Kaplan + Sadock's Synopsis of Psychiatry, 11e

872

Chapter 28: Psychotherapies

Table 28.6-3 Sample Autogenic Phrases

Table 28.6-4 Steps in Applied Relaxation

Theme

Examples of Self-Statements

Technique

Instructions

Heaviness

“My left arm is heavy.” “My left arm is warm.”

Progressive relaxation

Session 1: hands, arms, face, neck, and shoulders Session 2: back, chest, stomach, breathing, hips, legs, and feet As with progressive relaxation, except that the tension phase is omitted; when release- only relaxation is mastered, the patient can relax within 5 to 7 minutes A stimulus—the word relax —is presented just before exhalation; patients focus on their breathing while already in a relaxed state; the therapist says the word inhale just before each inhalation and the word relax just before each exhalation; after approximately five cycles, the patient mentally says these words (optionally dropping the inhale ) Patients can remain relaxed and move at the same time by differentially keeping muscles unrelated to the movement in a relaxed state; after achieving a relaxed state, patients lift an arm or a leg or look around in the room, while keeping movements and tension in other body parts at a minimum; patients also perform differential relaxation with slow exhalations, thinking the word relax before each exhalation and scanning their bodies for areas of tension; with this practice, relaxation is shortened to 20 to 30 seconds; patients are instructed to relax in this manner 15 to 20 times per day at certain predetermined events in their natural environment (e.g., when they look at a watch or make a telephone call. As a reminder, colored dots might be taped on the watch or phone. After some time, the dots are changed to a different color to keep their reminding power fresh). Patients relax just before entering the target situation; they stay in the situation for 10 to 15 minutes, using their relaxation skills as a coping technique; patients may initially be accompanied by the therapist; alternatively, if the patient’s problem is panic attacks or generalized anxiety, imagery or physical exercise is used to induce fearful sensations, which then are used for application training.

Warmth

Cardiac regulation Breathing adjustment

“My heartbeat is calm and regular.”

“It breathes me.”

Release-only relaxation

Solar plexus

“My solar plexus is warm.” “My forehead is cool.”

Forehead

Cue-controlled relaxation

Applied Tension Applied tension is a technique that is the opposite of relaxation; applied tension can be used to counteract the fainting response. The treatment extends over four sessions. In the first session, patients learn to tense the muscles of the arms, legs, and torso for 10 to 15 seconds (as if they were bodybuilders). The tension is maintained long enough for a sensation of warmth to develop in the face. The patients then release the tension, but do not progress to a state of relaxation. The maneuver is repeated five times at half-minute intervals. This method can be augmented with feedback of the patient’s blood pressure during the muscle contraction; increased blood pressure suggests that appropriate muscle tension was achieved. The patients continue to practice the technique five times a day. An adverse effect of treatment that sometimes develops is headache. In this case, the intensity of the muscle contraction and the frequency of treatment are reduced. Patients with blood and injury phobia show a unique, biphasic response when exposed to a phobic stimulus. The first phase is associated with increased heart rate and blood pres- sure. In the second phase, however, blood pressure suddenly falls and the patient faints. To treat the problem, patients are shown a series of slides that are provocative (e.g., mutilated bodies). They are coached in identifying early warning signs of fainting, such as queasiness, cold sweats, or dizziness, and in applying the learned muscle tension response quickly, contin- gent on these warning signs. Patients can also perform applied tension while donating blood or watching a surgical operation. The technique of isometric tension raises blood pressure, which prevents fainting. Applied Relaxation Applied relaxation involves eliciting a relaxation response in the stressful situation itself. The previous discussion showed that this is not advisable right away because of the possible ironic effects of relaxation. Therefore, patients should first practice relaxation in nonstressful circumstances. The method developed by Lars-Göran Öst and coworkers in Sweden has been proven efficacious for panic disorder and generalized anxiety disorder. Establishing the relaxation response in the patient’s natural environment consists of seven phases of one to two sessions each: progressive relaxation, release-only relax- ation, cue-controlled relaxation, differential relaxation, rapid relaxation, application training, and maintenance. Details are provided in Table 28.6-4.

Differential relaxation

in other settings, including sitting in different chairs, sitting at a desk while writing, talking on the phone, and walking. Rapid relaxation Patients relax by taking one to three breaths

Application training

Results Biofeedback, progressive relaxation, and applied tension have been shown to be effective treatment methods for a broad range of disorders. They form one basis of behavioral medicine in which the patient changes (or learns how to change) behavior that contributes to illness. They form a basis on which many complementary and alternative medical procedures are effective (e.g., yoga and Reiki) in which relaxation is an important com- ponent. Relaxation also informs more mainstream treatments, such as hypnosis.