Modifications And Variants Of Behaviour Therapy

Foa et al. (1984) showed that concurrent exposure and response prevention had superior outcome to using either component alone. To be effective the exposure must continue until there is a reduction in anxiety and urge to ritualise. Studies have shown that this takes approximately 90 minutes (Foa & Chambless, 1978; Rachman, Desilva & Roper, 1976) which can act as a guide. There is no clear evidence about the necessary frequency of exposure sessions but, in general, patients with more severe symptoms and those who have more difficulty complying with the treatment and homework may need more intensive treatment. Abramowitz, Foa & Franklin (2003) compared 15 sessions over three weeks (daily treatment) or eight weeks (twice-weekly treatment), with 20 patients in each group. Both treatment programmes were effective, with a trend towards more improvement in the intensive group at post treatment but no differences at follow up.

A meta-analysis by Abramowitz (1996), found that therapist-supervised exposure was more effective than self-controlled exposure. However the individual studies produced conflicting results. If a patient can do effective self-controlled exposure by himself from the start it is likely to have a powerful effect. For those patients who are unable to do so, the therapist can provide support, coaching and supervision to ensure that exposure to the feared stimulus continues until the patient's anxiety decreases. The meta-analysis also found that a combination of in vivo (exposure in real life settings) and imaginal exposure gave similar reduction in OCD symptoms to in vivo exposure alone. However the combined treatment was significantly more effective in reducing post-treatment levels of general anxiety. Imaginal exposure is useful when in vivo exposure is not possible - for example, to expose an individual to a fear about a disastrous consequence of not doing rituals. Complete response prevention was superior to partial or no response prevention, and having more sessions of longer length was predictive of greater reductions in OCD and general anxiety symptoms.

Anxiety and Panic Attacks

Anxiety and Panic Attacks

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