A 25 year old female presents with 2 year history of repetitive, irresistible thoughts of contamination with di associated with repetitive hand washing. She repos these thoughts to be her own and distressing; but is not able to overcome them along with medications. She is most likely to benefit from which of the following therapies:
A i.e. Exposure and Response preventionSystematic desensitization is behaviour therapy of choice for specific and social phobiasQ whereas exposure and response prevention is behaviour therapy of choice for obscessive- compulsive disorderQBehavior Therapy (BT)It is a sho duration (6-8 week) therapy based on theories of learning (Skinner's operant and Pavlov's classical conditioning) and assume that all behaviour is learned behaviour. So a behaviour that is followed by a reward (positive reinforcement) is more likely to occur again that behaviour is learned more easily if taught in small steps. It aims at changing maladaptive behaviour & substituting it with adaptive behaviot42. John B. Watson is father of behaviourism and Joseph Wolpe developed systemic desensitization. Types include:Systematic Desensitization (SD) Based on Wolpe's principle of counter conditioning or reciprocal inhibition, whereby a person over comes maladaptive anxiety by appoching the feared situation gradually in a state of complete psycophysiological relaxation It consists of 3 steps : relaxation training, hierarchy construction (i.e. a list is made of situations that provoke increasing degrees of anxiety) and desensitization (i.e. patient proceed systematically through the list from least to most anxiety provoking situation while in a deeply relaxed state)- Works best in clearly identifiable anxiety provoking stimulus such as phobias (simple & social) where it is BT of choiceQ, panic attacks, generalized anxiety disorder, obsessiove-compulsive disorder (BT of 2.d choice)Q and some sexual disorders. Therapeutic-Graded Exposure Similar to SD, except that relaxation training is not involved & treatment is usually carried out in a real life context to learn firsthand that no dangerous consequences will ensue. Flooding (Implosion)- Patient is exposed to maximum level of feared situation (near the top of hierarchy without a gradual buildup or relaxation exercises, as in SD) from the sta of treatment and remain their until autonomic habituation occurs/ anxiety diminishes. - Premature withdrawal from feared situation or prematurely terminating the fantasized scene (imaginal flooding) is equivalentContingency (Reinforcer) ) Contracting & Behaviour Exchange/Contingency Management- Operant is a term used to describe a mechanism by which a behavior operates on environment. In this learning model, behavior is not evoked or elicited (as in classic conditioning) but occurs independently, and environmental responses influence whether the behavior is continued or stopped. For a consequence to change a ceain behavior, the consequence must be contigent on the behavior. Contingency refers to the relationship between a behavior and the events that follow it. A consequence is contingent when it is delivred only after the target behavior is performed and it is otherwise not available.Reinforcement is a contigent event that strengthens the response that it follows (eg a child is given a chocolate when he smiles; the child then smiles again). Reinforcers are always individual (eg food may be reinforcer for a hungry person but not to one who has just finished a large meal). Primary reinf orcers are objects with their own intrinsic or inherent value such as food or water. Secondary reinforcers are objects that have acquired value (eg money). The notion of contingency is iron clad i.e. inconsistent applications of contingencies (such as not giving reward after desired behavior few times) results in poor response acquisition.A behavior may be positively reinforced, negatively reinforced or punishedPositive reinforcement increases the frequency of a paicular resonse by giving something ourable immediately after the response (eg candy).Negative reinforcement increases the frequency of a response by removing an aversive event immediately after response (scoulding / nagging stops after a child cleans his room).Punishment decreases the frequency of a response by either pesenting an aversive event following a response (eg spanking; punishment I) or a removal of a positive event following a response (eg allowance is withdrawn; punishment II).Contingent ActionPositive (+) EventNegative Event (-)GivenPositive ReinforcementPunishment ITaken AwayPunishment IINegative ReinforcementContinuous reinfofcement means that reinforcemnt /punishment is applied every time the behavior occurs. Intermittent reinforcement occurs a/t schedule (eg every 3rd time) whereas, variable reinforcement is randomly determined.- Shaping and Chaining are other operant strategies for acquisition of new behaviors. Shaping is a process of reinforcing (rewarding) successive (gradual) approximations that come increasingly close to a desired behavior goal because they resemble the desired behavior or include a component of desired behavior. For example, in the case of selective mutism, the ultimate goal of treatment would be to have the child speak aloud in full sentences in front of others. Shaping uses a process of slow, small steps to reach this final goal.- Most daily activities require a series of small behaviors or steps that when performed in sequence form a chain. Forward chaining consists of teaching the sequence of behaviors beginning with the initial step in the chain (from 1 to 10). In backward to an escape, that would reinforce both conditioned anxiety & avoidance behaviour andproduce the opposite of desired effect.It works best in specific phobias and is contraindicated when intense anxiety would be hazardous to a patient (eg hea disease or fragile psychological patient)Exposure and Response PreventionIt is BT of choice for obscessional ritualsQ and is based on concept that the urge to carry out rituals diminishes if rituals can berestrained for long periods (- an hour)- Steps include : explaining the rationle of treatment & agreeing targets for exposure with patient --> Modelling (i.e. therapist demonstrates procedure himself) --> initially therapist suppo & accompany patients while they strive to prevent the rituals --> Urge to carry out rituals is made greater by persuading the patient and they do this on their own. Eye Movement Desensitization &Reprocessing- Inducing. Saccadic eye movements (which are rapid oscillation of eyes that occur when person follows rapid side to side moving object) while a person is imagining or thinking about (i.e. exposing to) , an anxiety provoking event can yield a positive thought or image that results in decreased anxiety. Used in post traumatic stress disorders & phobias.Thought Stopping and Distraction- Automatic negative thoughts and repetitive, intrusive ruminations are some times too intense to address with purely cognitive interventions. So thought stopping, a behavioural ditraction technique capitalizes on the individuals ability to focusattention away from distressing thoughts by producing a sudden sensory stimulus. For example -Snapping a rubber band on the wrist as a distractor or visualizing a large red stop sign. The command "stop!" is paired with the image or snap- It has 4 stages : 1) defining & recording the behaviour to be changed (by another person) 2) identifying the stimuli and reinforcers by recording the events that immediately follow the behaviour, 3) redirecting reinforcement from problem behaviour to desired behaviours eg parents advised to attend less when child shouts & more when quiet, 4) monitoring progress.It relies on principles of 1) controlling over contingency or reinforcer controls behaviour, 2) positive contingency should be desirable & available sholy after the terms of contract have been met 3) terms of contract should be negotiated, specific & straight forward 4) pairing or chaining a high frequency behaviour (eg watching TV) to a low frequency one (eg doing paperwork/house work etc).1) Reinforcement is a privilege that must be earned2) Good contracts are based on even exchange3) The value of contract is influenced by the reinforcement received4) A contract increases freedom within the relationship for both paies to earn the reinforcement that they deserve- Sta out relatively rich (eg 1 hour TV after 15 minutes of homework) and progressively thinned in time.- Used mainly in t/t of children & people with learning disbility and patients with medication adherence (pairing medication taking with routine activities)Q. - Token Economy (token reinforcement & response cost) Programs are a formalized method of contingency management, which clearly spells out a series of behaviors that are expected (eg making bed, arriving on time, cleaning) and the contingencies for compliance / non-compliance with these behavior goals (i.e. reward or privileges achieved or not respectively). Some programs include response cost (a form of punishment), which is the removal or withdrawl of a reinforcer / reward following in appropriate/problem behavior (eg fining a child for swearing). Imposing fine / response cost is very effective for suppressing undesirable behavior. The combination of token reinforcement and response cost is more effective then either alone.Child Management Training (CMT) is most established contingency managment program that teaches disciplinary skills to parents and includes: 1) how to use reinforcement to change a chld's behavior (positive reinforcement training; 2) how to attend to a desirable behavior to increase its frequency and ignore undesirable behavior to decrease their frequency (eg praising a child when he plays quietly & ignoring a child when he is interrupting); 3) how to give commands and use time outs & response costs. Time out is a punishment by the removal of positive reinforcement.Asseiveness Training- Asseive behaviour enables a person to act in his own best interest, to stand up for himself without undue anxiety, to express honest feelings comfoably & to exercise personal rights without denying the right of others.- By a combination of coaching, modelling (role playing), role reversal, videofeed back etc patients are encouraged to judge the level of self asseion and practise appropriate verbal & non verbal behaviours.- It is usually required for 1) Setting limits on pushy friends or relatives, 2) Social encounters such as being ignored by gossiping shop assistant, countering a sales pitch or being persistent when returning defective merchandise:Problem Solving Skills Training (PST)Impulsive/Careless problem solving, characterized by hurried, impulsive and careless attempts at problem resolution. And avoidant problem solving is procrastination, passivity and over dependence on others to provide solutions.Master's and Johnson's Dual Sex Therapy- Developed by William Masters and Virginia Johnson is a behaviour therapy used for treatment of sexual dysfunctions. In premature ejacutation, semen's squeeze technique and in male erectile disorder or impotence, sensate focus technique (to discover sensate focuses on body excluding genitalia where manipulation leads to sexual arousal); In orgasm and psychosexual disorders, orgasmic conditioning & desensitization are used.Habbit Reversal Training (H)- Has 4 components which include training in 1) becoming aware of onset of behavior (awareness training), 2) monitoring of behaviour and habit control motivation 3) initiating competing responses, that are incompatible with the behavior and inconspicuous (invisible) to others eg fist clenching is incompatable with body focused repetitive behaviours such as hair pulling, nail biting & skin picking (completing response training is the core of H), 4) relaxation & social suppo- Used to treat (reduce) repetitive behaviours (habbits) like tics, Tourette's syndrome, hair pulling, nail bitting & stutteringQ. Positive effects have been repoed but the evidence to decide the effectiveness of treatment is insufficient Rational problem solving is systematic, planned & constructive- Problems are defined as life situations tht require responses for adaptive functioning. Solutions are coping responses that alter the nature of problems, negative emotional reactions to them, or both- PST may be effective in wide range of situations (eg patients with schizophrenia, depression, eating disorders), psychological problems (eg smoking, marital discord) and stress a/w chronic illness.Social Skills Training- Some social behaviours can be learned eg making eye contact or staing conversation, negotiating & compromising, conflict management, community living, friendship & dating, work, vocation, medication management and asseiveness (eg making/refusing requests, making/ responding to complaints, making apologies, expressing unpleasant feelings /fear, asking for information, refusing drugs etc), - Useful for socially inadequate people or in rehabilitation of chronic mental disorders (Schizophrenia, depression, social phobia)Behavioral Activation Treatment for Depression (BATD)- Depression is at least paially maintained by a lack of positive reinforcement. Severly depressed mood 1/t behavioral withdrawl, which inturn results in a loss of reinforcement from pleasureable events or activities.- Guiding principle of BATD is matching law, which states that behaviors are allocated to various alternatives (eg should I stay home or go out) based on the propoion of reinforcers obtained from the various alternatives. It says that depression persists because depressed behavior is more highly reinforced than nondepressed behavior. BATD increases the individual's exposure to positive out come of healthy behavior, there by increasing the frequency of these behaviors and reducing depressed behavior.Aversion Based Approches- Based on operant &/or counter conditioning strategies such as timeout, response cost and/or application of noxious stimulus to decrease the likelihood of undesived behavior.- Three different stimuli have been used as aversive conditioning stimuli 1) Chemical aversion (olfactory aversion = pairing of extremely noxious but harmless odors such as amonia with sexual perversion; gustatory /emetic aversion = pairing chemical that induces vomition with substance abuse). 2) Faradic or electrical aversion andVerbal aversion (k/a Cove sensitization) involves the presentation of an imaginal scene involving dent behavior that is immediately f/b a scene that produces nausea. All three types of aversion therapies are used for treatment of sexual detions and substance abuseQ (however alone is rarely sufficient to treat substance abuse/ dependence)
Exposure and response prevention.
Systematic desensitization.
Asseiveness training.
Sensate focusing.