Inhibitory Learning and Regulation During Exposure Therapy: From Basic Science to Clinical Application

Michelle Craske, University of California, Los Angeles, USA

 

The therapeutic strategy of repeated exposure is effective for fears and anxiety disorders, but a substantial number of individuals fail to respond. Translation from the basic science of inhibitory extinction learning and inhibitory regulation offers strategies for increasing response rates to exposure therapy. This workshop will present the application of these strategies, including prediction error correction (‘violation of expectancy’), variability across stimuli and contexts to enhance generalization, interference with hippocampal activation to enhance context generalization, bridging techniques to retrieve exposure memories in novel contexts, induction of positive valence, and linguistic processing (‘affect labeling’) of feared stimuli.

 

Key learning objectives:

1. Understand latest developments in extinction learning and their relevance to exposure therapy
2. Understand latest developments in inhibitory regulation and their relevance to exposure therapy
3. Understand methods for optimizing inhibitory learning during exposure therapy and its retrieval following exposure therapy
4. Understand methods for augmenting inhibitory regulation during exposure via affect labelling.

 

Implications for everyday clinical practice of CBT

Tailor methods for conducting exposure therapy to facilitate response rates and reduce return of fear

 

Michelle G. Craske, Ph.D., is Distinguished Professor of Psychology, Psychiatry and Biobehavioral Sciences, Director of the Anxiety and Depression Research Center, and Associate Director of the Staglin Family Music Center for Behavioral and Brain Health, at the University of California, Los Angeles.  She is a leader of the UCLA Depression Grand Challenge.  She has published extensively in the area of fear, anxiety and depression.  In particular, she investigates neurophysiological, environmental, cognitive and behavioral correlates and risk factors for anxiety and depression using longitudinal designs, fear extinction mechanisms and their neural underpinnings for exposure-based therapies for anxiety, reward sensitivity training for anhedonia, and implementation of treatments for anxiety and depression in non-research settings. She is Editor-in-Chief for Behaviour Research and Therapy. 

 

References

Craske, M.G., Treanor, M., Conway, C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23.

Craske, M.G., Hermans, D., & Vervliet, B. (in press). State of the art and future directions for extinction as a translational model for fear and anxiety. Philosophical Transactions B

Cognitive Behaviour Therapy for Body Dysmorphic Disorder

David Veale, King’s College London and South London and Maudsley NHS Trust, UK

 

Body Dysmorphic Disorder (BDD) is defined as a preoccupation with a perceived defect in one’s appearance, which is not noticeable to others. The preoccupation is associated with a distorted “felt” impression with many “safety seeking” behaviours such as mirror gazing, skin-picking, ruminating or constant comparing of one’s perceived defect to others. People with BDD often use strategies to camouflage and avoid situations and activities. They may have a poor quality of life, are socially isolated and are at high risk of committing suicide. Cognitive behaviour therapy and SSRI medications are recommended for treating BDD. CBT targets the various processes that maintain the preoccupation and distress.

 

Key learning objectives:

By the end of the workshop participants will:

1. Recognize and diagnose BDD in DSM5 and ICD11.
2. Understand a cognitive behavioural model of BDD and the factors that maintain the symptoms including comparing self with others; being excessive self-focused; camouflaging one’s appearance; monitoring and avoiding social threats such as shame, rejection and ridicule from others.
3. Use various assessment scales and conduct a functional analysis of cognitive processes andbehaviours that are used as safety seeking.
4. Assess and help clients wanting cosmetic procedures
5. Devise strategies for engagement and change with a focus on ceasing ruminating and comparing, dropping of avoidance and safety seeking behaviours; imagery rescripting for aversive memories.

 

Implications for everyday clinical practice of CBT

CBT is the only evidence based psychological therapy for BDD and may be helpful for treating other body image problems with body shame (e.g. eating disorders, disfigurement).

 

David Veale is a Consultant Psychiatrist and leads a national outpatient and residential unit service for people with severe treatment refractory Obsessive Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD) at the South London and Maudsley Trust and at the Priory Hospital North London. He is a member of the group revising the diagnostic guidelines for ICD11 for OCD and Related Disorders for the World Health Organisation. He was a member of the group that wrote the NICE guidelines on OCD and BDD in 2006 and chaired the NICE Evidence Update on OCD and BDD in 2013. He has authored or co-authored 90 empirically based articles, 6 books, 13 book chapters, and 35 teaching articles or reviews. He is an Honorary Fellow of the British Association of Behavioural and Cognitive Psychotherapies, a Fellow of the British Psychological Society and Fellow of the Royal College of Psychiatrists. He is a Trustee of the UK national charities, OCD Action and the BDD Foundation.

 

References

Phillips, K (2017) Body Dysmorphic Disorder: Advances in Research and     Clinical Practice. Oxford.

Veale, D. & Neziroglu (2010) Body dysmorphic disorder: a treatment manual Wiley: Chichester.

Veale, D., Willson, R, Clarke, A. (2009) Overcoming Body Image Problems (including BDD). Robinson

Cognitive Behavior Therapy for People with Irritable Bowel Syndrome 9IBS): Introducing Regul8 Manualised Treatment

Rona Moss-Morris, Professor of Psychology as Applied to Medicine

 

Regul8, an eight-session tailored cognitive behavioural therapy (CBT) programme for treating IBS, was developed as a potential cost-effective way of providing help to those individuals with IBS.  The therapy on which Regul8 is based has been developed over 18 years using rigorous empirical study.  The cognitive behavioural treatment mechanisms included in Regul8 are based on empirical studies predicting the onset and maintenance of IBS symptoms. The CBT is therefore specific to IBS rather than CBT for a related mood disorder.  The content was further developed and modified through early clinical trials (Kennedy et al., 2005; Moss-Morris et al., 2010).  The effectiveness of the patient manual together with 8 hours of telephone therapist contact time has been confirmed in a large effectiveness trial (n=520) which followed patients for up to one year (Everitt et al., 2018).

 

The Regul8 patient manual consists of 8 chapters including: (1) Understanding your IBS and the link between symptoms, thoughts, feelings and behaviours; (2) Assessing your symptoms in relation to stress and daily routines; (3) Changing behaviours in response to symptoms, developing consistent eating, activity and exercise routines; (4) Identifying your unhelpful thought patterns; (5) Generating alternative thoughts; (6) Managing stress and sleep (7) Managing emotions; (8) Managing flare-ups and the future.

 

This Worksop will focus on core aspects on this manualised approach.  The first will be how to engage patients with physical symptoms in a behavioural based therapy.  The use of explanatory models which include physical as well as psychological explanations of symptoms will be demonstrated.  Specific IBS avoidance and safety behaviours will be identified alongside methods to address these.  Finally, the importance of symptom and illness cognitions and high personal expectations will be discussed.

 

Key learning objectives:

1. Use the biopsychosocial model of IBS to provide a coherent, personalised explanation to patients as to why they experience IBS symptoms
2. Use this model to engage patients in future behavioural and cognitive change.
3. Identify IBS specific avoidance and safety behaviours and strategies for treating these.
4. Identify IBS-related unhelpful cognitive responses.

 

Implications for everyday clinical practice of CBT

The workshop is most appropriate for therapist who use CBT in everyday practice.  It provides an introduction to treating IBS specially using CBT.  The Regul8 manual for patients and the related therapist manuals are readily available for use.  We have also developed a Regul8 interactive and tailored web-based treatment.  We are currently working to bring this software to the market as it offers a low intensity version of the treatment.  Patients work through the website and are provided some minimal support by an experienced therapist (around 2.5 hours of therapy time).

 

Rona Moss-Morris is Professor of Psychology as Applied to Medicine and Head of Health Psychology at King’s College London. She has been researching psychological factors that affect symptom experience and adjusting to chronic physical health conditions for the past 20 years.  This research has been used to design cognitive behavioural interventions, including web-based interventions, for a range of patient groups.  RCTs to test the efficacy of these interventions form a key component of her research.  In 2015 she was awarded the British Psychological Society Division of Health Psychology’s Outstanding Contribution to Research Award and the Institute of Psychiatry, Psychology and Neuroscience Supervisory Excellence Award.  Her work on Multiple Sclerosis (MS) was awarded the MS Society Annual Award for MS Research of the Year in 2013.  She is a past editor of Psychology and Health and was National Advisor to NHS England for Improving Access to Psychological Therapies for People with Long Term and Medically Unexplained conditions from 2011-2016. 

 

References

Windgassen S, Moss-Morris, R. Chilcot, J., Sibelli, A., Goldsmith, K. & Chalder, T. The Journey between brain and gut: A systematic review of psychological mechanisms of treatment effect in irritable bowel syndrome. British Journal of Health Psychology. 2017;22:701.

Moss-Morris R, McAlpine L, Didsbury LP, Spence MJ. A randomized controlled trial of a cognitive behavioural therapy-based self-management intervention for irritable bowel syndrome in primary care. Psychological medicine. 2010;40:85-94.

Spence, M. J. & Moss-Morris, R. (2007). The cognitive behavioural model of irritable bowel syndrome: a prospective investigation of patients with gastroenteritis. Gut 56, 1066-71.

Somatic Symptoms in Psychopathology: Understanding the Mechanisms and Optimizing Treatment.

Omer Van den Bergh, University of Leuven, Belgium and Michael Witthöft, University of Mainz, Germany

 

Somatic symptoms (e.g., pain, fatigue, dizziness) are highly prevalent in psychopathology. They are intricately related to depressive and anxiety disorders, they occur in trauma- and stress-related disorders and they are the core of somatic symptom and related disorders. In addition, a substantial number of patients in primary and secondary medical care consults for somatic symptoms that cannot be linked to bodily dysfunction and are considered nonspecific, functional and/or stress-related. In psychotherapy, it is often not clear whether and how such symptoms should be targeted. Commonly, such symptoms are considered epiphenomena of a larger cognitive-emotional problem that is focused upon.

In this workshop, we will discuss critical evidence prompting a new model to understand the (often loose) relationship between somatic symptoms and bodily dysfunction that is based on a predictive processing view on the brain. In this view, experienced symptoms emerge as a result of two counterflowing and continuously interacting streams of information. One represents prior predictions of the brain and the other represents prediction errors related to somatic input. Depending on prior expectations (and their precision), symptoms may be more or less closely related to somatic input. From this view, we derive clinical implications for a comprehensive assessment and theory-based and mechanism-oriented treatment. In particular, we will discuss how stress- related physiology and nocebo-mechanisms dynamically interact to produce vicious circles and self-fulfilling prophecies maintaining somatic symptoms on the longer term. We will discuss and demonstrate new ways to counter such mechanisms.

 

Key learning objectives:

1. To understand the often loose relationship between experienced bodily symptoms and somatic activity and dysfunction
2. To be able to detect the critical mechanisms of the model in a patient’s story

To influence those mechanisms to the benefit to the patient

 

Implications for everyday clinical practice of CBT

The workshop aims at developing a transdiagnostic understanding on how somatic symptoms come about in psychopathology. This implies understanding the role of stress-related physiology in interaction with central processes in the brain that moderate the strength of the relationship between the symptoms and somatic input, as well as developing intervention techniques that counteract the symptoms. Because somatic symptoms that are little or not related to physiological dysfunction are highly prevalent in several diagnostic categories in psychopathology as well as in medical consultations in primary and secondary care, the workshop should benefit the practitioner in a variety of clinical settings.

 

Omer Van den Bergh is professor of health psychology at the University of Leuven, Belgium. He has been trained as a CBT-therapist and has extensive clinical experience in treating patients with stress-related problems, somatization disorder and medically unexplained symptoms in primary and secondary care.

 

Michael Witthöft is professor of clinical psychology, psychotherapy, and experimental psychopathology at the Johannes Gutenberg-University of Mainz, Germany. He is a licensed psychotherapist specialized in CBT with extensive experience in the treatment of anxiety disorders, somatoform disorders, and pathological health anxiety.

https://klipsy.uni-mainz.de/abteilungsmitglieder/witthoeft/

 

References

Schaefer, M., Egloff, B., Gerlach, A. L. & Witthöft, M. (2014). Improving heartbeat perception in patients with medically unexplained symptoms reduces symptom distress. Biological Psychology, 101, 69-76. doi: 10.1016/j.biopsycho.2014.05.012

Van den Bergh, O., & Walentynowicz. M. (2016). Accuracy and bias in retrospective symptom reporting. Current Opinion in Psychiatry, 29, 302-308. doi: 10.1097/YCO.0000000000000267

Van den Bergh, O., Witthöft, M., Petersen, S. & Brown, R.W. (2017). Symptoms and the body: Taking the inferential leap. Neuroscience & Biobehavioral Reviews, 74, 185-203. doi: 10.1016/j.neubiorev.2017.01.015

Culturally adapted Cognitive Behavior Therapy (CA-CBT) for Traumatized Refugees

Ulrich Stangier, Schahryar Kanananian & Marwan Yehya

 

Approximately every second asylum seeker suffers from trauma-related disorders requiring treatment, among them Posttraumatic Stress Disorder (PTSD), depression, anxiety, and somatic symptoms. Easily accessible, low-threshold treatments are needed that take the cultural background into account. CA-CBT is a well evaluated, transdiagnostic intervention for refugees, using psychoeducation, problem-solving, meditation, and Yoga-like exercises. The programme can be delivered in individual or group setting. CA-CBT is a promising transdiagnostic treatment, serving as an initial low-threshold therapy in a stepped care approach which may be followed by trauma-focused interventions such as Narrative Exposure Therapy and Cognitive Processing Therapy.

The workshop presents a comprehensive approach that focuses on the modification of dysfunctional emotion regulation processes (e.g., intrusive memories, rumination, grief, anxiety, anger) and dysfunctional behaviors (e.g., self-harming or violent behavior). The workshop offers: a) a short introduction to diagnostic features of traumatized refugees, b) a transdiagnostic model to understand mental health problems, and c) specific cognitive, emotion-focused and body-focused interventions depending on patients’ individual need. Special focus is placed on the assessment and implementation of culture-specific aspects in refugees from Middle East.

 

Presentation of the main cognitive interventions for BDD

1. Basic Psychopathological Models
2. Psychoeducation
3. Problem Solving
4. Meditation and Yoga

 

Ulrich Stangier, Ph.D., is Full Professor and Chair for Clinical Psychology and Psychotherapy and Director of Clinic for Behavior Therapy at Institute of Psychology, Goethe University Frankfurt. Main domains of research and publications refer to psychopathology and cognitive therapy of social anxiety disorder, depression, and body dysmorphic disorder; therapists’ adherence and competence in cognitive therapy. Clinical trials on the efficacy of cognitive therapy for social anxiety disorder, recurrent depression, and body dysmorphic disorder.

 

References

Hinton D., & Good B. (2016), Culture and PTSD: Trauma in Global and Historical Perspective. University of Pennsylvania Press.

Schauer, M., Neuner, F., Elbert, T. (2011). Narrative Exposure Therapy (NET). A Short-Term Intervention for Traumatic Stress Disorders (2. Ed.). Cambridge/ Göttingen: Hogrefe

Kananian, S., Ayoughi, S., Farugie, A., Hinton, D. & Stangier, U. (2017). Culturally Adapted Cognitive Behavioral Therapy with Afghan Refugees: a Pilot Study. European Journal of Psychotraumatology, 8, 1390362.

Kaysen, D., Lindgren, K., Zangana, G. A. S., Murray, L., Bass, J., & Bolton, P. (2013). Adaptation of cognitive processing therapy for treatment of torture victims: Experience in Kurdistan, Iraq. Psychological Trauma: Theory, Research, Practice, and Policy, 5(2), 184-192.