Kaplan + Sadock's Synopsis of Psychiatry, 11e

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28.8 Behavior Therapy

Table 28.8-2 Daily Monitoring of Rituals Each day, record the amount of time spent doing rituals in the morning, afternoon, and evening. Tuesday Wednesday Thursday Friday Saturday

Sunday

Monday

Morning Afternoon

2 hrs 3 hrs

1.5 hrs

2 hrs 3 hrs

Evening

1.5 hrs

Once a day, record the following details about an episode of rituals: Day Time Situation Feelings Thoughts (Obsessions)

Type of Ritual

Feelings After Rituals

Saturday 8 a.m.

Finished

Afraid Scared Worried

Shouldn’t have thrown away my napkin Might have left something under my plate What if I lost something important? Did I sign my name correctly? Did I write the correct amount? What if I give them the check and it is wrong?

Checking through trash Looking under plate Staring to see if I lost something Staring at the check Tracing the lines I wrote Standing there

Better For now, I think I have not lost anything

breakfast

Sunday 2 p.m.

At the store; signed a check

Worried Anxious

Anxious because I couldn’t finish checking

(Courtesy of M. A. Stanley, Ph.D., and D. C. Beidel, Ph.D.)

Aversion Therapy When a noxious stimulus (punishment) is presented immediately after a specific behavioral response, theoretically, the response is eventually inhibited and extinguished. Many types of nox- ious stimuli are used: electric shocks, substances that induce vomiting, corporal punishment, and social disapproval. The negative stimulus is paired with the behavior, which is thereby suppressed. The unwanted behavior may disappear after a series of such sequences. Aversion therapy has been used for alco- hol abuse, paraphilias, and other behaviors with impulsive or compulsive qualities, but this therapy is controversial for many reasons. For example, punishment does not always lead to the expected decreased response and can sometimes be positively reinforcing. Aversion therapy has been used with good effect in some cultures in the treatment of opioid addicts (Fig. 28.8-1). Saccadic eye movements are rapid oscillations of the eyes that occur when a person tracks an object that is moved back and forth across the line of vision. A few studies have demonstrated that inducing saccades while a person is imagining or thinking about an anxiety-producing event can yield a positive thought or image that results in decreased anxiety. Eye movement desensi- tization and reprocessing has been used in posttraumatic stress disorders and phobias. Positive Reinforcement When a behavioral response is followed by a generally reward- ing event, such as food, avoidance of pain, or praise, it tends to be strengthened and to occur more frequently than before the reward. This principle has been applied in a variety of situations. On inpatient hospital wards, patients with mental Eye Movement Desensitization and Reprocessing

to bring hoarded items from home and to discard all unnecessary items during the therapy session. At first, this created tremendous anxiety, but over time, Phillip was able to throw things away with less fear of losing something important. He also developed the abil- ity to conduct self-directed exposure at home. Other exposure ses- sions involved writing letters and mailing them without checking, reading passages from magazines and books only once, and sorting through junk mail to make quick decisions about what to save or discard. As Phillip was able to take on more responsibility for home- based exposure, session frequency decreased to two times per week, and then to once per week. After 3 months of treatment, Phillip’s scores on the YBOCS (Yale-Brown Obsessive-Compulsive Scale) and BDI (Beck Depression Inventory) had decreased to 20 and 19, respectively, demonstrating significant improvement in obsessive- compulsive symptoms and depression. His SPAI (Social Phobia and Anxiety Inventory) score, however, remained relatively unchanged, suggesting that he was still experiencing significant social anxiety. Next, while Phillip worked on maintaining the gains he had made following ERP, he and his therapist conducted some role plays to evaluate his social skills. It was apparent that Phillip had extreme difficulty with initiating and maintaining conversations. His eye con- tact also was quite poor in social interactions. Thus, the therapist devised a plan for teaching and practicing new skills, which also involved additional exposure to Phillip’s core fears as he was asked to resume contact with old friends and identify activities where he could meet new people. He practiced new behaviors first in session with his therapist and then developed a hierarchy of feared social situations in which he could practice his new behaviors. These prac- tice exercises also involved a form of exposure as Phillip was asked to make social contact, which produced fears of negative evaluation. After another 3 months of treatment focused on social skills training (and associated exposure), Phillip’s scores on the YBOCS and BDI had decreased further (YBOCS = 15; BDI = 13), and his SPAI score had decreased to 100. Phillip had gone back to school to take one class, he was spending small amounts of time with old friends, and he was volunteering a few hours each week at his church. (Courtesy of M. A. Stanley, Ph.D., and D. C. Beidel, Ph.D.)