Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 28: Psychotherapies

disorders receive a reward for performing a desired behavior, such as tokens that they can use to purchase luxury items or certain privileges. The process, known as token economy, has successfully altered behavior. Table 28.8-3 gives a summary of some clinical applications of behavior therapy.

Charles was a 70-year-old retired business executive. Through- out his life, his work consumed him. Although he married and had a family, his job was his primary focus. He went to the office early and came home late. He enjoyed what he did—it was stimulating and made him feel important and useful. But as he got older, his performance was not what it used to be, and he decided it was time to retire. However, his mood was pretty low when he no longer had a job. He did not have the energy to get more involved in his church or to develop other hobbies, so he sat around all day, without any social contacts. His wife and best friend encouraged him to go talk to someone. The therapist suggested that they try behavioral activation. Charles was somewhat skeptical, as it seemed too simple, but he needed to do something. The therapist spent some time with Charles talking about the kinds of activities that used to make him feel good and some of the things he used to enjoy. They then put together a list of things he might be able do—even if he did not feel much like it—just to see what would happen. The list included looking for vol- unteer work where he could use his job skills, spending more time with his wife in some of the activities they once had enjoyed (e.g., watching movies, taking walks), and rejuvenating an old hobby from his college days—fishing. Charles initially agreed to do some easy activities—go to one movie a week, take one walk a week, and con- tact his church activity leader about possible volunteer activities. He was surprised to find that even these “baby steps” helped him feel better. He had the chance to talk with other people and began to see that even in retirement, he could find useful and fun things to do. (Courtesy of M. A. Stanley, Ph.D., and D. C. Beidel, Ph.D.)

Figure 28.8-1 Treatment of addicts at Tham Krabok Monastery in Thailand results in a 70 percent success rate, according to its records. The 10-day free treatment begins with a vow to Buddha never to use narcotics again. Then, patients are given an herbal medicine that makes them vomit immediately. (FromWhite PT, Raymer S. The poppy—for good and evil. National Geographic. 1985;167:187, with permission.)

Table 28.8-3 Some Common Clinical Applications of Behavior Therapy

Disorder

Comments

Agoraphobia

Graded exposure and flooding can reduce the fear of being in crowded places. About 60% of patients so treated improve. In some cases, the spouse can serve as the model while accompanying the patient into the fear situation; however, the patient cannot get a secondary gain by keeping the spouse nearby and displaying symptoms. Aversion therapy in which the alcohol-dependent patient is made to vomit (by adding an emetic to the alcohol) every time a drink is ingested is effective in treating alcohol dependence. Disulfiram (Antabuse) can be given to alcohol-dependent patients when they are alcohol free. Such patients are warned of the severe physiological consequences of drinking (e.g., nausea, vomiting, hypotension, collapse) with disulfiram in the system.

Alcohol

dependence

Anorexia nervosa Observe eating behavior; contingency management; record weight Bulimia nervosa Record bulimic episodes; log moods Hyperventilation Hyperventilation test; controlled breathing; direct observation Other phobias

Systematic desensitization has been effective in treating phobias, such as fears of heights, animals, and flying. Social skills training has also been used for shyness and fear of other people. Electric shocks or other noxious stimuli can be applied at the time of a paraphilic impulse, and eventually the impulse subsides. Shocks can be administered by either the therapist or the patient. The results are satisfactory but must be reinforced at regular intervals. The token economy procedure, in which tokens are awarded for desirable behavior and can be used to buy ward privileges, has been useful in treating inpatients with schizophrenia. Social skills training teaches patients with schizophrenia how to interact with others in a socially acceptable way so that negative feedback is eliminated. In addition, the aggressive behavior of some patients with schizophrenia can be diminished through those methods. Sex therapy, developed by William Masters and Virginia Johnson, is a behavior therapy technique used for various sexual dysfunctions, especially male erectile disorder, orgasm disorders, and premature ejaculation. It uses relaxation, desensitization, and graded exposure as the primary techniques.

Paraphilias

Schizophrenia

Sexual

dysfunctions

Shy bladder

Inability to void in a public bathroom; relaxation exercises

Type A behavior

Physiological assessment, muscle relaxation, biofeedback (on electromyogram [EMG]