinction and
effectively blocked the return of previously
learned fear. they confirmed that these effects
could not be attributed to the presence of a
learning model per se but were specifically
driven by the model‘s experience of safety.
16 May 2017

Recent advances
• Virtual reality therapy
• Applied tension therapy
• Breathing retraining
• Neuro-linguistic programming
• Play, story, drawing
16 May 2017

Virtual reality exposure therapy
Virtual reality exposure therapy (VRET) employs modern
technology to simulate ET, and is only used in the treatment of
phobias.
In VRET, a virtual scene is designed to portray a realistic
encounter with the stimuli using auditory and visual sensory
channels (Tortella-Feliu, 2011). VRET is created from the
perspective of the person sitting before the computer, so the
interaction is as similar as possible to true ET. Some studies
found that VRET shows effect sizes similar to those of traditional
in vivo exposure (Tortella-Feliu, 2011). While VRET is very new
and requires further research and design, it allows for innovation
to enter the therapeutic process by introducing technology
(Tortella-Feliu, 2011).
16 May 2017

16 May 2017

Applied tension therapy
• For blood – injury – injection type
• In applied tension the muscles of the arms, legs, and
torso are tensed but not relaxed, will prevent the drop
of blood pressure and fainting.
• The diphasic pattern of symptoms and reasons for
feeling faint should be explained and this treatment
presented as a coping skill.
• First patient learn through modelling and tense the
body muscles for 10-15 seconds at a time then release
to normal.
• Repeat it till the patient learns the early sign of blood
pressure dropout and practice it immediately.
16 May 2017

Breathing retraining
• The way we feel is affected by the way we breathe.
When we are frightened, we don‘t need to take a
deep breath; we need to take a normal breath and
exhale slowly. Breathing out is associated with
relaxation, not breathing in. While concentrating on
a long, slow exhalation, say the words ‗calm‘ or
‗relax‘ , these are good words to use because they
are already associated with feeling peaceful and at
ease. They can also be dragged out to match the
long, slow exhalation, as in ‗r-e-e-e-l-a-a-a-x‘ or ‗c-a-
a-a-a-a-l-m‘.
16 May 2017

Instructions of breathing retraining
• take in a normal breath through your nose with
your mouth closed
• pause briefly while you count to four
• exhale very slowly (mouth open or closed,
whichever feels most comfortable) while saying
‗calm‘ or ‗relax‘ to yourself
• repeat the process. It is a good idea to repeat
the whole sequence 6 to 10 times at least twice a
day.
16 May 2017

Neuro-linguistic programming
• Neuro-Linguistic Programming (NLP) is a form of
exposure therapy that typically only requires one session
to treat phobias (Jemmer, 2005). NLP is used to
neutralize troubling memories and situations, and is
unique in that the client is not required to disclose
anything about the phobia to the practitioner. The
process employs ‗dissociated visualization‘, and is
commonly encorporated in the treatment of post-
traumatic stress disorder.
• Dog phobia of ms x 25 yrs old - During therapy session
patient would imagine that in the projection booth of a
movie theater. Looking down into the theater, she would
―see‖ herself sitting in the seats below. She would then
―turn on‖ the projector.
16 May 2017

Continue …..
A grainy, black and white film is displayed, depicting themselves having
exposure of a street dog. Throughout the viewing, patient must try to
remain composed and dissociated while watching herself having a
phobic response, and the visualization of herself seeing herself watch a
film can help her feel removed, and disconnected. Though the
encounter is only imagined, a client with a severe phobia may still
experience intense fear and anxiety, and the practitioner must
constantly remind her that she is safe, she is in the projector booth, and
she is in control of the film. The exercise is done multiple times with the
client experiencing less and less anxiety each time. Then the NLP
practitioner asks the client to ―reassociate‖ with the film, imagining
herself in the scene, which is now pictured in 3-dimensions and in vivid
color. She is asked to imagine the sounds, smells, and sensations of the
scene. The final stage of the process involves ―erasing the phobic
memory trace‖ by imagining the film rewinding very quickly, over and
over again (Jemmer, 2005).
•
• If NLP is successful, clients report feeling secure, calm, and detached
from the stimulus.
16 May 2017

Play, story, drawing
• Very useful for children and sometime for adults
also with low IQ.
• Cathartic way to release the traumatic experience
and modify it by using metaphors (Japanese
story- dear jindgi) with developing other
alternate coping skills through play and story.
16 May 2017

CBT for Social Phobia
• Behavioural experiment (evaluated irrational beliefs
in the light of audience feedback) – video recording
• Evidence analysis of performance
• Daily Thought Record for others behaviour or
reaction
• Reattributing performance
• Exposure and response prevention
• Social skill training
• Systematic desensitization
16 May 2017

CBT for Claustrophobia
• In-vivo or Imaginal exposure
• Prolonged exposure with assistance
• Virtual reality therapy
• Introcepective exposure (This method attempts to
recreate internal physical sensations within a patient
in a controlled environment and is a less intense
version of in vivo exposure.)
• Breathing retraining
• Survey technique
• Behavioural experiment
16 May 2017

CBT for Agoraphobia
16 May 2017

Phobia cbt

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