Mastery of your Specific Phobia: Craske, Antony and Barlow

 Contents (Frankly only the first four chapters are interesting)
Chapter 1. Introduction    1
Evolution of Behavioural Treatment for Specific Phobia    1
Chapter 2 Structure of the Mastery of your Specific Phobia (MSP) Program and Practical Issues in its implementation    2
Chapter 3 Specific phobias: phenomenology    2
Summary of points covered in chapter 1 of the client workbook    2
Main Concepts conveyed to client    3
Chapter 4    3
Specific Phobias: How do they develop    3
Main Concepts conveyed to clients    3
Chapter 5 Learning about your specific phobia    4
Chapter 6 Developing a treatment plan    4
Chapter 8 Preparing for exposure    5
Chapter 9 Specifics of Exposure    6
Chapter 10 Exposure to specific bodily sensations    6
Chapter 11 General Issues relating to client workbook    6
Chapter 12 Overcoming  Blood, injection and injury phobias    6
Chapter 13 Overcoming claustrophobia    7

Chapter 1. Introduction

Evolution of Behavioural Treatment for Specific Phobia

Treatment started in 1958 from Wolpe who introduced systematic desensitisation, pairing progressively more distressing images with a competing relaxing response. Through a process called reciprocal inhibition then the anxiety response is diminished, extinguished.  This imaginal counter conditioning is then generalised to in-vivo situations.

In the 1970’s it was shown that you don’t need to pair with the relaxation to get similar results, rather you just need to repeat the process. It was also shown greater efficacy was derived from in-vivo exposure, as opposed to imaginal.

Currently exposure techniques are augmented with cognitive restructuring.

It has also been seen that there is heterogeneity amongst different phobias, which has resulted in different treatments, thus with blood phobias, the treating aspect has been treated with applied tension which raises the blood pressure. With panic disorders the locus of treatment has been in overcoming the fear of bodily sensations.

Chapter 2 Structure of the Mastery of your Specific Phobia (MSP) Program and Practical Issues in its implementation

The MSP program is in three sections:

1.       The nature of anxiety and specific phobias

2.       Introduction to treatment procedures

3.       Detailed treatment procedure and specific phobia implementation

If other problems are presented with a specific phobia, then if the other problem is causing more distress, then the recommendation is to treat that first. MSP is only for specific phobia, e.g. insects, heights, blood, injection, vomit, closed in places and not social phobia, OCD and GAD.

Medication

Medications are seen to have limited benefit, with the exception of those with panic symptoms where pharmacotherapy and behavioural treatments are show to be effective. There is little evidence that medication interferers with exposure.

The therapist needs to comfortable with the object of clients phobia, so may need to ensure this is the case with some exposure work of their own.

Involving family members or people that live with the client, by familiarising them with the client workbook can help as it minimizes any mini sabotages that those around the client might unwittingly do.

Section 2

Introduction to Specific Phobias and their treatment

Chapter 3 Specific phobias: phenomenology

Summary of points covered in chapter 1 of the client workbook

·         A phobia differs from fear due to the excessive nature. A phobia also interferes with a person’s life in a way that a fear doesn’t.

·         A phobic either avoids a situation or finds a situation causes them high levels of anxiety both before and during.

·         A phobic recognises their fear is irrational, and excessive

·         Types of phobia

o   Animals, e.g. spiders

o   Environment, e.g. heights

o   Situational: e.g. closed in places, or travelling by air

o   Blood, injection and injury phobias

·         There is a natural choice of phobias, that represents generally held social fears

·         Phobias are very common and it is estimated that 1`1% of the population have one

Main Concepts conveyed to client

·         Reassurance that phobic reactions are not very different from normal fear

·         Categorise phobias, to provoke an objective reaction from the client to facilitate a problem solving approach

·         Look at cost\benefit of the phobia. Highlight that their excessive fear will take some work to overcome and requires some motivation to do it. This requires learning new skills not just learning new insights

·         The length of time you have had a phobia, is not as significant for treatment as compared to the amount of time and effort you put into fixing it

·         The best way to judge the efficacy of treatment is to try it for a while and judge the evidence

Chapter 4

Specific Phobias: How do they develop

Some fears are very common in the population to help the survival of the species, these are called prepared fears. Thus there is a vulnerability to certain objects, as there is a common held fear albeit low level to these objects.  If there is a negative event that is paired with a prepared fear then it can become strongly related if the negative event holds the feared outcome for the object.

There are three pathways to phobia

1.       Traumatic event paired with a neutral object

2.       Vicarious learning, where someone else’s traumatic event is paired with a neutral object

3.       Information transmission, where you learn about traumatic events and pair with a neutral object

Factors responsible for maintenance are avoidant behaviour which prevents correction of fearful misinterpretation. Relief from escape which promotes avoidant behaviours.

Main Concepts conveyed to clients

Fears are not random, nor do they represent a weakness in character, rather there are specific pathways to learn this behaviour.  Explanations of why fears develops promotes a client to becoming a scientific observer which is a hall mark of CBT.

Some people cannot remember the specific event that triggered their phobia, but this does not prevent treatment. So a phobia develops through pairing a negative event with a neutral stimulus.

Chapter 5 Learning about your specific phobia

Phobias can be a combination of anxiety focussed on the object and anxiety focussed on the fearful reaction, so racing heart to the fearful object, i.e. fear of fear.

Avoidant behaviour can be:

1.       Avoiding contact

2.       Protective behaviours

3.       Medication

4.       Distraction

5.       Reliance on safety signals

Cues to elicit fear may be internal or external, a sensation or an object. Likewise they can be situational so someone with claustrophobia may only be scared shortness of breath means they are going to suffocate when they are in an elevator. Sometimes people aren’t aware of the interoceptive cues that generate the fear, in the same way they aren’t aware of cognitive cues, or sometimes external cues, again this can be explain by habituation because you have done this for so long then it becomes second nature.  Internally generated cues need a different approach to treatment as they are less predictable and cannot be avoided.  Anxious thoughts enhance the fear response from the cue.

Mood congruency is where negative thoughts are more likely to come to mind when feeling anxious or fearful.  Memory gets distorted by mood, so on-going monitoring is recommended rather than memory.

One of the main aspects about MSP is to develop an objective awareness of your phobia and not a subjective one that is influenced by mood. Problem solving shows to improve pain management rather than wishful thinking.  On the spot recording of thoughts, emotions and behaviours fosters a problem solving approach rather than focussing on how bad it felt.

If you avoid totally then monitor what happens if you imagine doing what you fear.

Reasons clients may not self-monitor

1.       Fear

2.       Lack of motivation

With fear, you can reassure that the fear will diminish with repetition. With lack of motivation, then you may suggest that now is not the right time to be doing this work.

Chapter 6 Developing a treatment plan

MSP contains two aspects:

1.       Educational information, cognitive restructuring and correcting misinterpretation of phobic objects

2.       Exposure to feared object, exposure to the fear

Exposure to external objects is done in a hierarchical fashion easiest first. Exposure to feared sensations is complemented by a slow diaphragmatic breathing to counter hyper ventilation. This could end up as a safety behaviour, and studies show that it’s not more effective using this breathing technique. However generally doing breathing techniques and relaxation techniques gets the client to have more confidence and control over their bodily sensations.

Treatment targets for exposure target phobic anticipation, fear and avoidance behaviour.

Fear of the object is moderated by perceptions of predictability, controllability and safety. Predictability relates to when the encounter will begin and when it will end. Controllability refers to knowing what to do to end the encounter. Safety refers to the perception of the object as being harmless.

There is an importance of context in exposure. The original stimulus has been paired with a neutral stimulus, when you expose in office, then the neutral stimulus has two meanings, a feared and a non-feared meaning, and the activation of which is context dependent, in the office it activates the non-feared meaning, thus you must expose in the actual lived situation if the office work is not effective.

As you expose, then you habituate, and you extinguish the pairing between the stimuli, you also cognitively restructure, and increase self-efficacy. All of these aspects are contained in the power of exposure and should be brought to light.

The fear response that you get in phobia, is derived from our ability to survive and is natural and harmless.

The fear response often goes with the disgust response, and exposure will diminish both in time.

When anxious people have a cognitive bias towards danger, when depressed towards self failure, therefore it is important to stay problem focussed and evaluate the evidence.

A basic premise is that discomfort can be endured and that difficult situations can be coped with. In some occasions decatastrophising in more important, in other cases evidence based probability is more important. So in some cases there is a very low chance of something happening but it would be catastrophic, in other cases there is a higher chance of something happening but not that it would be catastrophic.

When highly anxious the levels of catastrophisation tend to increase as does the sense of the likelihood of something happening.

Chapter 8 Preparing for exposure

Exposure can fail through failing to expose the right event, e.g. a one off, as opposed to regular distressing experiences, subtle avoidance, too little repetition, too much time between repetitions.

Exposure increases a feeling of mastery and increase ability to overcome fear.

You need to generate a feared hierarchy for exposure, then start off at the bottom one. Some phobias are multi-dimensional, so fear of driving may be a function of the length of drive, the time of day etc. So in this instance it would be worth creating 3 hierarchies. Likewise some phobias are amenable to graduation, e.g. flying, so in this instance the hierarchy could be around safety behaviours, so travelling with someone, sitting at the front of the plane etc.

Chapter 9 Specifics of Exposure

Clients should practice exposure until the anxiety they get is mild, then they should move onto the next item. One long continuous exposure is usually better than several short ones. Clients should practice exposure at least 3 times a week. Clients are encouraged to expose themselves gradually without using any safety behaviours. It can help a client to tell them about the normal anxiety pattern, of how it rises and falls. At the early stages of exposure, it can help to have a prediction to test against the actual. Overlearning is a good mechanism for relapse prevention, so do a greater level of exposure than is necessary.

Chapter 10 Exposure to specific bodily sensations

·         Fears of interoceptive triggers are based on misinterpretations

·         Treatment can work be changing the misinterpretations and learning that the physical sensation can be endured

·         Slow diaphragmatic breathing is a way of overcoming interoceptive sensations

·         Fears can be interoceptive and exteroceptive. Fear of an animal can be a combination of fear of the sight of the animal and fear of the increase in heart rate

·         Interoceptive exposure begins with inducing the feeling outside of the phobic situation, then moving to the interoceptive exposure in the phobic situation

Chapter 11 General Issues relating to client workbook

Didn’t read this as didn’t feel relevant and haven’t read the client workbook, although I have bought it!

Chapter 12 Overcoming  Blood, injection and injury phobias

·         Diphasis physiological response= impairment of speech and verbal comprehension, is one that you can get with these types of phobias.

·         Treatment starts with a detailed functional analysis, what are the modulators of the phobia, what are the antecedents to it? You should list phobic cues and thoughts

·         Instruct client on applied tension, to show how to stop fainting.

·         Consult with physicians before engaging in exposure, there are some medical conditions that relate to a needle phobia

·         Encourage friends to support client during time of heightened anxiety

·         Exposure techniques can include gory videos, finger prick blood tests. You should also work in conjunction with a nurse\dentist depending on phobic type

·         Blood and injection phobias are the only phobias that result in a drop in blood pressure

·         Some clients veins are difficult to find as they are small, and this results in more pain when doing an injection

·         Applied tension, is tensing muscles to avoid fainting, make sure this doesn’t become a safety behaviour!

·         Vasovagal reaction is a malaise mediated by the vagus nerve that leads to fainting

·         Before doing anything that might result in fainting get a medical examination and check for heart disease.

Chapter 13 Overcoming claustrophobia

·         Claustrophobia shares the most features of any phobia with claustrophobia, therefore you should screen for any panic attacks outside of a claustrophobic situation, in case panic disorder is more appropriate

Chapter 14 Overcoming Animal and insect phobias

·         When you use an animal for exposure, research its behaviour to lessen the unpredictability of it, for instance more docile after feeding

·         If a client has the option of killing an insect or removing  it from the home, the latter is better as it says the animal isn’t dangerous

Chapter 15 Overcoming height phobias

·         People with height phobias can be scared of physical sensations, so rubbery legs means I’m going to fall over

·         Height phobias include, fear of falling, fear of being pushed and fear of jumping

Chapter 16 Fear of driving

·         Here the fear can be as a passenger or a driver

Chapter 17 Fear of Flying

·         Statistically the most dangerous thing about flying is the drive to the airport

·         As theres no escape from an airplane, it can help to start off reducing the amount of safety behaviours, rather than banishing them

Chapter 18 Overcoming phobias of storms, water, choking or vomiting

·         Spinning is useful to induce  nauseous feeling

·         Wearing a tongue depressor can give a gagging feeling