|Year : 2019 | Volume
| Issue : 2 | Page : 151-154
Treatment of phobia using modified form of exposure and response prevention
BS Chavan, Tanupreet Kaur, Navneet Kaur
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
|Date of Submission||12-Jul-2018|
|Date of Decision||02-Aug-2018|
|Date of Acceptance||08-Oct-2018|
|Date of Web Publication||26-Jun-2019|
Dr. Tanupreet Kaur
Department of Psychiatry, Government Medical College and Hospital, Sector 32, Chandigarh
Source of Support: None, Conflict of Interest: None
Exposure therapies are based on the premise that fears are acquired through associative learning (classical or operant conditioning). Commonly used behavior therapies are flooding and systematic desensitization in patients of phobia. However, in our index case, we could not introduce any of these modes of therapy due to patient-limited factors; thus, we introduced modified exposure and response prevention in which we tried to overcome the limitations of commonly used behavioral therapy techniques. She underwent 12 sessions and showed good and quick results.
Keywords: Exposure, modified, phobia, therapy
|How to cite this article:|
Chavan B S, Kaur T, Kaur N. Treatment of phobia using modified form of exposure and response prevention. Indian J Soc Psychiatry 2019;35:151-4
|How to cite this URL:|
Chavan B S, Kaur T, Kaur N. Treatment of phobia using modified form of exposure and response prevention. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Sep 16];35:151-4. Available from: http://www.indjsp.org/text.asp?2019/35/2/151/261486
| Introduction|| |
Interventions to eliminate fear use the same conditioning principles, and elimination of maladaptive fears requires exposure (contact) with the feared object, event, or situation. Graduated procedures (i.e., desensitization) use hierarchical approach to exposure, whereas flooding involves immediately exposing the patient to the most feared stimulus. Graduated approach may decrease patient dropout, noncompliance, and resistance., However, flooding achieves faster results, reducing distress in a quicker period of time.
Here, we discuss a case of fur phobia where we used modified exposure and response prevention (MERP) therapy. In MERP, we exposed a patient to the most feared stimulus, but while exposing unlike the classical flooding, we broke the fearful situation into subcomponents and exposed the patient in the graded manner starting from top. We did not use any relaxation technique which is an essential component of systematic desensitization (SD).
| Case Report|| |
Miss X, a 29-year-old girl, 1st in birth order, self-employed in a web designing firm, living in Hindu nuclear family, and hailing from an urban background came to the Department of Psychiatry, Government Medical College, Chandigarh. Her father informed that when she was 5 years old, another girl threw a teddy bear on her while she was opening gifts on her brother's birthday. She got scared and screamed a lot. That teddy had a battery-operated system and had inbuilt mechanism of jumping and it suddenly jumped when it was placed on the table. She got scared and ran outside the room. Following this incident, whenever she would touch the teddy bears and other soft toys, she would become anxious and she would have palpitations, fearfulness, shivering, and would cry a lot. Thus, she started avoiding situations where there was a possibility of teddy bear. However, there was no history of flashbacks, startle response, and nightmares during this period. Apart from it no there was no other dysfunction in her daily life functioning. She continued her study and no academic problem was reported. However, her teddy bear-related fear progressed further and she even started having anxiety symptoms at the touch of other soft toys and fur clothes. She would not allow the family members to keep soft toys at home and her family members also would not allow anyone from their neighborhood and relatives to bring soft toys to their house. Whenever she would visit the toy shops, she would not get scared on seeing soft toys placed over there, however, would not allow anybody to pick-up the teddy bear as she would fear that the person might throw it over her. With the increase in the severity of fear and anxiety on touching and seeing somebody with soft toys, she started experiencing difficulty in her personal life. On two occasions, she got hurt when she ran out of the room on seeing somebody carrying soft toy. Her fear of teddy bear got expanded to all types of soft toys, fur gloves, fur jackets, caps, and even dogs and cats with fur. She stopped attending social gatherings fearing sight of soft toys. She also stopped celebrating her birthday as she feared that somebody might bring teddy bear or soft toy. She forced her father not to keep any soft toy neither in the house nor in the car. The patient's family members would always make adjustments for her such as not keeping soft toys at home or not allowing anyone to bring soft/fur toys to their place. However, when she was brought to us, she was going to married so family members and patient wanted to get treatment as she would shift to new place. There was no history of hypersensitivity to soft toys, free-floating anxiety, spontaneous panic attacks, fear for crowded/closed spaces, height, posttraumatic stress disorder (PTSD), low mood, decreased interest to work, decrease in pleasurable activities, anhedonia, depressive ideations, obsessive-compulsive disorder (OCD), substance abuse, or focal neurological deficit.
On mental status examination, the patient was alert and oriented, with constant preoccupation with excessive fear of teddy bears and soft toys. Insight was preserved, i.e., she knew that her fear was irrational, illogical, and mostly psychological and agreed for treatment. Thus, a diagnosis of specific phobia as per International Classification of Diseases 10 was made. In the past, the patient did not seek any treatment. The patient was not willing for medication. Since there was no comorbid anxiety or depressive symptoms, it was decided to treat her only with behavior therapy (BT). To begin with hierarchy of fearful items was prepared and she was assisted to list all the items, she was afraid of. Later, she was told to arrange the feared item in the ascending order depending on the severity of fear and anxiety. [Table 1] depicts the list of fearful situations along with the degree of severity prepared by the patient.
Before starting BT, behavior analysis was done to assess the behavioral assets, deficits, and motivation for the therapy using behavior assessment pro forma used in the behavior therapy section of the Department of Psychiatry, Government Medical College, Chandigarh. On the basis of detailed evaluation and clinical assessment, it was found that the patient was motivated and was willing to tolerate the anxiety expected to be experienced by the patient during the therapy planned for her, provided the therapist was around. There was no limitation from the patient's side for SD, but authors were more comfortable and had observed more favorable responses of exposing the individual to most anxiety-provoking situation like flooding as compared to systemic desensitization in his clinical experience. Further, there was no medical condition contraindicating exposure to temporarily high levels of anxiety. Thus, to begin with, it was planned to use ERP.
On the principal of ERP, therapist decided to expose her to most anxiety-provoking stimuli along with prevention of escape from the feared situation. However, when the patient saw black color furs glove on the table of therapist, she ran out of the room and refused to continue the treatment. The patient was brought inside with lot of persuasion. ERP technique was negotiated with her and it was decided to use modified ERP where the maximum fearful situation was further broken into subcomponents, and she was exposed to these components from the least fearing. For example, the most fearing item of fear of gloves was broken into the following subcomponents:
- Therapist holding the fur gloves in his hands
- Keeping the gloves one feet away from the patient
- Bringing the gloves closer to her
- Asking the patient to touch the gloves with single finger
- Picking up the gloves
- Holding the gloves tightly
- Wearing the gloves.
During this process, the patient experienced unbearable anxiety and required constant motivation and encouragement. When the anxiety became unbearable, the patient was told to count backward from 100 for distraction purpose. After 2 sessions, the patient became comfortable and did not report any fear or anxiety while wearing the gloves. At this stage, next item of fearful situation, i.e., black color teddy bear was selected. Although the patient reported less fear than, she had before coming for treatment, but still, she was not comfortable in touching the teddy bear. Again, the item was broken into subcomponent, and she was gradually exposed to these situations starting from least anxiety provoking to highest anxiety provoking. In two sessions, the patient was comfortable in holding teddy bears. Similarly, she was exposed to other situations in a graded manner, and by the time she reached the pink color teddy bear (serial no 6 in the hierarchy list); the patient reported that she does not have any fear for rest of the situations from serial number 7 to 9. The patient requested one booster session after 7 days of the last session, and when she came after 7 days, she was carrying 2 large-size teddy bear and wore black color fur gloves. The BT was stopped at this stage. She underwent 12 sessions of MERP.
| Discussion|| |
Although ERP is considered as first-line treatment for OCDs,,, and phobic disorders,, it may not be possible to use ERP in cases where anxiety is marked, and there are medical conditions contraindicating exposure to excessive anxiety-provoking situations. In such cases, the therapist either to use other less anxiety provoking techniques including SD, cognitive BT (CBT), relaxation technique or firstly manages the patient's anxiety using pharmacological management. However, these options are either less effective or time-consuming as compared to ERP.
In the present case, therapists decided to use ERP; however, the patient became almost panicky in the first session and refused to continue ERP treatment. In such a scenario, one would have considered SD or CBT, but due to limited time available with the patient (she was getting married after 6 weeks) and therapists' comfort and faith in ERP, modified ERP was planned. Primarily, it was ERP as the exposure was started from the most anxiety-provoking situation at the top of hierarchy, and no relaxation techniques were used. However, the technique was modified in the sense that the highest anxiety-producing situation at the top of hierarchy was further broken into subcomponents, and distraction was used to get her focus away from the fearful object. This is different from the SD as the exposure was started from the most anxiety-provoking object unlike SD where the patient is exposed to the lowest anxiety-provoking situation and relaxation technique is an integral part of SD.
The advantage of using modified ERP was that the treatment was completed in 12 sessions of 30 min each (total 6 h) and the improvement was retained at 2 weeks after the last follow-up. Although the patient is not on regular follow-up, we contacted her telephonically and the patient is maintaining well. Abstinence at the conclusion of treatment, patient's motivation, and involvement of family members favors better outcome and less chances of relapse.
Recent publications are mainly highlighting the efficacy of CBT. Ougrin carried out meta-analysis of 20 randomized controlled trials (n = 1,308) which directly compared the efficacy of CBT and ERP and concluded that both CBT and ERP were equally effective in PTSD, OCD, and panic disorder (PD). However, CBT was more effective than ERP in social phobia. In a review article by Choy et al. in 2007, authors looked for the short and long term efficacy of various non pharmacological techniques used in the treatment of phobia. This included in vivo exposure, virtual reality, cognitive therapy and others. They concluded that although most phobias responded robustly to in vivo exposure but poor acceptance and poor retention were the major drawbacks found with the exposure therapy. We also found two studies in which various nonpharmacological interventions were compared. One meta-analytic review of social-phobia treatment was done by Fedoroff and Taylor in 2001. They calculated effect sizes for 7 trials of exposure therapy, 7 of cognitive therapy, and 21 of combined exposure and cognitive therapy. Cognitive therapy alone (effect size 0.72) and exposure plus cognitive therapy (effect size 0.84) were considered highly effective, and no difference was observed from one another. Exposure therapy had the largest mean effect size of all the psychotherapies (effect size 1.08). However, 95% of confidence interval included 0; authors thus concluded that the effects of exposure alone were not significantly greater than zero. On follow-up of cases, behavioral, cognitive, and combination treatments were equally efficacious. In 1997, Gould et al. reviewed 16 studies of nonpharmacological intervention in patients with social phobia. Nine comparisons were with exposure alone, eight with exposure plus cognitive restructuring, and four with cognitive restructuring alone. Authors concluded that exposure therapy either alone or in combination with cognitive restructuring is somewhat more effective than cognitive restructuring alone. Authors could not find much of recent literature available on BT. However, historically, it is the main mode of therapy used to treat phobia and OCD and should be encouraged to use in the current scenario as well.
| Conclusion|| |
As we have used MERP in only one patient, so need to treat more patients to establish the validity of treatment. We can conclude that MERP has shown good results in index case covering the limitations of standard BT. We should apply it on more cases to achieve better and quick results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaplan H, Ruiz P, Sadock B, Sadock V. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2009.
Chopra HD. Systematic desensitization therapy. Indian J Psychiatry 1975;17:63-72. [Full text]
Lang PJ, Lazovik AD. Experimental desensitization of phobia. J Abnorm Soc Psychol 1963;66:519-25.
Boulougouris JC, Marks IM. Implosion (flooding) – A new treatment for phobias. Br Med J 1969;2:721-3.
Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The pediatric OCD treatment study (POTS) randomized controlled trial. JAMA 2004;292:1969-76.
Abramowitz JS, Whiteside SP, Deacon BJ. The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis. Behav Ther 2005;36:55-63.
Watson HJ, Rees CS. Meta-analysis of randomized, controlled treatment trials for pediatric obsessive-compulsive disorder. J Child Psychol Psychiatry 2008;49:489-98.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 1998;37:27S-45S.
Chambless DL, Ollendick TH. Empirically supported psychological interventions: Controversies and evidence. Annu Rev Psychol 2001;52:685-716.
Kaplan JS, Tolin DF. Exposure therapy for anxiety disorders: Theoretical mechanisms of exposure and treatment strategies. Psychiatric Times 2011;28:33-7.
Ougrin D. Efficacy of exposure versus cognitive therapy in anxiety disorders: Systematic review and meta-analysis. BMC Psychiatry 2011;11:200.
Choy Y, Fyer AJ, Lipsitz JD. Treatment of specific phobia in adults. Clin Psychol Rev 2007;27:266-86.
Fedoroff IC, Taylor S. Psychological and pharmacological treatments of social phobia: A meta-analysis. J Clin Psychopharmacol 2001;21:311-24.
Gould RA, Buckminster S, Pollack MH, Otto MW, Yap L. Cognitive behavioural and pharmacological treatment for social phobia: A meta-analysis. Clin Psychol Sci Pract 1997;4:291-306.