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PubMed2000

Posttraumatic stress disorder: psychological factors and psychosocial interventions.

In this article, we propose that successful processing of traumatic events involves emotional engagement with the trauma memory, organization of the trauma narrative, and correction of dysfunctional cognitions that often follow trauma. We further propose that the success of psychosocial treatments of posttraumatic stress disorder hinges on the ability of the treatments to address impairments in these processes. We focus our presentation of psychosocial interventions on cognitive-behavioral treatments (CBT), since this approach had gained the most empirical support to date, and describe the results of controlled trials that compare the relative efficacy of several CBT interventions.

Adaptation, Psychological↗
PubMed1990

Post traumatic stress disorder: an eclectic approach.

A number of victims of post traumatic stress disorder, apart from the rest of their symptom constellation, suffer flashbacks. These flashbacks occur during the waking state and frequently are very disabling. From among this group of patients, we have identified a few who demonstrate epileptiform discharge emanating from temporal lobe foci. We have postulated that indeed the flashbacks might represent an amalgam of abnormal neuronal firing along with the expression of a dynamically charged event. Eight cases are documented which illustrate this pattern. In all eight cases, the flashbacks were completely controlled through the use of anticonvulsant medication (carbamazepine and one case of valproate). Other symptoms were treated more traditionally. A modification to a conventional psychotherapeutic approach is introduced which does not merely foster abreaction but also introduces a process of desensitization to the highly charged events. The sessions during which the patient relives the precipitant to the syndrome are audiotaped. Following the experience of working through in therapy, the patient is encouraged to replay the tape(s) repeatedly over several months to facilitate flooding/desensitization. The two case summaries which are presented illustrate the integration of pharmacotherapeutic intervention, a focal short-term dynamic approach, and a behavioral model.

Abreaction↗
PubMed1989

The use of an in vitro flooding package in the treatment of traumatized adolescents.

An in vitro flooding package was used to treat the posttraumatic stress disorders of two adolescents. Traumatic scenes were identified through nonstructured interviews, and stimulus response imagery cues were presented according to a multiple baseline across traumatic scenes design. Posttreatment and 6-month follow-up assessments revealed meaningful improvements in the patients' affective, behavioral, and cognitive parameters.

Adaptation, Psychological↗
PubMed1998

Psychotherapy in the overall management strategy for social anxiety disorder.

Cognitive-behavioral therapies (CBTs) are effective treatments for social anxiety disorder/social phobia. Although a variety of procedures are included under the term cognitive-behavioral treatment, it is, however, clear that the key factor influencing treatment outcome for social anxiety disorder is exposure to feared situations. Two formalized CBT programs are cognitive-behavioral group therapy (CBGT) and social effectiveness training (SET). They both involve exposure, but differ in that CBGT focuses on correction of cognitive errors, whereas SET uses social skills training in addition to exposure to feared social situations. CBGT is more efficacious than a psychological placebo and has shown efficacy comparable to that of phenelzine in a double-blind, placebo-controlled study. The onset of effect of phenelzine was more rapid, whereas the effect of CBGT was more sustained. The major component of SET, imaginal and/or in vivo exposure, has been demonstrated to be more effective than pill placebo or the beta-blocker atenolol. Many questions remain regarding CBT strategies and their place in the overall management of patients with social anxiety disorder. Depending upon the particular patient profile, various combinations of drug and/or CBT may prove to be the optimal treatment strategy.

Behavior Therapy↗
PubMed1976

Losing a symptom through keeping it. A review of paradoxical treatment techniques and rationale.

The therapeutic technique of symptom prescription has been used by practitioners from a variety of clinical schools. This article reviews techniques based on learning theory, symptom redefinition, paradoxical intention, and directive therapy, among other approaches. A conceptual framework for understanding these various approaches is offered, utilizing data from psychoanalysis, learning theory, and interpersonal communication theory.

Acting Out↗
PubMed1990

Extinction of a conditioned emotional response: massed and distributed exposures.

Using the lick-suppression methodology of Jacobs, Buttrick & Kennedy (Pavlovian Journal of Biological Science, 23, 29-34, 1988), a conditioned emotional response (CER) was established in 24 rats using off-the-baseline pairings of a light (the conditional stimulus) and brief footshock (the unconditioned stimulus). Following conditioning, the rats were assigned to one of three extinction groups differing in whether they received massed or distributed off-the-baseline exposure to the conditional stimulus. The effects of differential treatment were assessed on-the-baseline on test days, when the extinction of the CER was monitored. Rats receiving a single, long exposure to the conditional stimulus showed greater resistance to extinction than the rats in the distributed groups. They also showed a difference pattern of CER extinction. The results were discussed and compared to similar studies that have explored the massed vs distributed dimension, both in CER and avoidance-extinction (using response prevention or flooding). The relation of animal studies to parallel human studies using exposure therapy was also discussed.

Animals↗
PubMed1988

Autonomic changes after treatment of agoraphobia with panic attacks.

Twenty-three patients meeting DSM-III criteria for agoraphobia with panic attacks and 14 age-, race-, and sex-matched nonanxious controls were tested in the laboratory and on a test walk in a shopping mall. The patients were tested before and after about 15 weeks of treatment with placebo and exposure therapy, imipramine and exposure therapy, or imipramine and initial antiexposure instructions. Controls were tested twice at a similar interval, but without any treatment. On test day 1, patients compared to controls showed higher average heart rate and skin conductance levels and greater numbers of skin conductance fluctuations in the laboratory, and higher heart rates before and during the test walk. Between pretreatment and posttreatment tests, clinical ratings improved and skin conductance levels decreased in all treatment groups. Heart rate levels in the laboratory, on the other hand, decreased in patients on placebo and rose in patients on imipramine. Thus, imipramine compromises the usefulness of heart rate as a measure of emotional arousal. Higher pretreatment heart rates predicted greater clinical improvement.

Adult↗
PubMed1977

Psychotherapies: an overview.

The author schematically describes the three predominating themes in the development of the psychotherapies: dynamic, behavioral, and experiential. These themes represent different conceptualizations of the fundamental nature of man and his ills, therapeutic processes or change agents, the basic nature of the physician-patient relationship, and the primary techniques and methods used. Although there appears to be some unifying thread connecting the four different areas within each theme, a comparable bond does not exist across the three themes. The author questions the potential unification of the psychotherapies and poses specific dimensions for further exploration.

Autogenic Training↗
PubMed1978

Severe depersonalization treated by behavior therapy.

The author reports the use of behavior therapy in the treatment of two cases of severe intractable depersonalization. Outcome criteria included full psychiatric assessment, patients' self-ratings, and psychometric test scores. Treatment by flooding was highly effective in one case, and associated obsessive symptoms and anticipatory anxiety were substantially decreased in the other. Behavioral techniques may prove especially helpful in cases in which anticipatory anxiety, phobic avoidance, and obsessive perseveration are exacerbating features.

Adult↗
PubMed1991

Psychiatric complications during flooding therapy for posttraumatic stress disorder.

The authors use six case vignettes to illustrate underrecognized complications occurring during flooding therapy for posttraumatic stress disorder (PTSD), including exacerbation of depression, relapse of alcoholism, and precipitation of panic disorder. A common denominator to the majority of these cases appears to be the mobilization of negative posttrauma appraisal, accompanied by shame, guilt, and anger. The authors suggest that flooding may not be helpful for these negative emotions in the manner that it is for anxiety. Suggestions for preventing and treating complications of flooding therapy for PTSD include employing more cognitive forms of therapy in cases at risk; supporting abstinence from alcohol and other substances; providing adjunctive pharmacologic treatment as indicated, e.g., tricyclics for depression or panic; and providing long-term follow-up.

Acute Disease↗
PubMed1986

Agoraphobia: relative and combined effectiveness of therapist-assisted in vivo exposure and imipramine.

Sixty-two chronically agoraphobic patients completed a controlled study to assess the effects of 1) imipramine up to 200 mg/day (mean = 130 mg/day), 2) 12 weekly therapist-assisted in vivo exposure sessions (flooding), and 3) imipramine plus flooding. The control group received systematic therapeutic instructions for self-directed in vivo exposure (programmed practice). Clinical measures of global severity, phobia, panic, anxiety, depression, and behavioral performance tests were administered before treatment and at Weeks 4, 8, and 12 of treatment. Results revealed significant improvement in all groups on all measures over the course of treatment; almost a third of the control patients showed marked improvement. Imipramine had significant effects on improvement of phobias and markedly increased clinical response rates in patients receiving 150-200 mg/day. Less chronicity and severity of condition also predicted better clinical outcome. Flooding had limited effects above and beyond programmed practice, and no imipramine-flooding interactions effects were found.

Adult↗
PubMed1995

Advances in behavioral-cognitive therapy of social phobia.

Behavioral-cognitive therapy is a cost-effective treatment for social phobia. The doctor's role is to teach the patient how to do successful self-exposure. The clinician acts as a guide and monitor; there is no need to waste time accompanying the patient into the phobic situation. The patient first reads a self-exposure manual to learn how to confront panic-evoking social cues for prolonged period without avoidance until habituation sets in. This might require an hour daily of self-exposure over weeks or months. As patients habituate to social cues to which they have exposed themselves, they arrange exposure to fresh cues until they become used to all. The patient tracks progress by recording completed exposure-homework tasks in a daily diary. In instances where it is technically difficult to do regular exposure, the patient carries out imagined tape-recorded exposure in his/her own voice. The therapist can briefly help the patient role-play such exposure. Rational role-play enhances outcome of body dysmorphic disorder or delusional disorder somatic type with prominent social phobia. Cognitive therapy can be useful. Most social phobics improve with behavioral-cognitive treatment without medication. When patients have low mood, concurrent antidepressants can be synergistic.

Antidepressive Agents↗