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Is there any empirical support evaluating the fast phobia cure?

Is there any empirical support evaluating the fast phobia cure?


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There have been several papers going against the effectiveness of NLP. One aggregate paper is referenced in the Wikipedia article on NLP, namely Witkowski (2010). However, NLP seems to encompass a wide variety of techniques. I'm particularly interested in the fast phobia cure.

Is there any empirical support for or against the fast phobia cure?

References

  • Witkowski, Tomasz (1 January 2010). "Thirty-Five Years of Research on Neuro-Linguistic Programming. NLP Research Data Base. State of the Art or Pseudoscientific Decoration?". Polish Psychological Bulletin 41 (2). doi:10.2478/v10059-010-0008-0.

Witkowski has written several articles reviewing NLP (2010, 2012) and in each case has found few studies that indicate clear support for the technique. He also argues that the articles which indicate no support for NLP are generally of stronger methodological quality than those which do not. The fast phobia cure is not directly mentioned in either paper.

Jemmer (2005) provides an overview of the fast phobia technique, and describes a handful of studies which have used and reported on it; you may find his paper to be a starting point for identifying information on the technique, although it seems most of the studies he cited are in the NLP database and it is unclear if they have been published in peer review journals. Jemmer's article acknowledges the lack of evidence, and is primarily written from a theoretical perspective.

A 2011 review identified three peer-reviewed studies and 1 dissertation that examined NLP techniques for phobia and reported the techniques to be effective (Biswal & Prusty). The review does not go into detail as to the exact NLP techniques used in these studies but this may be a source of literature for further reading. Biswal and Prusty (2011) also highlight some of the theoretical issues which have hampered NLP research and provide a helpful overview distinguishing some of NLP's techniques from other psychotherapeutic techniques.

A 2012 review examined 10 peer-reviewed NLP studies which were either randomized controlled trials or pre-post designs, 3 of which assessed fast phobia techniques (Sturt et al.). Some effects were found in terms of decreased fear or anxiety, but these generally occurred in all treatment groups (not just NLP) or in studies with no control group. Most outcomes were self-report measures. However, these studies may be the most relevant to your initial question.

Overall, the consensus of these reviews indicates that there is little evidence to support the use of NLP in general, including the fast phobia cure. However, the studies also note that the lack of high quality research may indicate more rigorous studies are needed before discarding the NLP concept entirely. Additionally, the reviews point out that several NLP phobia techniques are similar to other psychotherapy techniques for treating phobia, so there may be stronger evidence for those subcomponents elsewhere in the literature. These reviews should provide a good starting point and working vocabulary if you are interested in researching those subcomponents.

Biswal, R., & Prusty, B. (2011). Trends in neuro-linguistic programming (NLP): A critical review. Social Science International, 27(1), 41-56.

Jemmer, P. (2005). Phobia: Fear and loathing in mental spaces. European Journal of Clinical Hyponosis, 6(3), 24-32.

Sturt, J., Ali, S., Robertson, W., Metcalfe, D., Grove, A., Bourne, C., & Bridle, C. (2012). Neurolinguistic programming: A systematic review of the effects on health outcomes. British Journal of General Practice, November, e757-e764.

Witkowski, T. (2010). Thirty-five years of research on neuro-linguistic programming. NLP Research Database. State of the art or pseudoscientific decoration? Polish Psychological Bulletin, 41(2), 58-66.

Witkowski, T. (2012). A review of research findings on neuro-linguistic programming. The Scientific Review of Mental Health Practice, 9(1), 29-40.


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    Exposure Therapy for Anxiety Disorders

    Exposure-based therapies are highly effective for patients with anxiety disorders, to the extent that exposure should be considered a first-line, evidence-based treatment for such patients. In clinical practice, however, these treatments are underutilized, which highlights the need for additional dissemination and training.

    Over a quarter of the people in the US population will have an anxiety disorder sometime during their lifetime. 1 It is well established that exposure-based behavior therapies are effective treatments for these disorders unfortunately, only a small percentage of patients are treated with exposure therapy. 2,3 For example, in the Harvard/Brown Anxiety Research Project, only 23% of treated patients reported receiving even occasional imaginal exposure and only 19% had received even occasional in vivo exposure. 4 In part, this may be a lack of well-trained professionals, because most mental health clinicians do not receive specialized training in exposure-based therapies. 5,6

    Another factor may be that many health care professionals do not understand the principles of exposure or may even hold (usually unfounded) negative beliefs about this form of treatment. Surveys of psychologists who treat patients with PTSD show that the majority do not use exposure therapy and most believe that exposure therapy is likely to exacerbate symptoms. 7,8 However, individuals with trauma histories and PTSD express a preference for exposure therapy over other treatments. 9 Furthermore, exposure therapy does not appear to lead to symptom exacerbation or treatment discontinuation. 10 Indeed, a wealth of evidence indicates that exposure-based therapy is associated with improved symptomatic and functional outcomes for patients with PTSD. 11

    The available research literature suggests that exposure-based therapy should be considered the first-line treatment for a variety of anxiety disorders. Here we review a handful of the most influential studies that demonstrate the efficacy of exposure therapy. We also discuss theoretical mechanisms, practical applications, and empirical support for this treatment and provide practical guidelines for clinicians who wish to use exposure therapy and empirical evidence to guide their decision making.

    Exposure therapy is defined as any treatment that encourages the systematic confrontation of feared stimuli, which can be external (eg, feared objects, activities, situations) or internal (eg, feared thoughts, physical sensations). The aim of exposure therapy is to reduce the person’s fearful reaction to the stimulus.

    Graded exposure vs flooding

    Most exposure therapists use a graded approach in which mildly feared stimuli are targeted first, followed by more strongly feared stimuli. This approach involves constructing an exposure hierarchy in which feared stimuli are ranked according to their anticipated fear reaction (Table 1). Traditionally, higher-level exposures are not attempted until the patient’s fear subsides for the lower-level exposure. By contrast, some therapists have used flooding, in which the most difficult stimuli are addressed from the beginning of treatment (an older variant, implosive therapy, is not discussed in this article). In clinical practice, these approaches appear equally effective however, most patients and clinicians choose a graded approach because of the personal comfort level. 12,13

    In vivo vs imaginal

    In vivo exposure refers to real-world confrontation of feared stimuli. Sometimes, in vivo exposure is not feasible (eg, it would be both difficult and hazardous for someone with combat-related PTSD to experience the sights, sounds, and smells of combat in real life). In such cases, imaginal exposure can be a useful alternative. In imaginal exposure, the patient is asked to vividly imagine and describe the feared stimulus (in this case, a traumatic memory), usually using present-tense language and including details about external (eg, sights, sounds, smells) and internal (eg, thoughts, emotions) cues.

    In recent years, virtual reality exposure therapy (patients are immersed in a virtual world that allows them to confront their fears) has been examined as an alternative means of imaginal exposure, and preliminary data suggest that it can be quite effective. 14,15 Imaginal exposures can also be useful for confronting fears of worst-case scenarios (eg, patients with obsessive-compulsive disorder [OCD] who imagine that they might contract a deadly illness, patients with social phobia who imagine that they are being ridiculed) to reduce the aversiveness of the thought.

    What is already known about exposure therapy for anxiety disorder?

    ? Exposure therapy is defined as any treatment that encourages the systematic confrontation of feared stimuli, with the aim of reducing a fearful reaction. Over a quarter of the people in the US population will have an anxiety disorder sometime during their lifetime, and available research literature suggests that exposure-based therapies should be considered the first-line treatment for these disorders. Although it is well established that exposure-based therapies are effective treatments for these disorders, however, only a small percentage of patients are actually treated with this approach.

    What new information does this article provide?

    ? We review the results of a handful of the most influential studies that demonstrate the efficacy of exposure therapy and disseminate information about the theoretical mechanisms, practical applications, and empirical support for this treatment. In addition, we provide practical guidelines for clinicians who wish to use exposure-based therapies and empirical evidence to guide their decision making.

    What are the implications for psychiatric practice?

    ? In clinical practice, exposure-based therapies for anxiety disorders are underutilized, which highlights the need for additional dissemination and training. We hope the dissemination of the theoretical mechanisms, practical applications, and empirical support for exposure-based therapies in this article will encourage mental health practitioners to embrace this modality as a viable and easily accessible option in the treatment of anxiety disorders.

    Internal vs external

    Exposures can target internal and/or external cues. Exposures to external cues include a spider-phobic patient handling a spider, or a height-phobic patient systematically approaching increasing heights in a skyscraper. Using exposure to internal cues, a patient with panic disorder can run in place to experience physiological sensations (eg, heart palpitations) that elicit anxious reactions, a patient with generalized anxiety disorder (GAD) can purposefully induce worry thoughts, a patient with PTSD can revisit traumatic memories, and a patient with OCD can intention-ally evoke intrusive and aversive thoughts.

    With or without relaxation

    One of the earliest variations of exposure therapy was systematic desensitization, in which patients engage in imaginal exposure to feared stimuli while simultaneously undergoing progressive muscle relaxation. 16 Subsequent dismantling studies have shown that exposure, rather than relaxation, is the active ingredient and that relaxation does not improve outcomes. 17 The addition of relaxation exercises has been counterproductive in some patients, such as those with panic disorder. 18 Because of the apparent importance of interoceptive exposure (ie, learning to tolerate uncomfortable physical sensations), relaxation exercises aimed at decreasing these sensations may actually attenuate the outcome of therapy, in much the same way as does the use of as-needed short-acting benzodiazepines. 19

    Efficacy of exposure therapy

    Several studies have demonstrated the efficacy of exposure-based therapies for anxiety disorders, a finding that is summarized in several published meta-analyses. 20,21 st 22 examined the effects of single-session in vivo exposure (that lasts 1 to 3 hours) for patients with specific phobias. At posttreatment follow-up (after an average of 4 years), 90% of these patients still had significant reduction in fear, avoidance, and overall level of impairment and 65% no longer had a specific phobia.

    Barlow and colleagues 23 investigated the effects of interoceptive exposure with components of cognitive restructuring (cognitive-behavioral therapy [CBT]), imipramine, and a combination of the two in patients with panic disorder. At first, all treatments appeared equally efficacious however, at 6 months’ follow-up, 32% of patients in the CBT group continued to maintain their treatment gains compared with 20% in the imipramine group and 24% in the combined-treatment group.

    Foa and colleagues 24 randomized patients with OCD to receive in vivo exposure and response prevention, clomipramine, or a combination of both. For patients who completed the study, 86% in the exposure group improved on a measure that examined the frequency and severity of obsessions and compulsions compared with 48% in the clomipramine group and 79% in the combined-treatment group.

    Several others have also demonstrated the efficacy of exposure-based treatments or treatment components for patients with GAD, so-cial anxiety disorder, and PTSD. 25-27

    Theoretical mechanisms of exposure therapy

    Biologically, the extinction of fear appears to be mediated by N-methyl-d-aspartate receptor activity in the basolateral amygdala, a finding that has led to the use of neuroplasticity compounds such as d-cycloserine to augment exposure. 28,29 There are 4 major theories that attempt to explain the psychological mechanisms of exposure therapy: habituation, extinction, emotional processing, and self-efficacy (Table 2).

    Habituation theory purports that after repeated presentations of a stimulus, the response to that stimulus will decrease. 30 For example, initial exposure to ocean water can be cold. However, over time and with repeated exposures, the water feels less cold as the person acclimates. Similarly, when repeatedly facing a fear-provoking stimulus in exposure therapy, the patient experiences habituation, or a natural reduction in fear response. While many clinicians aim for habituation to occur within the session, researchers have found that optimal treatment effects occur during the period of learning consolidation between sessions. 31,32

    Extinction theory emerges from a classic conditioning model in which the unconditioned stimulus is a situation, place, or person that initially caused fear (the unconditioned response)-for example, a dog bite. Through the process of stimulus generalization, fear reactions become learned (conditioned response) and are elicited by other stimuli, such as dogs that are not dangerous (conditioned stimuli). Because of the aversiveness of the conditioned response, fearful individuals are motivated to avoid the conditioned stimuli, thus reinforcing avoidance behavior as well as the belief that relief from fear only comes from avoidance. 33

    Exposure therapy is thought to weaken the conditioned response through repeated exposure to the conditioned stimuli in the absence of the unconditioned stimulus. For example, exposure to dogs (conditioned stimuli) without being bitten (absence of unconditioned stimulus) weakens the relationship between the conditioned stimuli and the fear of conditioned response. One limitation of extinction theory is that most phobic patients do not identify an initial conditioning event. 34

    Emotional processing theory suggests that fear is stored in memory as a network of stimuli (eg, social gathering), response (eg, sweaty palms), and meaning (eg, “I’m not good at socializing, I’m a failure”) components. 35 Fearful individuals are thought to ascribe faulty meanings to stimuli in a way that increases fear toward those stimuli. Exposure to fear-provoking stimuli is thought to result in a new way of processing information and to correct the faulty fear structure. 36,37 For example, in patients with social anxiety disorder, social interactions can be perceived as rewarding, even if the patients have sweaty palms and feel some anxiety.

    The self-efficacy theory focuses more on increasing skills and mastery over a situation or performance than on reducing a fear response directly. 38 Persons with anxiety disorders tend to underestimate their capabilities to cope with fear. Therefore, persons able to face their fear and successfully tolerate it without avoiding it or withdrawing from it begin to realize they are more capable and resilient than they had imagined. Thus, they become more willing to face their fears in different contexts, thereby generalizing treatment effects.

    These theoretical mechanisms of exposure are not mutually exclusive, and all might be correct for any given patient. With repeated exposures, patients experience reduced sensations of fear (habituation), learn a new set of associations (extinction), feel increasingly able to cope with fear (self-efficacy), and generate new interpretations of the meanings of previously feared stimuli (emotional processing).

    Treatment guidelines

    Treatment guidelines for clinicians who use exposure therapy are shown in Table 3. The first step in successful exposure therapy is the development of an exposure hierarchy. The patient and clinician brainstorm as many feared external and internal stimuli as possible and then rate them in order of difficulty. The most common ranking method is the Subjective Units of Discomfort (SUD) scale, which assigns a 0 to 100 numeric value to each item. 39 (This scale can be found online in Wikipedia and at http://www.newworldencyclopedia.org/entry/Joseph-Wolpe.)

    The next step is to conduct exposures in a gradual and systematic manner. Repeated use of the SUD scale will help track the patient’s fear level as it increases and decreases. Typically, a higher item is not attempted until the patient’s SUD level decreases significantly for a lower-ranked item.

    During exposure therapy, safety behaviors should be eliminated to the extent possible. Safety behaviors refer to all unnecessary actions the patient takes to feel better or to prevent feared catastrophes. Left unchecked, safety behaviors can undermine the process of exposure therapy by teaching the patient a rule of conditional safety (eg, “The only way to be safe during a panic attack is to have my medication with me”) rather than a rule of unconditional safety (eg, “Panic attacks will not harm me, regardless of whether I am carrying my medications”).

    Cognitive restructuring may also be used as an adjunct to exposure therapy. Cognitive restructuring refers to identifying and challenging irrational, unrealistic, or maladaptive beliefs. In patients with anxiety disorders, 2 of the more common faulty thinking patterns (ie, cognitive distortions) are probability overestimation and catastrophizing. Probability overestimation refers to the overprediction of unlikely outcomes, such as the belief that a commercial flight is highly likely to crash. Catastrophizing refers to the magnification of the consequences of aversive outcomes, such as the belief that making a mistake during a speech will lead to a lifetime of ridicule and ostracism. During the process of exposure exercises, the therapist helps the patient identify these cognitive distortions examine the evidence for and against the beliefs and rehearse new, more realistic ways of thinking.

    Exposure-based therapies are highly effective for patients with anxiety disorders, to the extent that exposure should be considered a first-line, evidence-based treatment for such patients. In clinical practice, however, these treatments are underutilized, which highlights the need for additional dissemination and training. We hope this information will encourage clinicians to embrace exposure-based therapies for anxiety disorders as a viable and easily accessible treatment option.

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    12. Ost LG, Alm T, Brandberg M, Breitholtz E. One vs five sessions of exposure and five sessions of cognitive therapy in the treatment of claustrophobia. Behav Res Ther. 200139:167-183.
    13. Moulds ML, Nixon RD. In vivo flooding for anxiety disorders: proposing its utility in the treatment posttraumatic stress disorder. J Anxiety Disord. 200620:498-509.
    14. Michaliszyn D, Marchand A, Bouchard S, et al. A randomized, controlled clinical trial of in virtuo and in vivo exposure for spider phobia. Cyberpsychol Behav Soc Netw. 201013:689-695.
    15. Meyerbröker K, Emmelkamp PM. Virtual reality exposure therapy in anxiety disorders: a systematic review of process-and-outcome studies. Depress Anxiety. 201027:933-944.
    16. Wolpe J. The systematic desensitization treatment of neuroses. J Nerv Ment Dis. 1961132:189-203.
    17. Telch MJ, Lucas JA, Schmidt NB, et al. Group cognitive-behavioral treatment of panic disorder. Behav Res Ther. 199331:279-287.
    18. Schmidt NB, Woolaway-Bickel K, Trakowski J, et al. Dismantling cognitive-behavioral treatment for panic disorder: questioning the utility of breathing retraining. J Consult Clin Psychol. 200068:417-424.
    19. Westra HA, Stewart SH, Conrad BE. Naturalistic manner of benzodiazepine use and cognitive behavioral therapy outcome in panic disorder with agoraphobia. J Anxiety Disord. 200216:233-246.
    20. Norton PJ, Price EC. A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. J Nerv Ment Dis. 2007195:521-531.
    21. Tolin DF. Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clin Psychol Rev. 201030:710-720.
    22. Öst LG. One-session treatment for specific phobias. Behav Res Ther. 198927:1-7.
    23. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial [published corrections appear in JAMA. 2000284:2450 JAMA. 2000284:2597]. JAMA. 2000283:2529-2536.
    24. Foa EB, Liebowitz MR, Kozak MJ, et al. Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry. 2005162:151-161.
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    26. Gerardi M, Cukor J, Difede J, et al. Virtual reality exposure therapy for post-traumatic stress disorder and other anxiety disorders. Curr Psychiatry Rep. 201012:298-305.
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    Part 1: What guidelines should be applied to the evaluation of psychological research and practices? Part 2: What ethical dilemmas might arise in psychological research and how might they be avoided?


    BACKGROUND

    Social media is a common part of modern social life, yet is not easily defined since concepts, design and usage are readily changing with new technology and shifting user habits (Obar & Wildman, 2015 ). Nonetheless, all social media share common core elements: (1) the social media user is both a creator and consumer of content, sharing their own content and reacting on others’ by commenting, sharing or “liking” (2) the user profile is essential for creating and gaining access to content and (3) social media provides the possibility of establishing social networks such as “friends” (e.g., Facebook) or “followers” (e.g., Twitter) (Obar & Wildman, 2015 ). Traditional internet forums and chat applications do not aim to facilitate social networks and are therefore not considered to be social media, although they are sometimes extensions of them (e.g., Facebook Messenger) and have similar features (e.g., liking posts and following specific forum users). Internet and social media interactions also share common features: for instance, communication is seldom carried out in real time or face-to-face.

    Social anxiety disorder (SAD) or social phobia (American Psychiatric Association, 2013 ) is common among anxiety disorders, with a point prevalence of 15.6% in Sweden (Furmark, 1999 ). Fear of being criticized or negatively evaluated is the core characteristic, leading to avoidance of social situations which in turn impacts daily functioning (American Psychiatric Association, 2013 ). For individuals with SAD, modern social media may serve as an alternative venue for social interaction that is less distressing, although they may ultimately maintain catastrophic beliefs and functional impairments. Results of a recent meta-analysis confirm a preference for computer-mediated communication over communication face-to-face among socially anxious individuals (Prizant-Passal, Shechner, & Aderka, 2016 ). Higher social anxiety appears associated with perceiving internet interactions as less risky when it comes to being negatively evaluated (Lee & Stapinski, 2012 ), entailing that social media may provide a context where social anxiety is more easily controlled, since symptoms of anxiety such as blushing or shaking will not show (Prizant-Passal et al., 2016 ). Safety behaviors, that is, behaviors that are used in order to avoid an expected social catastrophe, could therefore be seen as being automatically employed while interacting on social media. Social media specific safety behaviors such as removing tags of oneself from photos or monitoring others’ responses to one’s posts also seem to be used more frequently by individuals with higher social anxiety (Carruthers, Warnock-Parkes, & Clark, 2019 ). At the same time, higher social anxiety has been associated with more frequent self-disclosures when communicating over the internet compared to face-to-face (Weidman, Fernandez, Levinson, Augustine, Larsen, & Rodebaugh, 2012 ), as well as having more information on Facebook profiles (such as interests) compared to others (Fernandez, Levinson, & Rodebaugh, 2012 ), strengthening the hypothesis that computer-mediated communication is perceived as less anxiety-provoking than face-to-face interactions.

    The preference for computer-mediated communication would suggest that socially anxious individuals spend more time on the internet or social media compared to others. The empirical support for this hypothesis is however mixed and inconclusive (Prizant-Passal et al., 2016 ). A recent review states that there is no clear association between time spent on social media and social anxiety (Seabrook, Kern, & Rickard, 2016 ). However, for the reasons discussed above, overall time spent on social media might be too unspecific as a measure. More detailed measurements are needed in order to better understand social media usage among individuals with social anxiety. Measuring passive and active use of social media seems promising in that regard. Passive use is characterized by consuming content without social interaction, whereas active use involves creating content and interacting with others (Frison & Eggermont, 2016 ). Indeed, a recent study found that higher social anxiety was associated with passive use of Facebook and remained the only significant predictor when entered together with content production and interactive communication in a regression model (Shaw, Timpano, Tran, & Joormann, 2015 ). There is no agreement in the extant literature on what is defined as active social media use, with some studies finding two separate factors for active use public and private (Frison & Eggermont, 2015 , 2016 ), while others find only one factor (i.e. active use) (Thorisdottir, Sigurvinsdottir, Asgeirsdottir, Allegrante, & Sigfusdottir, 2019 ). Public active use such as commenting on friends’ posts offers less control of privacy (e.g., visibility and recipients) compared to private active use such as chatting using Facebook Messenger (Green, Wilhelmsen, Wilmots, Dodd, & Quinn, 2016 ). However, the division of active use is complicated since privacy settings can vary from user to user (Green et al., 2016 ) and also depends on what social media platform is being used. Although the internet and social media might be less anxiety provoking than face-to-face interactions, the quality of relationships, for example, reciprocity and openness, has been reported to be low for socially anxious individuals regardless of relationships being online or face-to-face (Lee & Stapinski, 2012 ). At the same time, social support derived from Facebook has been shown to contribute to subjective well-being more so than social support face-to-face, and Facebook could therefore play an important role for individuals with social anxiety (Indian & Grieve, 2014 ).

    In sum, the association between social anxiety and social media use is complex and needs to be explored further. A better understanding of the role of social media use and its association with social anxiety could inform treatment models to accommodate this aspect of modern life, for example, by creating exposure exercises involving social media usage. The Social Anxiety Scale for Social Media Users (SAS-SMU) (Alkis, Kadirhan, & Sat, 2017 ) is a recently developed self-report measure of social anxiety in the context of social media use and could facilitate further research. The original SAS-SMU is in Turkish and has since then been translated into an English version (Alkis et al., 2017 ), which has been employed in several studies (Aluh, Chukwuobasi, & Mosanya, 2019 Farrell, 2019 Ruggieri, Santoro, Pace, Passanisi, & Schimmenti, 2020 ). However, only its Turkish version has been validated previously (Alkis et al., 2017 ). Cross-culturally validated scales are needed since cultural factors can influence the manifestation of social anxiety (Spence & Rapee, 2016 ).

    The current study describes the development of a Swedish version of the SAS-SMU and the psychometric evaluation thereof, including examining underlying dimensions, internal consistency as well as convergent and divergent validity in a Swedish population. We also explore in-depth associations between different types of social media use (passive and active) and social anxiety.


    Cognitive Approach to Depression

    Characteristics of Depression

    Depression is a mood, or affective disorder. This mental Illness is a collection of physical, emotional, mental and behavioral experiences that are severe, prolonged and damaging to everyday functioning.

    The criteria for depression to be diagnosed using the DSM-IV-TR is that at least 5 or more symptoms of depression should be apparent. The possible symptoms include:

    Behavioral (How do you BEHAVE when you're depressed?): Neglect of personal appearance, loss of appetite, disturbed sleep patterns (insomnia), loss of energy (tiredness), withdrawal from others.

    Emotional (How do you FEEL when you're depressed?): Intense sadness, irritability, apathy (loss of interest of enjoyment), feelings of worthlessness, anger.

    Cognitive (How do you THINK when you're depressed?): Negative thoughts, lack of concentration, low self-esteem, poor memory, recurrent thoughts of death, low confidence.

    The cognitive approach believes that depression stems from faulty cognitions about others, our world and us. This faulty thinking may be through cognitive deficiencies (lack of planning) or cognitive distortions (processing information inaccurately). These cognitions cause distortions in the way we see things and caused behavior such as depression.

    Ellis suggested depression occurs through irrational thinking, while Beck proposed the cognitive triad.

    AO2 Scenario Question

    Ben recently moved away from home to go to university. He was loving his new life of going out, meeting new friends, his new university course. However, after a while he struggled getting out of bed and started to become very tired.

    His eating patterns changed and he lost a lot of weight. He noticed that he got angry at little things and snapped at his friends. When he was sat in lectures, he found it hard to concentrate for long periods of time.

    Identify the behavioral, emotional and cognitive aspects of Ben’s state. (3 marks)

    Beck’s Negative Triad

    The cognitive triad are three forms of negative (i.e. helpless and critical) thinking that are typical of individuals with depression: namely negative thoughts about the self, the world and the future. These thoughts tended to be automatic in depressed people as they occurred spontaneously.

    For example, depressed individuals tend to view themselves as helpless, worthless, and inadequate. They interpret events in the world in a unrealistically negative and defeatist way, and they see the world as posing obstacles that can’t be handled. Finally, they see the future as totally hopeless because their worthlessness will prevent their situation improving.

    The negative triad interacts with negative schemas and cognitive biases to produce depressive thinking.

    Cognitive biases are distortions of thought processes. Individuals with depression are prone to making logical errors in their thinking and they tend to focus selectively on certain negative aspects of a situation while ignoring equally relevant positive information.

    In addition to cognitive biases, the negative triad is also influenced by schemas. In essence, schemas can be seen as deeply held beliefs that have their origins primarily in childhood. Beck believed that depression prone individuals develop a negative self-schema. They possess a set of beliefs and expectations about themselves that are essentially negative and pessimistic.

    Beck claimed that negative schemas may be acquired in childhood as a result of a traumatic event (e.g. parental or peer rejection). Schemas influence how a person interprets events and experiences in their life. Beck predicted that in depression ‘latent’ (i.e. dormant) negative schemas that have been formed in childhood become activated by a life events or ongoing stressors.

    Negative schemas and cognitive biases maintain the negative triad, a pessimistic view of the self, the world (not being able to cope with the demands of the environment) and the future.

    It may be that negative thinking generally is also an effect rather than a cause of depression. Perhaps individuals only start experiencing negative thoughts after having developed depression. However, evidence that negative thinking can be involved in the development of depression was obtained by Lewinsohn et al. (2001).

    They measured negative thinking in non-depressed adolescents. One year later, the life events of participants over the previous 12 months were assessed, and also whether they were suffering from depression.

    The results showed those who had experienced many negative life events had an increased likelihood of developing depression only if they were initially high in negative attitudes. This study supports the theory that negative beliefs are a risk factor for developing depression when exposed to stressful life events.

    The cognitive approach to depression is limited in that genetic factors are ignored.

    Little attention is paid to the role of social factors relating to life events and gender in the cognitive explanation of depression.

    Ellis’s ABC Model

    Albert Ellis (1957, 1962) proposes that each of us hold a unique set of assumptions / beliefs about ourselves and our world that serve to guide us through life and determine our reactions to the various situations we encounter.

    Unfortunately, some people’s assumptions are largely irrational, guiding them to act and react in ways that are inappropriate and that prejudice their chances of happiness and success. Albert Ellis calls these basic irrational assumptions.

    According to Ellis, depression does not occur as a direct result of a negative event but rather is produced by the irrational thoughts (i.e. beliefs) triggered by negative events.

    Ellis believes that it is not the activating event (A) that causes depression (C), but rather that a person interpret these events unrealistically and therefore has an irrational belief system (B) that helps cause the consequences (C) of depressive behavior.

    For example, some people irrationally assume that they are failures if they are not loved by everyone they know (B) - they constantly seek approval and repeatedly feel rejected (C). All their social interactions (A) are affected by this assumption, so that a great party can leave them dissatisfied because they don’t get enough compliments.

    The precise role of cognitive processes is yet to be determined. It is not clear whether faulty cognitions are a cause of the psychopathology or a consequence of it.

    Sometimes these negative cognitions are in fact a more accurate view of the world: depressive realism.

    Cognitive theories lend themselves to testing. When experimental subjects are manipulated into adopting unpleasant assumptions or thought they became more anxious and depressed (Rimm & Litvak, 1969).

    Treatment - CBT

    How would you use the therapy

    Cognitive behavioral therapy aims to change the way a client thinks, by challenging irrational and maladaptive thought processes and this will lead to a change in behavior as a responses to new thinking patterns. Specifically, our thoughts determine our feelings and our behavior.

    Therefore, negative - and unrealistic - thoughts can cause us distress and result in problems. When a person suffers with psychological distress, the way in which they interpret situations becomes skewed, which in turn has a negative impact on the actions they take.

    Cognitive therapists help clients to recognize the negative thoughts and errors in logic that cause them to be depressed. The therapist also guide clients to question and challenge their dysfunctional thoughts, try out new interpretations, and ultimately apply alternative ways of thinking in their daily lives.

    The clients learn to discriminate between their own thoughts and reality. They learn the influence that cognition has on their feelings, and they are taught to recognize observe and monitor their own thoughts.

    The behavior part of the therapy involves setting homework for the client to do (e.g. keeping a diary of thoughts). The therapist gives the client tasks that will help them challenge their own irrational beliefs.

    The idea is that the client identifies their own unhelpful beliefs and them proves them wrong. As a result, their beliefs begin to change. For example, someone who is anxious in social situations may be set a homework assignment to meet a friend at the pub for a drink.

    CBT would be used when a person's faulty thinking was effecting their life in a negative way.

    A strength of this therapy is that it has shown to be very effective in treating depression, in fact, it has shown to produce longer lasting recovery than antidepressants.

    The precise role of cognitive processes is yet to be determined. It is not clear whether faulty cognitions are a cause of the psychopathology or a consequence of it.

    Sometimes these negative cognitions are in fact a more accurate view of the world: depressive realism.

    Cognitive theories lend themselves to testing. When experimental subjects are manipulated into adopting unpleasant assumptions or thought they became more anxious and depressed (Rimm & Litvak, 1969).

    An important advantage of CBT is that it tends to be short (compared to psychoanalysis), taking three to six months for most emotional problems. Patients attend a session a week, each session lasting either 50 minutes or an hour.

    Another strength is that it can reduce ethical issues – the way this therapy works is that the client is actively involved and in control. They feel empowered as they are helping themselves.

    AO2 Scenario Question

    Jack suffers from depression. His symptoms include loss of concentration, lack of sleep and struggles to sleep at night. He finds himself having absolutist thinking thinking that everything is negative and bad all the time.

    How might a cognitive behavior therapist tackle Jack’s depression? (4 marks)


    The behavioural approach to treating phobias

    The behavioural approach in the treatment of phobias focused on systematic desensitisation, and a technique known as flooding.

    Systematic Desensitisation

    Systematic desensitisation is based on the assumption that if phobias are a learned response as classical and operant conditioning suggests, then they can be unlearnt.

    Phobics may avoid the stimulus that causes them to fear hence they never learn the irrationality of this fear. Through a process of classical conditioning, systematic desensitisation teaches patients to replace their fearful feelings through a process of hierarchal stages which gradually introduces the person to their feared situation one step at a time.

    The hierarchy is constructed prior to treatment starting from the least feared to most feared situation working towards contact and exposure. Throughout these stages, patients are taught relaxation techniques that help manage their anxiety and distress levels to help them cope but also to associate these feelings of calmness towards the phobia. Earlier stages may involve pictures of the phobic situation (a picture of a snake for example if this is their fear) which may then lead to the goal of holding one. As patients master each step they move on to the next. For other scenario’s covert desensitisation is used which involves imagining contact instead.

    Relaxation techniques taught may help the patient focus on their breathing and taking slower, deeper breaths as anxiety often results in faster, shallow breathing and this helps manage this. Mindfulness techniques such as “here and now” skills may also be used which involves focusing on a particular object or visualising a relaxing scene. Progressive muscle relaxation involves straining and relaxing muscle groups gently and this can help relax the body from tension too.

    Counter-conditioning involves classical condition and may also be used as part of systematic desensitisation by creating a new association which runs alongside the current phobic situation. For example, the patient may be taught to associate relaxation instead of fear to their phobic situation and as fear and relaxation are incompatible with one another, anxiety is reduced.

    Systematic desensitisation evaluation

    A weakness for systematic desensitisation is that it is not appropriate for all patients and only those who have the capacity to learn relaxation strategies and for those who have imaginations vivid enough to imagine the feared situations in question. There is also no guarantee that learning to imagine and cope with phobic situations will actually translate into it working in the real world either.

    Another weakness is systematic desensitisation is time-consuming and costly for people to use which may make it inappropriate. Patients need to attend numerous appointments and to build trust with their practitioner who is a stranger which can in itself be difficult. Also, the strategy is dependent on the skill-set of the practitioner themselves which can affect how long this treatment takes or if it works at all.

    A strength, however, is that there is strong evidence that suggests systematic desensitisation is effective with numerous research studies finding it a success. McGrath et al (1990) reported 75% of patients responded positively with S and exposure to the feared stimulus (Vivo techniques) was believed to be one of the main reasons. Vitro techniques which involve patients imagining the feared stimulus were less effective in comparison (Choy et al 2007).
    There are ethical issues which arise with SD as it deliberately exposes patients to their fears which can cause psychological harm as there is no guarantee they will cope with it well. They may go on to have nightmares or their fear may even get worse to a point their life becomes dysfunctional. With this in mind, it may not always be appropriate for all patients and a cost-benefit analysis may be needed to weigh the benefits and costs with both short-term and long-term in mind.

    A strength of systematic desensitisation over CBT is it requires relatively little insight from the patient. Where CBT requires a person to have a good level of insight and self-awareness into their thinking to challenge their irrational thoughts, systematic desensitisation relies on simple conditioning which is easily learnt by patients.

    Systematic desensitisation: Flooding

    Flooding is an alternative approach to systematic desensitisation and either exposes the patient directly to their phobia or they are asked to imagine an extreme form of it.

    The client is also taught and encouraged to use relaxation techniques prior to the exposure to the phobic situation which continues until the patient is able to fully relax.

    In fear-based situations, the patient will release adrenaline however this will eventually cease with relaxation being associated with their feared stimulus as they are unable to use their normal avoidance methods. The procedure can be conducted using virtual reality too.

    Systematic desensitisation: Flooding evaluation

    Flooding raises serious ethical issues as it deliberately exposes patients to their fears which can cause severe psychological harm as there is no guarantee they can eventually cope with the situation. They may go on to have nightmares or even make their phobia worse to a point that their life becomes dysfunctional. With this in mind, it may not always be appropriate for all patients and a cost-benefit analysis may be needed to weigh the benefits and costs with both short-term and long-term in mind.

    As not everyone may be able to cope with this form of treatment, its effectiveness may be down to individual differences. Not everyone enjoys good physical health and subjecting such individuals to highly stressful situations through flooding may risk health problems i.e. heart attacks.

    A benefit to flooding, however, is the treatment is relatively quick to administer and effective with Choy et al (2007) reporting it to be more effective than SD.

    Possible exam questions for the behavioural approach to treating phobias:

    • Outline and evaluate how systematic desensitisation can be used to treat phobias
    • Outline and evaluate how flooding is used to treat phobias
    • Outline and evaluate the behavioural approach to treating phobias (12 marks AS, 16 marks A-level).

    Albert Ellis

    Key Study: Ellis' ABC Model 1962

    Albert Ellis helped define the cognitive approach and our understanding of it. This approach is rooted in the understanding that it is our thoughts which create our emotions and behaviour. He called this his ABC model, which is explained in further detail below.


    How it works

    The rewind technique, also known as the fast phobia cure, evolved from the technique developed by Richard Bandler one of the co-founders of Neuro Linguistic Programming (NLP). He called it the VK dissociation technique (the V stands for visual and the K for kinaesthetic — feelings). The version recommended by the European Therapy Studies Institute has been refined and streamlined, as a result of its own research into why and how best it works.[2] It is highly useful for individuals who, after exposure to traumatic events, have developed PTSD or lesser forms of the condition. When Keith began practising the rewind technique with traumatised clients, he found it consistently effective, almost immediately.

    Simply described, the technique works by allowing the traumatised individual, whilst in a safe relaxed state, to reprocess the traumatic memory so that it becomes stored as an 'ordinary', albeit unpleasant, and non- threatening memory rather than one that continually activates a terror response. This is achieved by enabling the memory to be shifted in the brain from the amygdala to the neocortex.

    The amygdala's role is to alert us to danger and stimulate the body's 'fight or fight' reaction. Normally, all initial sensations associated with a threatening experience are passed to the amygdala and formed into a sensory memory, which in turn is passed on to the hippocampus and from there to the neocortex where it is translated into a verbal or narrative memory and stored. When an event appears life-threatening, however, there can be sudden information overload and the sensory memories stay trapped in the amygdala instead of being passed on to, and made sense of by, the neocortex. While trapped in the amygdala, the trauma memory has no identifiable meaning. It cannot be described, only re-experienced in some sensory form, such as panic attacks or flashbacks. The rewind technique allows that sensory memory to be converted into narrative, and be put into perspective.

    The Rewind Technique:

    The rewind technique should be carried out by an experienced practitioner and is only performed once a person is in a state of deep relaxation.

    When they are fully rested, they are encouraged to bring their anxiety to the surface and then are calmed down again by being guided to recall or imagine a place where they feel totally safe and at ease. Their relaxed state is the deepened and they are asked to imagine that, in their special safe place, they have a TV set or other device with a screen, and a remote control.

    They are asked to imagine floating to one side, out of body, and watch themselves watching the screen, without actually seeing the picture (double disassociation). They watch themselves watching a 'film' of the traumatic even that is still effecting them. The film begins at a point before the trauma occurred and ends at a point at which the trauma is over and they feel safe again.

    They are then asked, in their imagination, to float back into their body and experience themselves going swiftly backwards through the trauma, from safe point to safe point, as if they were a character in a video that is being rewound. They then watch the same images but as if on a TV screen while pressing the fast-forward button (disassociation). All this is repeated back and forth, at whatever speed feels comfortable, and as many times as needed, till the scenes evoke no emotion from the client.

    If the feared circumstance is one that will be confronted again in the future - for instance, driving a car or using a lift - the person is asked, while still relaxed, to see themselves doing so confidently.

    Besides being safe, quick, and painless, the technique has the advantage of being non-voyeuristic. Intimate details do not have to be made public.


    Summary and Conclusions

    The current accumulated research and clinical focus on comorbid anxiety and substance use disorders has provided important insights into the prevalence, development and maintenance patterns, clinical impact, and treatment considerations for these intertwined psychiatric problems. However, further research is imperative to further spur the field toward solidifying the empirical foundations for state-of-the-art, standard clinical care. Additionally, future studies exploring the uniqueness of the associations between specific disorder pairings (e.g., comorbid SAD and alcohol dependence versus comorbid GAD and sedative dependence) are necessary to yield information on optimizing tailored treatments. Fortunately, research in these areas is ongoing and primed to advance psychiatric care for individuals experiencing comorbid anxiety and substance use disorders.


    Types of Brief Therapy

    There are many approaches to brief therapy. Typically, existing long-term therapies have been adapted to a short-term context.

    Single-Session Therapy

    Theory of Single-Session Therapy

    In single-session therapy, the therapist and client meet only once. The goal of single-session therapy is to encourage new learning, enhance coping, and promote growth. Typically, a single session is used to help a client shift perspective or acquire skills. Single-session therapy is most effective for individuals with specific problems who (a) need a change in perspective, (b) need an evaluation or referral, (c) feel stuck about processing a past event, (d) are looking for reassurance, or (e) have a specific problem that is within their power to solve. In contrast, individuals in inpatient care, individuals needing continuing support to process traumatic past events (e.g., childhood sexual abuse), individuals with eating disorders or chronic pain, and individuals with conditions caused by biological or chemical mechanisms (e.g., schizophrenia) are not as likely to benefit from single-session therapy or any of the brief therapies.

    Techniques of Single-Session Therapy

    Diverse techniques are employed in single-session therapy. For example, the therapist may contact the client by phone before meeting to obtain detailed information about the presenting problem and to ask the client to complete specific tasks before the session. A second popular technique is to focus on ambiguity during the session. Focusing on ambiguity allows the therapist to introduce new ways of looking at the same problem. Clients often practice possible solutions during the session. Rehearsing ideal outcomes or practicing new skills can help a client feel more able to transfer skills from the therapy session to everyday life. After the session is over, the therapist informs the client that he or she can return for another session if necessary.

    Cognitive-Behavioral Brief Therapy

    Theory of Cognitive-Behavioral Brief Therapy

    Cognitive-behavioral brief therapy focuses on schemas. Schemas are templates that individuals use in order to make decisions, guide responses, or explain situations. Schemas develop from life experiences and become a standard of normal behavior. Thus, whenever a critical event occurs, the individual uses a schema to decide how to react. Schemas may not be based on accurate information, so relying on some schemas may result in cognitive distortions. For example, if a child were punished whenever interrupting an adult, that child may develop beliefs that make him or her hesitant to interrupt, even as an adult.

    Techniques of Cognitive-Behavioral Brief Therapy

    The focus in cognitive-behavioral brief therapy is to identify and replace distorted cognitions based on schemas. Goal setting is central to cognitive-behavioral brief therapy. It serves as a mechanism for measuring treatment effectiveness. Each goal should have specific objectives, be worded positively, and be realistic. Cognitive-behavioral brief therapy focuses on meeting each goal, as opposed to focusing on client insight or the process of therapy.

    Short-Term Dynamic Psychotherapy

    Theory of Short-Term Dynamic Psychotherapy

    Short-term dynamic psychotherapy focuses on affect phobia. Affect phobia is an internal phobia in which individuals are afraid to experience a particular feeling (e.g., anger, shame). According to short-term dynamic theory, affect is the basic motivation that drives individuals, and affect phobias are the culprit of most behavior problems.

    Triangles are used to diagram conflicts and people in short-term dynamic psychotherapy. The triangle of conflict is used to conceptualize the way an individual avoids a feeling and the triangle of person is used to conceptualize the recipient of that feeling. The triangle of conflict uncovers defenses, anxieties, and adaptive feelings. Each point on a triangle is called a pole. The defense pole consists of behaviors (e.g., avoidance), thoughts (e.g., “I’m incompetent”), or feelings (e.g., fear). These defenses can be adaptive and helpful, but they become harmful when they result in maladaptive behaviors. The anxiety pole consists of inhibitory feelings that lead individuals to become vigilant about their own or others’ behaviors. There are four major categories of inhibitory feelings: anxiety, shame/guilt, emotional pain, and contempt/disgust. The feelings pole represents normal adaptive behaviors that are motivated by underlying basic feelings and impulses (e.g., grief, anger, excitement, sexual desire). These feelings can be healthy, but individuals avoid them when the feelings are associated with a negative experience. The triangle of conflict helps the therapist to identify defensive patterns used by the client to avoid feelings, identify how and why a client is using inhibitory feelings, and help the client understand the underlying affect that is being avoided.

    The triangle of person helps the therapist recognize the relationships where patterns of avoidance occur. These can include past relationships, current relationships, or the relationship between the client and therapist.

    Techniques of Short-Term Dynamic Psychotherapy

    The goal of short-term dynamic psychotherapy is to restructure defenses, affect, and attachments. There are several main objectives. First, the client should acknowledge and understand the defensive pattern. Second, the client should be motivated to change the defensive pattern. Third, in order to desensitize the affect phobia, the client must experience and express appropriate feelings. Fourth, the therapist must listen to the client and help identify healthy feelings that can help the client to behave more effectively and experience relief from his or her symptoms.

    Gestalt Brief Therapy

    Theory of Gestalt Brief Therapy

    From a Gestalt perspective, individuals are experiencing difficulty because they have become fragmented by disowning different parts of themselves. Therefore, the aim of Gestalt brief therapy is to reintegrate the fragmented parts of the individual. Once the reintegration process has occurred, the individual can successfully interact with him- or herself, others, and the environment. In Gestalt brief therapy, the focus is on growth and process. Nonverbal cues are a key part of Gestalt brief therapy. In fact, if the verbal content of the client is in conflict with the nonverbal content of the client, the nonverbal content is usually considered more important. For example, if a client reports feeling relaxed but fidgets constantly, then the therapist would assume that the client is not relaxed. The therapist may also point out this incongruence during the session.

    Techniques of Gestalt Brief Therapy

    Gestalt brief therapy uses Duey Freeman’s therapeutic circle as a guide for brief therapy. There are six stages in Gestalt brief therapy. First, therapy must begin with a present or here-and-now focus. Gestalt brief therapy helps the client to increase awareness of immediate feelings, experiences, and situations. Second, an issue is identified. The therapist does not direct the client to identify a particular issue. Instead, the therapist simply helps the client increase awareness of the here and now, and trusts the client to talk about an issue that is important.

    Third, the therapist may conduct an “experiment” during the session. Gestalt therapy considers techniques to be experiments. For example, the therapist may make a client aware of nonverbal cues throughout the session. Perhaps the most popular experiment is the empty chair technique. In this experiment, a client is asked to initiate a dialogue between the two parts of the self that are in conflict, or with another person with whom the client is experiencing conflict. Each time the client switches perspectives, the client switches chairs and talks to an empty chair as if the other part of the self or the other person were in the chair.

    Fourth, the therapist identifies and discusses the behavior that is causing the problem. This moves the discussion from the present to the past, but in Gestalt brief therapy, the past is discussed in the context of how the client is currently experiencing issues from the past in the present. Therefore, the emphasis is not on discussing the past, but experiencing the past. Fifth, the client and therapist explore alternative behaviors. These alternate behaviors may be external or internal. Sixth, the therapist and client discuss how life is different when trying these alternate behaviors. The therapist assists the client in the integration of these new behaviors into daily life.


    How it works

    The rewind technique, also known as the fast phobia cure, evolved from the technique developed by Richard Bandler one of the co-founders of Neuro Linguistic Programming (NLP). He called it the VK dissociation technique (the V stands for visual and the K for kinaesthetic — feelings). The version recommended by the European Therapy Studies Institute has been refined and streamlined, as a result of its own research into why and how best it works.[2] It is highly useful for individuals who, after exposure to traumatic events, have developed PTSD or lesser forms of the condition. When Keith began practising the rewind technique with traumatised clients, he found it consistently effective, almost immediately.

    Simply described, the technique works by allowing the traumatised individual, whilst in a safe relaxed state, to reprocess the traumatic memory so that it becomes stored as an 'ordinary', albeit unpleasant, and non- threatening memory rather than one that continually activates a terror response. This is achieved by enabling the memory to be shifted in the brain from the amygdala to the neocortex.

    The amygdala's role is to alert us to danger and stimulate the body's 'fight or fight' reaction. Normally, all initial sensations associated with a threatening experience are passed to the amygdala and formed into a sensory memory, which in turn is passed on to the hippocampus and from there to the neocortex where it is translated into a verbal or narrative memory and stored. When an event appears life-threatening, however, there can be sudden information overload and the sensory memories stay trapped in the amygdala instead of being passed on to, and made sense of by, the neocortex. While trapped in the amygdala, the trauma memory has no identifiable meaning. It cannot be described, only re-experienced in some sensory form, such as panic attacks or flashbacks. The rewind technique allows that sensory memory to be converted into narrative, and be put into perspective.

    The Rewind Technique:

    The rewind technique should be carried out by an experienced practitioner and is only performed once a person is in a state of deep relaxation.

    When they are fully rested, they are encouraged to bring their anxiety to the surface and then are calmed down again by being guided to recall or imagine a place where they feel totally safe and at ease. Their relaxed state is the deepened and they are asked to imagine that, in their special safe place, they have a TV set or other device with a screen, and a remote control.

    They are asked to imagine floating to one side, out of body, and watch themselves watching the screen, without actually seeing the picture (double disassociation). They watch themselves watching a 'film' of the traumatic even that is still effecting them. The film begins at a point before the trauma occurred and ends at a point at which the trauma is over and they feel safe again.

    They are then asked, in their imagination, to float back into their body and experience themselves going swiftly backwards through the trauma, from safe point to safe point, as if they were a character in a video that is being rewound. They then watch the same images but as if on a TV screen while pressing the fast-forward button (disassociation). All this is repeated back and forth, at whatever speed feels comfortable, and as many times as needed, till the scenes evoke no emotion from the client.

    If the feared circumstance is one that will be confronted again in the future - for instance, driving a car or using a lift - the person is asked, while still relaxed, to see themselves doing so confidently.

    Besides being safe, quick, and painless, the technique has the advantage of being non-voyeuristic. Intimate details do not have to be made public.


    The behavioural approach to treating phobias

    The behavioural approach in the treatment of phobias focused on systematic desensitisation, and a technique known as flooding.

    Systematic Desensitisation

    Systematic desensitisation is based on the assumption that if phobias are a learned response as classical and operant conditioning suggests, then they can be unlearnt.

    Phobics may avoid the stimulus that causes them to fear hence they never learn the irrationality of this fear. Through a process of classical conditioning, systematic desensitisation teaches patients to replace their fearful feelings through a process of hierarchal stages which gradually introduces the person to their feared situation one step at a time.

    The hierarchy is constructed prior to treatment starting from the least feared to most feared situation working towards contact and exposure. Throughout these stages, patients are taught relaxation techniques that help manage their anxiety and distress levels to help them cope but also to associate these feelings of calmness towards the phobia. Earlier stages may involve pictures of the phobic situation (a picture of a snake for example if this is their fear) which may then lead to the goal of holding one. As patients master each step they move on to the next. For other scenario’s covert desensitisation is used which involves imagining contact instead.

    Relaxation techniques taught may help the patient focus on their breathing and taking slower, deeper breaths as anxiety often results in faster, shallow breathing and this helps manage this. Mindfulness techniques such as “here and now” skills may also be used which involves focusing on a particular object or visualising a relaxing scene. Progressive muscle relaxation involves straining and relaxing muscle groups gently and this can help relax the body from tension too.

    Counter-conditioning involves classical condition and may also be used as part of systematic desensitisation by creating a new association which runs alongside the current phobic situation. For example, the patient may be taught to associate relaxation instead of fear to their phobic situation and as fear and relaxation are incompatible with one another, anxiety is reduced.

    Systematic desensitisation evaluation

    A weakness for systematic desensitisation is that it is not appropriate for all patients and only those who have the capacity to learn relaxation strategies and for those who have imaginations vivid enough to imagine the feared situations in question. There is also no guarantee that learning to imagine and cope with phobic situations will actually translate into it working in the real world either.

    Another weakness is systematic desensitisation is time-consuming and costly for people to use which may make it inappropriate. Patients need to attend numerous appointments and to build trust with their practitioner who is a stranger which can in itself be difficult. Also, the strategy is dependent on the skill-set of the practitioner themselves which can affect how long this treatment takes or if it works at all.

    A strength, however, is that there is strong evidence that suggests systematic desensitisation is effective with numerous research studies finding it a success. McGrath et al (1990) reported 75% of patients responded positively with S and exposure to the feared stimulus (Vivo techniques) was believed to be one of the main reasons. Vitro techniques which involve patients imagining the feared stimulus were less effective in comparison (Choy et al 2007).
    There are ethical issues which arise with SD as it deliberately exposes patients to their fears which can cause psychological harm as there is no guarantee they will cope with it well. They may go on to have nightmares or their fear may even get worse to a point their life becomes dysfunctional. With this in mind, it may not always be appropriate for all patients and a cost-benefit analysis may be needed to weigh the benefits and costs with both short-term and long-term in mind.

    A strength of systematic desensitisation over CBT is it requires relatively little insight from the patient. Where CBT requires a person to have a good level of insight and self-awareness into their thinking to challenge their irrational thoughts, systematic desensitisation relies on simple conditioning which is easily learnt by patients.

    Systematic desensitisation: Flooding

    Flooding is an alternative approach to systematic desensitisation and either exposes the patient directly to their phobia or they are asked to imagine an extreme form of it.

    The client is also taught and encouraged to use relaxation techniques prior to the exposure to the phobic situation which continues until the patient is able to fully relax.

    In fear-based situations, the patient will release adrenaline however this will eventually cease with relaxation being associated with their feared stimulus as they are unable to use their normal avoidance methods. The procedure can be conducted using virtual reality too.

    Systematic desensitisation: Flooding evaluation

    Flooding raises serious ethical issues as it deliberately exposes patients to their fears which can cause severe psychological harm as there is no guarantee they can eventually cope with the situation. They may go on to have nightmares or even make their phobia worse to a point that their life becomes dysfunctional. With this in mind, it may not always be appropriate for all patients and a cost-benefit analysis may be needed to weigh the benefits and costs with both short-term and long-term in mind.

    As not everyone may be able to cope with this form of treatment, its effectiveness may be down to individual differences. Not everyone enjoys good physical health and subjecting such individuals to highly stressful situations through flooding may risk health problems i.e. heart attacks.

    A benefit to flooding, however, is the treatment is relatively quick to administer and effective with Choy et al (2007) reporting it to be more effective than SD.

    Possible exam questions for the behavioural approach to treating phobias:

    • Outline and evaluate how systematic desensitisation can be used to treat phobias
    • Outline and evaluate how flooding is used to treat phobias
    • Outline and evaluate the behavioural approach to treating phobias (12 marks AS, 16 marks A-level).

    Albert Ellis

    Key Study: Ellis' ABC Model 1962

    Albert Ellis helped define the cognitive approach and our understanding of it. This approach is rooted in the understanding that it is our thoughts which create our emotions and behaviour. He called this his ABC model, which is explained in further detail below.


    Summary and Conclusions

    The current accumulated research and clinical focus on comorbid anxiety and substance use disorders has provided important insights into the prevalence, development and maintenance patterns, clinical impact, and treatment considerations for these intertwined psychiatric problems. However, further research is imperative to further spur the field toward solidifying the empirical foundations for state-of-the-art, standard clinical care. Additionally, future studies exploring the uniqueness of the associations between specific disorder pairings (e.g., comorbid SAD and alcohol dependence versus comorbid GAD and sedative dependence) are necessary to yield information on optimizing tailored treatments. Fortunately, research in these areas is ongoing and primed to advance psychiatric care for individuals experiencing comorbid anxiety and substance use disorders.


    Frontiers in Psychology

    The editor and reviewers' affiliations are the latest provided on their Loop research profiles and may not reflect their situation at the time of review.


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      BACKGROUND

      Social media is a common part of modern social life, yet is not easily defined since concepts, design and usage are readily changing with new technology and shifting user habits (Obar & Wildman, 2015 ). Nonetheless, all social media share common core elements: (1) the social media user is both a creator and consumer of content, sharing their own content and reacting on others’ by commenting, sharing or “liking” (2) the user profile is essential for creating and gaining access to content and (3) social media provides the possibility of establishing social networks such as “friends” (e.g., Facebook) or “followers” (e.g., Twitter) (Obar & Wildman, 2015 ). Traditional internet forums and chat applications do not aim to facilitate social networks and are therefore not considered to be social media, although they are sometimes extensions of them (e.g., Facebook Messenger) and have similar features (e.g., liking posts and following specific forum users). Internet and social media interactions also share common features: for instance, communication is seldom carried out in real time or face-to-face.

      Social anxiety disorder (SAD) or social phobia (American Psychiatric Association, 2013 ) is common among anxiety disorders, with a point prevalence of 15.6% in Sweden (Furmark, 1999 ). Fear of being criticized or negatively evaluated is the core characteristic, leading to avoidance of social situations which in turn impacts daily functioning (American Psychiatric Association, 2013 ). For individuals with SAD, modern social media may serve as an alternative venue for social interaction that is less distressing, although they may ultimately maintain catastrophic beliefs and functional impairments. Results of a recent meta-analysis confirm a preference for computer-mediated communication over communication face-to-face among socially anxious individuals (Prizant-Passal, Shechner, & Aderka, 2016 ). Higher social anxiety appears associated with perceiving internet interactions as less risky when it comes to being negatively evaluated (Lee & Stapinski, 2012 ), entailing that social media may provide a context where social anxiety is more easily controlled, since symptoms of anxiety such as blushing or shaking will not show (Prizant-Passal et al., 2016 ). Safety behaviors, that is, behaviors that are used in order to avoid an expected social catastrophe, could therefore be seen as being automatically employed while interacting on social media. Social media specific safety behaviors such as removing tags of oneself from photos or monitoring others’ responses to one’s posts also seem to be used more frequently by individuals with higher social anxiety (Carruthers, Warnock-Parkes, & Clark, 2019 ). At the same time, higher social anxiety has been associated with more frequent self-disclosures when communicating over the internet compared to face-to-face (Weidman, Fernandez, Levinson, Augustine, Larsen, & Rodebaugh, 2012 ), as well as having more information on Facebook profiles (such as interests) compared to others (Fernandez, Levinson, & Rodebaugh, 2012 ), strengthening the hypothesis that computer-mediated communication is perceived as less anxiety-provoking than face-to-face interactions.

      The preference for computer-mediated communication would suggest that socially anxious individuals spend more time on the internet or social media compared to others. The empirical support for this hypothesis is however mixed and inconclusive (Prizant-Passal et al., 2016 ). A recent review states that there is no clear association between time spent on social media and social anxiety (Seabrook, Kern, & Rickard, 2016 ). However, for the reasons discussed above, overall time spent on social media might be too unspecific as a measure. More detailed measurements are needed in order to better understand social media usage among individuals with social anxiety. Measuring passive and active use of social media seems promising in that regard. Passive use is characterized by consuming content without social interaction, whereas active use involves creating content and interacting with others (Frison & Eggermont, 2016 ). Indeed, a recent study found that higher social anxiety was associated with passive use of Facebook and remained the only significant predictor when entered together with content production and interactive communication in a regression model (Shaw, Timpano, Tran, & Joormann, 2015 ). There is no agreement in the extant literature on what is defined as active social media use, with some studies finding two separate factors for active use public and private (Frison & Eggermont, 2015 , 2016 ), while others find only one factor (i.e. active use) (Thorisdottir, Sigurvinsdottir, Asgeirsdottir, Allegrante, & Sigfusdottir, 2019 ). Public active use such as commenting on friends’ posts offers less control of privacy (e.g., visibility and recipients) compared to private active use such as chatting using Facebook Messenger (Green, Wilhelmsen, Wilmots, Dodd, & Quinn, 2016 ). However, the division of active use is complicated since privacy settings can vary from user to user (Green et al., 2016 ) and also depends on what social media platform is being used. Although the internet and social media might be less anxiety provoking than face-to-face interactions, the quality of relationships, for example, reciprocity and openness, has been reported to be low for socially anxious individuals regardless of relationships being online or face-to-face (Lee & Stapinski, 2012 ). At the same time, social support derived from Facebook has been shown to contribute to subjective well-being more so than social support face-to-face, and Facebook could therefore play an important role for individuals with social anxiety (Indian & Grieve, 2014 ).

      In sum, the association between social anxiety and social media use is complex and needs to be explored further. A better understanding of the role of social media use and its association with social anxiety could inform treatment models to accommodate this aspect of modern life, for example, by creating exposure exercises involving social media usage. The Social Anxiety Scale for Social Media Users (SAS-SMU) (Alkis, Kadirhan, & Sat, 2017 ) is a recently developed self-report measure of social anxiety in the context of social media use and could facilitate further research. The original SAS-SMU is in Turkish and has since then been translated into an English version (Alkis et al., 2017 ), which has been employed in several studies (Aluh, Chukwuobasi, & Mosanya, 2019 Farrell, 2019 Ruggieri, Santoro, Pace, Passanisi, & Schimmenti, 2020 ). However, only its Turkish version has been validated previously (Alkis et al., 2017 ). Cross-culturally validated scales are needed since cultural factors can influence the manifestation of social anxiety (Spence & Rapee, 2016 ).

      The current study describes the development of a Swedish version of the SAS-SMU and the psychometric evaluation thereof, including examining underlying dimensions, internal consistency as well as convergent and divergent validity in a Swedish population. We also explore in-depth associations between different types of social media use (passive and active) and social anxiety.


      Types of Brief Therapy

      There are many approaches to brief therapy. Typically, existing long-term therapies have been adapted to a short-term context.

      Single-Session Therapy

      Theory of Single-Session Therapy

      In single-session therapy, the therapist and client meet only once. The goal of single-session therapy is to encourage new learning, enhance coping, and promote growth. Typically, a single session is used to help a client shift perspective or acquire skills. Single-session therapy is most effective for individuals with specific problems who (a) need a change in perspective, (b) need an evaluation or referral, (c) feel stuck about processing a past event, (d) are looking for reassurance, or (e) have a specific problem that is within their power to solve. In contrast, individuals in inpatient care, individuals needing continuing support to process traumatic past events (e.g., childhood sexual abuse), individuals with eating disorders or chronic pain, and individuals with conditions caused by biological or chemical mechanisms (e.g., schizophrenia) are not as likely to benefit from single-session therapy or any of the brief therapies.

      Techniques of Single-Session Therapy

      Diverse techniques are employed in single-session therapy. For example, the therapist may contact the client by phone before meeting to obtain detailed information about the presenting problem and to ask the client to complete specific tasks before the session. A second popular technique is to focus on ambiguity during the session. Focusing on ambiguity allows the therapist to introduce new ways of looking at the same problem. Clients often practice possible solutions during the session. Rehearsing ideal outcomes or practicing new skills can help a client feel more able to transfer skills from the therapy session to everyday life. After the session is over, the therapist informs the client that he or she can return for another session if necessary.

      Cognitive-Behavioral Brief Therapy

      Theory of Cognitive-Behavioral Brief Therapy

      Cognitive-behavioral brief therapy focuses on schemas. Schemas are templates that individuals use in order to make decisions, guide responses, or explain situations. Schemas develop from life experiences and become a standard of normal behavior. Thus, whenever a critical event occurs, the individual uses a schema to decide how to react. Schemas may not be based on accurate information, so relying on some schemas may result in cognitive distortions. For example, if a child were punished whenever interrupting an adult, that child may develop beliefs that make him or her hesitant to interrupt, even as an adult.

      Techniques of Cognitive-Behavioral Brief Therapy

      The focus in cognitive-behavioral brief therapy is to identify and replace distorted cognitions based on schemas. Goal setting is central to cognitive-behavioral brief therapy. It serves as a mechanism for measuring treatment effectiveness. Each goal should have specific objectives, be worded positively, and be realistic. Cognitive-behavioral brief therapy focuses on meeting each goal, as opposed to focusing on client insight or the process of therapy.

      Short-Term Dynamic Psychotherapy

      Theory of Short-Term Dynamic Psychotherapy

      Short-term dynamic psychotherapy focuses on affect phobia. Affect phobia is an internal phobia in which individuals are afraid to experience a particular feeling (e.g., anger, shame). According to short-term dynamic theory, affect is the basic motivation that drives individuals, and affect phobias are the culprit of most behavior problems.

      Triangles are used to diagram conflicts and people in short-term dynamic psychotherapy. The triangle of conflict is used to conceptualize the way an individual avoids a feeling and the triangle of person is used to conceptualize the recipient of that feeling. The triangle of conflict uncovers defenses, anxieties, and adaptive feelings. Each point on a triangle is called a pole. The defense pole consists of behaviors (e.g., avoidance), thoughts (e.g., “I’m incompetent”), or feelings (e.g., fear). These defenses can be adaptive and helpful, but they become harmful when they result in maladaptive behaviors. The anxiety pole consists of inhibitory feelings that lead individuals to become vigilant about their own or others’ behaviors. There are four major categories of inhibitory feelings: anxiety, shame/guilt, emotional pain, and contempt/disgust. The feelings pole represents normal adaptive behaviors that are motivated by underlying basic feelings and impulses (e.g., grief, anger, excitement, sexual desire). These feelings can be healthy, but individuals avoid them when the feelings are associated with a negative experience. The triangle of conflict helps the therapist to identify defensive patterns used by the client to avoid feelings, identify how and why a client is using inhibitory feelings, and help the client understand the underlying affect that is being avoided.

      The triangle of person helps the therapist recognize the relationships where patterns of avoidance occur. These can include past relationships, current relationships, or the relationship between the client and therapist.

      Techniques of Short-Term Dynamic Psychotherapy

      The goal of short-term dynamic psychotherapy is to restructure defenses, affect, and attachments. There are several main objectives. First, the client should acknowledge and understand the defensive pattern. Second, the client should be motivated to change the defensive pattern. Third, in order to desensitize the affect phobia, the client must experience and express appropriate feelings. Fourth, the therapist must listen to the client and help identify healthy feelings that can help the client to behave more effectively and experience relief from his or her symptoms.

      Gestalt Brief Therapy

      Theory of Gestalt Brief Therapy

      From a Gestalt perspective, individuals are experiencing difficulty because they have become fragmented by disowning different parts of themselves. Therefore, the aim of Gestalt brief therapy is to reintegrate the fragmented parts of the individual. Once the reintegration process has occurred, the individual can successfully interact with him- or herself, others, and the environment. In Gestalt brief therapy, the focus is on growth and process. Nonverbal cues are a key part of Gestalt brief therapy. In fact, if the verbal content of the client is in conflict with the nonverbal content of the client, the nonverbal content is usually considered more important. For example, if a client reports feeling relaxed but fidgets constantly, then the therapist would assume that the client is not relaxed. The therapist may also point out this incongruence during the session.

      Techniques of Gestalt Brief Therapy

      Gestalt brief therapy uses Duey Freeman’s therapeutic circle as a guide for brief therapy. There are six stages in Gestalt brief therapy. First, therapy must begin with a present or here-and-now focus. Gestalt brief therapy helps the client to increase awareness of immediate feelings, experiences, and situations. Second, an issue is identified. The therapist does not direct the client to identify a particular issue. Instead, the therapist simply helps the client increase awareness of the here and now, and trusts the client to talk about an issue that is important.

      Third, the therapist may conduct an “experiment” during the session. Gestalt therapy considers techniques to be experiments. For example, the therapist may make a client aware of nonverbal cues throughout the session. Perhaps the most popular experiment is the empty chair technique. In this experiment, a client is asked to initiate a dialogue between the two parts of the self that are in conflict, or with another person with whom the client is experiencing conflict. Each time the client switches perspectives, the client switches chairs and talks to an empty chair as if the other part of the self or the other person were in the chair.

      Fourth, the therapist identifies and discusses the behavior that is causing the problem. This moves the discussion from the present to the past, but in Gestalt brief therapy, the past is discussed in the context of how the client is currently experiencing issues from the past in the present. Therefore, the emphasis is not on discussing the past, but experiencing the past. Fifth, the client and therapist explore alternative behaviors. These alternate behaviors may be external or internal. Sixth, the therapist and client discuss how life is different when trying these alternate behaviors. The therapist assists the client in the integration of these new behaviors into daily life.


      Exposure Therapy for Anxiety Disorders

      Exposure-based therapies are highly effective for patients with anxiety disorders, to the extent that exposure should be considered a first-line, evidence-based treatment for such patients. In clinical practice, however, these treatments are underutilized, which highlights the need for additional dissemination and training.

      Over a quarter of the people in the US population will have an anxiety disorder sometime during their lifetime. 1 It is well established that exposure-based behavior therapies are effective treatments for these disorders unfortunately, only a small percentage of patients are treated with exposure therapy. 2,3 For example, in the Harvard/Brown Anxiety Research Project, only 23% of treated patients reported receiving even occasional imaginal exposure and only 19% had received even occasional in vivo exposure. 4 In part, this may be a lack of well-trained professionals, because most mental health clinicians do not receive specialized training in exposure-based therapies. 5,6

      Another factor may be that many health care professionals do not understand the principles of exposure or may even hold (usually unfounded) negative beliefs about this form of treatment. Surveys of psychologists who treat patients with PTSD show that the majority do not use exposure therapy and most believe that exposure therapy is likely to exacerbate symptoms. 7,8 However, individuals with trauma histories and PTSD express a preference for exposure therapy over other treatments. 9 Furthermore, exposure therapy does not appear to lead to symptom exacerbation or treatment discontinuation. 10 Indeed, a wealth of evidence indicates that exposure-based therapy is associated with improved symptomatic and functional outcomes for patients with PTSD. 11

      The available research literature suggests that exposure-based therapy should be considered the first-line treatment for a variety of anxiety disorders. Here we review a handful of the most influential studies that demonstrate the efficacy of exposure therapy. We also discuss theoretical mechanisms, practical applications, and empirical support for this treatment and provide practical guidelines for clinicians who wish to use exposure therapy and empirical evidence to guide their decision making.

      Exposure therapy is defined as any treatment that encourages the systematic confrontation of feared stimuli, which can be external (eg, feared objects, activities, situations) or internal (eg, feared thoughts, physical sensations). The aim of exposure therapy is to reduce the person’s fearful reaction to the stimulus.

      Graded exposure vs flooding

      Most exposure therapists use a graded approach in which mildly feared stimuli are targeted first, followed by more strongly feared stimuli. This approach involves constructing an exposure hierarchy in which feared stimuli are ranked according to their anticipated fear reaction (Table 1). Traditionally, higher-level exposures are not attempted until the patient’s fear subsides for the lower-level exposure. By contrast, some therapists have used flooding, in which the most difficult stimuli are addressed from the beginning of treatment (an older variant, implosive therapy, is not discussed in this article). In clinical practice, these approaches appear equally effective however, most patients and clinicians choose a graded approach because of the personal comfort level. 12,13

      In vivo vs imaginal

      In vivo exposure refers to real-world confrontation of feared stimuli. Sometimes, in vivo exposure is not feasible (eg, it would be both difficult and hazardous for someone with combat-related PTSD to experience the sights, sounds, and smells of combat in real life). In such cases, imaginal exposure can be a useful alternative. In imaginal exposure, the patient is asked to vividly imagine and describe the feared stimulus (in this case, a traumatic memory), usually using present-tense language and including details about external (eg, sights, sounds, smells) and internal (eg, thoughts, emotions) cues.

      In recent years, virtual reality exposure therapy (patients are immersed in a virtual world that allows them to confront their fears) has been examined as an alternative means of imaginal exposure, and preliminary data suggest that it can be quite effective. 14,15 Imaginal exposures can also be useful for confronting fears of worst-case scenarios (eg, patients with obsessive-compulsive disorder [OCD] who imagine that they might contract a deadly illness, patients with social phobia who imagine that they are being ridiculed) to reduce the aversiveness of the thought.

      What is already known about exposure therapy for anxiety disorder?

      ? Exposure therapy is defined as any treatment that encourages the systematic confrontation of feared stimuli, with the aim of reducing a fearful reaction. Over a quarter of the people in the US population will have an anxiety disorder sometime during their lifetime, and available research literature suggests that exposure-based therapies should be considered the first-line treatment for these disorders. Although it is well established that exposure-based therapies are effective treatments for these disorders, however, only a small percentage of patients are actually treated with this approach.

      What new information does this article provide?

      ? We review the results of a handful of the most influential studies that demonstrate the efficacy of exposure therapy and disseminate information about the theoretical mechanisms, practical applications, and empirical support for this treatment. In addition, we provide practical guidelines for clinicians who wish to use exposure-based therapies and empirical evidence to guide their decision making.

      What are the implications for psychiatric practice?

      ? In clinical practice, exposure-based therapies for anxiety disorders are underutilized, which highlights the need for additional dissemination and training. We hope the dissemination of the theoretical mechanisms, practical applications, and empirical support for exposure-based therapies in this article will encourage mental health practitioners to embrace this modality as a viable and easily accessible option in the treatment of anxiety disorders.

      Internal vs external

      Exposures can target internal and/or external cues. Exposures to external cues include a spider-phobic patient handling a spider, or a height-phobic patient systematically approaching increasing heights in a skyscraper. Using exposure to internal cues, a patient with panic disorder can run in place to experience physiological sensations (eg, heart palpitations) that elicit anxious reactions, a patient with generalized anxiety disorder (GAD) can purposefully induce worry thoughts, a patient with PTSD can revisit traumatic memories, and a patient with OCD can intention-ally evoke intrusive and aversive thoughts.

      With or without relaxation

      One of the earliest variations of exposure therapy was systematic desensitization, in which patients engage in imaginal exposure to feared stimuli while simultaneously undergoing progressive muscle relaxation. 16 Subsequent dismantling studies have shown that exposure, rather than relaxation, is the active ingredient and that relaxation does not improve outcomes. 17 The addition of relaxation exercises has been counterproductive in some patients, such as those with panic disorder. 18 Because of the apparent importance of interoceptive exposure (ie, learning to tolerate uncomfortable physical sensations), relaxation exercises aimed at decreasing these sensations may actually attenuate the outcome of therapy, in much the same way as does the use of as-needed short-acting benzodiazepines. 19

      Efficacy of exposure therapy

      Several studies have demonstrated the efficacy of exposure-based therapies for anxiety disorders, a finding that is summarized in several published meta-analyses. 20,21 st 22 examined the effects of single-session in vivo exposure (that lasts 1 to 3 hours) for patients with specific phobias. At posttreatment follow-up (after an average of 4 years), 90% of these patients still had significant reduction in fear, avoidance, and overall level of impairment and 65% no longer had a specific phobia.

      Barlow and colleagues 23 investigated the effects of interoceptive exposure with components of cognitive restructuring (cognitive-behavioral therapy [CBT]), imipramine, and a combination of the two in patients with panic disorder. At first, all treatments appeared equally efficacious however, at 6 months’ follow-up, 32% of patients in the CBT group continued to maintain their treatment gains compared with 20% in the imipramine group and 24% in the combined-treatment group.

      Foa and colleagues 24 randomized patients with OCD to receive in vivo exposure and response prevention, clomipramine, or a combination of both. For patients who completed the study, 86% in the exposure group improved on a measure that examined the frequency and severity of obsessions and compulsions compared with 48% in the clomipramine group and 79% in the combined-treatment group.

      Several others have also demonstrated the efficacy of exposure-based treatments or treatment components for patients with GAD, so-cial anxiety disorder, and PTSD. 25-27

      Theoretical mechanisms of exposure therapy

      Biologically, the extinction of fear appears to be mediated by N-methyl-d-aspartate receptor activity in the basolateral amygdala, a finding that has led to the use of neuroplasticity compounds such as d-cycloserine to augment exposure. 28,29 There are 4 major theories that attempt to explain the psychological mechanisms of exposure therapy: habituation, extinction, emotional processing, and self-efficacy (Table 2).

      Habituation theory purports that after repeated presentations of a stimulus, the response to that stimulus will decrease. 30 For example, initial exposure to ocean water can be cold. However, over time and with repeated exposures, the water feels less cold as the person acclimates. Similarly, when repeatedly facing a fear-provoking stimulus in exposure therapy, the patient experiences habituation, or a natural reduction in fear response. While many clinicians aim for habituation to occur within the session, researchers have found that optimal treatment effects occur during the period of learning consolidation between sessions. 31,32

      Extinction theory emerges from a classic conditioning model in which the unconditioned stimulus is a situation, place, or person that initially caused fear (the unconditioned response)-for example, a dog bite. Through the process of stimulus generalization, fear reactions become learned (conditioned response) and are elicited by other stimuli, such as dogs that are not dangerous (conditioned stimuli). Because of the aversiveness of the conditioned response, fearful individuals are motivated to avoid the conditioned stimuli, thus reinforcing avoidance behavior as well as the belief that relief from fear only comes from avoidance. 33

      Exposure therapy is thought to weaken the conditioned response through repeated exposure to the conditioned stimuli in the absence of the unconditioned stimulus. For example, exposure to dogs (conditioned stimuli) without being bitten (absence of unconditioned stimulus) weakens the relationship between the conditioned stimuli and the fear of conditioned response. One limitation of extinction theory is that most phobic patients do not identify an initial conditioning event. 34

      Emotional processing theory suggests that fear is stored in memory as a network of stimuli (eg, social gathering), response (eg, sweaty palms), and meaning (eg, “I’m not good at socializing, I’m a failure”) components. 35 Fearful individuals are thought to ascribe faulty meanings to stimuli in a way that increases fear toward those stimuli. Exposure to fear-provoking stimuli is thought to result in a new way of processing information and to correct the faulty fear structure. 36,37 For example, in patients with social anxiety disorder, social interactions can be perceived as rewarding, even if the patients have sweaty palms and feel some anxiety.

      The self-efficacy theory focuses more on increasing skills and mastery over a situation or performance than on reducing a fear response directly. 38 Persons with anxiety disorders tend to underestimate their capabilities to cope with fear. Therefore, persons able to face their fear and successfully tolerate it without avoiding it or withdrawing from it begin to realize they are more capable and resilient than they had imagined. Thus, they become more willing to face their fears in different contexts, thereby generalizing treatment effects.

      These theoretical mechanisms of exposure are not mutually exclusive, and all might be correct for any given patient. With repeated exposures, patients experience reduced sensations of fear (habituation), learn a new set of associations (extinction), feel increasingly able to cope with fear (self-efficacy), and generate new interpretations of the meanings of previously feared stimuli (emotional processing).

      Treatment guidelines

      Treatment guidelines for clinicians who use exposure therapy are shown in Table 3. The first step in successful exposure therapy is the development of an exposure hierarchy. The patient and clinician brainstorm as many feared external and internal stimuli as possible and then rate them in order of difficulty. The most common ranking method is the Subjective Units of Discomfort (SUD) scale, which assigns a 0 to 100 numeric value to each item. 39 (This scale can be found online in Wikipedia and at http://www.newworldencyclopedia.org/entry/Joseph-Wolpe.)

      The next step is to conduct exposures in a gradual and systematic manner. Repeated use of the SUD scale will help track the patient’s fear level as it increases and decreases. Typically, a higher item is not attempted until the patient’s SUD level decreases significantly for a lower-ranked item.

      During exposure therapy, safety behaviors should be eliminated to the extent possible. Safety behaviors refer to all unnecessary actions the patient takes to feel better or to prevent feared catastrophes. Left unchecked, safety behaviors can undermine the process of exposure therapy by teaching the patient a rule of conditional safety (eg, “The only way to be safe during a panic attack is to have my medication with me”) rather than a rule of unconditional safety (eg, “Panic attacks will not harm me, regardless of whether I am carrying my medications”).

      Cognitive restructuring may also be used as an adjunct to exposure therapy. Cognitive restructuring refers to identifying and challenging irrational, unrealistic, or maladaptive beliefs. In patients with anxiety disorders, 2 of the more common faulty thinking patterns (ie, cognitive distortions) are probability overestimation and catastrophizing. Probability overestimation refers to the overprediction of unlikely outcomes, such as the belief that a commercial flight is highly likely to crash. Catastrophizing refers to the magnification of the consequences of aversive outcomes, such as the belief that making a mistake during a speech will lead to a lifetime of ridicule and ostracism. During the process of exposure exercises, the therapist helps the patient identify these cognitive distortions examine the evidence for and against the beliefs and rehearse new, more realistic ways of thinking.

      Exposure-based therapies are highly effective for patients with anxiety disorders, to the extent that exposure should be considered a first-line, evidence-based treatment for such patients. In clinical practice, however, these treatments are underutilized, which highlights the need for additional dissemination and training. We hope this information will encourage clinicians to embrace exposure-based therapies for anxiety disorders as a viable and easily accessible treatment option.

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      Cognitive Approach to Depression

      Characteristics of Depression

      Depression is a mood, or affective disorder. This mental Illness is a collection of physical, emotional, mental and behavioral experiences that are severe, prolonged and damaging to everyday functioning.

      The criteria for depression to be diagnosed using the DSM-IV-TR is that at least 5 or more symptoms of depression should be apparent. The possible symptoms include:

      Behavioral (How do you BEHAVE when you're depressed?): Neglect of personal appearance, loss of appetite, disturbed sleep patterns (insomnia), loss of energy (tiredness), withdrawal from others.

      Emotional (How do you FEEL when you're depressed?): Intense sadness, irritability, apathy (loss of interest of enjoyment), feelings of worthlessness, anger.

      Cognitive (How do you THINK when you're depressed?): Negative thoughts, lack of concentration, low self-esteem, poor memory, recurrent thoughts of death, low confidence.

      The cognitive approach believes that depression stems from faulty cognitions about others, our world and us. This faulty thinking may be through cognitive deficiencies (lack of planning) or cognitive distortions (processing information inaccurately). These cognitions cause distortions in the way we see things and caused behavior such as depression.

      Ellis suggested depression occurs through irrational thinking, while Beck proposed the cognitive triad.

      AO2 Scenario Question

      Ben recently moved away from home to go to university. He was loving his new life of going out, meeting new friends, his new university course. However, after a while he struggled getting out of bed and started to become very tired.

      His eating patterns changed and he lost a lot of weight. He noticed that he got angry at little things and snapped at his friends. When he was sat in lectures, he found it hard to concentrate for long periods of time.

      Identify the behavioral, emotional and cognitive aspects of Ben’s state. (3 marks)

      Beck’s Negative Triad

      The cognitive triad are three forms of negative (i.e. helpless and critical) thinking that are typical of individuals with depression: namely negative thoughts about the self, the world and the future. These thoughts tended to be automatic in depressed people as they occurred spontaneously.

      For example, depressed individuals tend to view themselves as helpless, worthless, and inadequate. They interpret events in the world in a unrealistically negative and defeatist way, and they see the world as posing obstacles that can’t be handled. Finally, they see the future as totally hopeless because their worthlessness will prevent their situation improving.

      The negative triad interacts with negative schemas and cognitive biases to produce depressive thinking.

      Cognitive biases are distortions of thought processes. Individuals with depression are prone to making logical errors in their thinking and they tend to focus selectively on certain negative aspects of a situation while ignoring equally relevant positive information.

      In addition to cognitive biases, the negative triad is also influenced by schemas. In essence, schemas can be seen as deeply held beliefs that have their origins primarily in childhood. Beck believed that depression prone individuals develop a negative self-schema. They possess a set of beliefs and expectations about themselves that are essentially negative and pessimistic.

      Beck claimed that negative schemas may be acquired in childhood as a result of a traumatic event (e.g. parental or peer rejection). Schemas influence how a person interprets events and experiences in their life. Beck predicted that in depression ‘latent’ (i.e. dormant) negative schemas that have been formed in childhood become activated by a life events or ongoing stressors.

      Negative schemas and cognitive biases maintain the negative triad, a pessimistic view of the self, the world (not being able to cope with the demands of the environment) and the future.

      It may be that negative thinking generally is also an effect rather than a cause of depression. Perhaps individuals only start experiencing negative thoughts after having developed depression. However, evidence that negative thinking can be involved in the development of depression was obtained by Lewinsohn et al. (2001).

      They measured negative thinking in non-depressed adolescents. One year later, the life events of participants over the previous 12 months were assessed, and also whether they were suffering from depression.

      The results showed those who had experienced many negative life events had an increased likelihood of developing depression only if they were initially high in negative attitudes. This study supports the theory that negative beliefs are a risk factor for developing depression when exposed to stressful life events.

      The cognitive approach to depression is limited in that genetic factors are ignored.

      Little attention is paid to the role of social factors relating to life events and gender in the cognitive explanation of depression.

      Ellis’s ABC Model

      Albert Ellis (1957, 1962) proposes that each of us hold a unique set of assumptions / beliefs about ourselves and our world that serve to guide us through life and determine our reactions to the various situations we encounter.

      Unfortunately, some people’s assumptions are largely irrational, guiding them to act and react in ways that are inappropriate and that prejudice their chances of happiness and success. Albert Ellis calls these basic irrational assumptions.

      According to Ellis, depression does not occur as a direct result of a negative event but rather is produced by the irrational thoughts (i.e. beliefs) triggered by negative events.

      Ellis believes that it is not the activating event (A) that causes depression (C), but rather that a person interpret these events unrealistically and therefore has an irrational belief system (B) that helps cause the consequences (C) of depressive behavior.

      For example, some people irrationally assume that they are failures if they are not loved by everyone they know (B) - they constantly seek approval and repeatedly feel rejected (C). All their social interactions (A) are affected by this assumption, so that a great party can leave them dissatisfied because they don’t get enough compliments.

      The precise role of cognitive processes is yet to be determined. It is not clear whether faulty cognitions are a cause of the psychopathology or a consequence of it.

      Sometimes these negative cognitions are in fact a more accurate view of the world: depressive realism.

      Cognitive theories lend themselves to testing. When experimental subjects are manipulated into adopting unpleasant assumptions or thought they became more anxious and depressed (Rimm & Litvak, 1969).

      Treatment - CBT

      How would you use the therapy

      Cognitive behavioral therapy aims to change the way a client thinks, by challenging irrational and maladaptive thought processes and this will lead to a change in behavior as a responses to new thinking patterns. Specifically, our thoughts determine our feelings and our behavior.

      Therefore, negative - and unrealistic - thoughts can cause us distress and result in problems. When a person suffers with psychological distress, the way in which they interpret situations becomes skewed, which in turn has a negative impact on the actions they take.

      Cognitive therapists help clients to recognize the negative thoughts and errors in logic that cause them to be depressed. The therapist also guide clients to question and challenge their dysfunctional thoughts, try out new interpretations, and ultimately apply alternative ways of thinking in their daily lives.

      The clients learn to discriminate between their own thoughts and reality. They learn the influence that cognition has on their feelings, and they are taught to recognize observe and monitor their own thoughts.

      The behavior part of the therapy involves setting homework for the client to do (e.g. keeping a diary of thoughts). The therapist gives the client tasks that will help them challenge their own irrational beliefs.

      The idea is that the client identifies their own unhelpful beliefs and them proves them wrong. As a result, their beliefs begin to change. For example, someone who is anxious in social situations may be set a homework assignment to meet a friend at the pub for a drink.

      CBT would be used when a person's faulty thinking was effecting their life in a negative way.

      A strength of this therapy is that it has shown to be very effective in treating depression, in fact, it has shown to produce longer lasting recovery than antidepressants.

      The precise role of cognitive processes is yet to be determined. It is not clear whether faulty cognitions are a cause of the psychopathology or a consequence of it.

      Sometimes these negative cognitions are in fact a more accurate view of the world: depressive realism.

      Cognitive theories lend themselves to testing. When experimental subjects are manipulated into adopting unpleasant assumptions or thought they became more anxious and depressed (Rimm & Litvak, 1969).

      An important advantage of CBT is that it tends to be short (compared to psychoanalysis), taking three to six months for most emotional problems. Patients attend a session a week, each session lasting either 50 minutes or an hour.

      Another strength is that it can reduce ethical issues – the way this therapy works is that the client is actively involved and in control. They feel empowered as they are helping themselves.

      AO2 Scenario Question

      Jack suffers from depression. His symptoms include loss of concentration, lack of sleep and struggles to sleep at night. He finds himself having absolutist thinking thinking that everything is negative and bad all the time.

      How might a cognitive behavior therapist tackle Jack’s depression? (4 marks)


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