90 Minute In-Vivo Exposure Sessions for the Treatment of Anxiety

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"Tony Banana" tony_ban...@hotmail.com

http://www.beckinstitute.org http://www.academyofct.org/ Beck Institute GSB Building, City Line and Belmont Avenues, Suite 700 Bala Cynwyd, PA 19004-1610 Phone 610.664.3020 Fax 610.664.4437 90 Minute In-Vivo Exposure Sessions for the Treatment of Anxiety The efficacy of in vivo exposure in the cognitive treatment of anxiety and panic disorders is well known. Techniques such as over-breathing to simulate panic and/or imaginal exposure are essential elements in most cognitive therapy protocols. These tools provide a number of helpful elements to the treatment process. They allow the therapist to collect important data.
Patients report the sensations and fears they are experiencing at the moment. In addition the therapist can often observe previously unreported safety behaviors patients are using (which they may or may not be consciously aware of) to manage the symptoms??”behaviors that perpetuate the problem. Exposure in session also provides a safe environment for patients to experience symptoms and to challenge the catastrophic cognitions ***ociated with them. Doing so helps to reinforce the idea that the symptoms are not dangerous even though they feel dangerous.
As a clinical intern at the Beck Institute I recently treated a patient for whom in-vivo exposure was very important. At intake, ???Tom??? reported that he had been having several panic attacks a week for several years and had been taking anxiolytic medication for 12 months, but had not noticed any significant decrease in the frequency or severity of his panic attacks. The number of places in which he felt comfortable outside of his house was rapidly decreasing, and his avoidant strategies were having a marked negative impact on his relationships with his parents, his girlfriend, and his employer. He frequently left work early because of anxiety, refused to participate in family vacations (sometimes insisting that another family member stay home with him in case he had an attack), and had all but completely stopped taking his girlfriend out on dates. Though he could conjure up images of the catastrophic predictions that fueled his panic attacks (e.g. losing control, going crazy, ultimately being institutionalized), the images, even when paired with overbreathing, did not elevate his anxiety sufficiently to elicit and evaluate his catastrophic misinterpretations.
We collaboratively developed a hierarchy of anxiety-provoking situations with the initial intention of having the patient carry out exposure trials as homework ***ignments. Tom identified a number of locations outside his home that he thought of as threatening. The further away from his home a location was situated, the higher he rated it on our anxiety scale.
Restaurants, however, were an exception. They were near the top of the hierarchy because he catastrophically predicted that eating in a restaurant when he was anxious would make him physically ill and he might vomit in public. As it turned out, Tom avoided eating altogether when he was feeling anxious--which led to further stomach distress that he misinterpreted as anxiety.
The exposure hierarchy involved car trips of steadily increasing distance and duration, in increasingly unfamiliar locations, culminating in a trip into the city for lunch. We agreed that I would go along on these trips and that our exposure sessions would last 90 minutes.
Our sessions started at the office. Tom would rate his initial anxiety and write down all his negative predictions about the trip. We would then get in his car and he would drive us on our pre-determined route. During this process, I made a number of observations that further informed the treatment. He did indeed have a number of safety behaviors that he had failed to report. He turned on the air-conditioner full blast, would decrease speed at times when he felt his anxiety rising, and drove close to the shoulder in case he needed to pull over and head home. These safety behaviors served to reduce his anxiety at the moment but perpetuated his fear of his symptoms (???If I don??™t [engage in these safety behaviors], then my anxiety will increase and maybe [the catastrophe] really will happen.???) Over the course of the exposure sessions we eliminated a number of these behaviors, thus allowing him to learn that he did not have to avoid his symptoms. This cognitive shift ultimately made it easier for Tom to meet each hierarchical goal.
At the end of each exposure session, we spent about ten minutes debriefing the experience. Tom compared his earlier predictions with the actual outcome. He learned that his anxiety, while uncomfortable, was not dangerous and that it need not interfere with his daily functioning. In addition to the benefits of the cognitive restructuring, the patient benefited from the desensitizing elements of the exposure and from the subsequent mastery experience following each session. Though anxiety-provoking and challenging in many ways, these sessions provided positive reinforcement and objective data that contradicted his negative beliefs about anxiety.
Our exposure sessions culminated with a driving trip into the city during which Tom parked his car in an unfamiliar garage. We then took a taxi several blocks away to a restaurant where we ate, walked back to the garage and then drove back to the office. In this way we addressed several components of his anxiety: we reduced the occurrence of safety behaviors while driving, reduced his fear of driving into unfamiliar places far from home, and challenged his beliefs about the catastrophic consequences of eating while anxious. Tom continued to challenge himself in other ways outside of therapy and contacted me weeks later to let me know that he was planning a vacation with friends that would involve cross-country travel.
As an intern under supervision at the Beck Institute, I was able to schedule 90-minute sessions with some of my ***igned clients. This is not always possible in large clinical settings or when elements of treatment planning are contingent on managed care authorizations. However, I have found, in this case in particular, that extended sessions allow for richer exposure sessions and can ultimately shorten the duration of treatment.

"seeyouinseptember" seeyouinst...@nospam.net

So Tony , your ***ociated wth this place. I know of this place.It unfortunately didn't work for me. This cognitive therapy gives people an alternative I guess, especially this sensitivity and desensitivity sessions.
Just because it doesn't work for me, doesn't mean it won't work for others.
I think anxiety and fears  have many complex modalities and causes. There are suggestions there is a gene causation in panic or OCD .(forget which) .
I think there is allergy, possibly food, possibly family , possibly adrenalin physical stress causes etc. learning to densensitize might work , but you tell that to the people who are convinced breathing exercises and learning to control breathing is better or medications. Unfortunately to me, the reality is some people will always have fears , until this science becomes better and more accurate. Until then many people are going to spend countless time in trial and error in suspect treatment centers such as this , which you describe. I am sure the center (use to be a women center) that your referring to has some success but as someone who studies the latest data, the best thing that can be said, is its but one approach to treating anxiety.
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"Tony Banana" tony_ban...@hotmail.com

I've never been to the Beck Institute.  I just found out about it today.
1. Pills 2. CBT/REBT 3. Pills and CBT/REBT Any other ideas of managing Panic Disorder ?
Thanks, Tony

"seeyouinseptember" seeyouinst...@nospam.net

Any other ideas?  First off at the risk of sounding inaccurate, I was at a place not far from there, called the Belmont Institute and also at the Women Medical College which has a similar program . This was around six years ago.
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Philip Peters phi...@p-peters.demon.nl

Beck is one of the founders of cognitive therapy (Ellis being the other one). CBT/REBT has proven statistically to be the only therapy that rightfully claim very good results with anxiety/panic. Calling the Beck Institute a *suspect treatment center* is ridiculous. I am sorry that cognitive therapy seems not to have helped you (one wonders what happened and whether you had a *good* therapist but indeed CBT doesn't have a 100% score, nothing has) but you can't generalize your personal experience. Fortunately you do hint at this in your last sentence. Would you share with us what other appraoches (except medication) you find valid for anxiety/panic? Maybe we can all learn something from that.
Philip

NIGHT-HAWK StealthFigh...@SkunkWorks.com

What a ****ing genius you are Tony, can I hang around with you? :-D

"seeyouinseptember" seeyouinst...@nospam.net

Philip, Like I said after sleep today, I well might not have been at the Beck institute. Is this place near the Belmont Institute?  Anyway do you work for them? I can't generalize about this program? Which other things might work for anxiety? Food, allergy, family therapy , environment, meds maybe, breathing exercises, exercise .
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"Tony Banana" tony_ban...@hotmail.com

These are all stress reduction techniques.  I do find that my case of PD gets worse as stress in my life increases, whether it is based on my own rational or irrational thoughts.
Foods and environment can lead to physical stress which can also increase our mental stress if we let our thoughts do so.
Allergies have caused a great deal of stress in my life.  Feeling fatigued from sinus allergies can make it difficult to function in life, resulting in relationship difficulties with your family and employer.
Tony

Philip Peters phi...@p-peters.demon.nl

I don't know the Belmont Institute. I am in Europe. But the Beck Institute, like the Ellis Institute, is internationally famous.
   Anyway do you Hm...*IDEA*! ;-) I said one can't generalize one's own experiences about what works or not to be valid for others. And there is more than sufficient statistical material to prove that CBT as practiced in the Beck Institute is a very powerful tool in the treatment of anxiety/panic.
  Which other things Breathing exercises are part of every CBT-program. Food (I take it you also mean supplements and *medical foods*?) can supplement meds and CBT but won't as a rule get rid of an anxiety disorder all by itself. The same goes for physical exercise. How *allergy* has now become a therapeutic tool is beyond me ;-) The same goes for the *environment*.
If you mean *changing your environment* in the sense of go and live in a healthier place (bot physically and emotionally) that's always a good idea but in the most pastoral and idyllic of cultures there is just as much anxiety (disorder) as where we are. Family therapy can be helpful to make the system function better *around* someone's anxiety disorder and deal with it in a sensible way but it won't cure it.
Philip ...