CBT17 - Exposure and Response Prevention - Fall 2020

Staring Down Panic
Communicating the Elements of Exposure

and Response Prevention to Patients
Suffering from Anxiety Disorders
Brian D. Ott, Ph.D.
William James College

Massachusetts General Hospital
Harvard Medical School
www.drbrianott.net
www.drbrianott.net
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x x
x
x
x x
NIMH – http://www.nimh.nih.gov/statistics/index.shtml
ANXIETY Lifetime 12 Month Onset

Prevalence Point (Mean Age)
DISORDERS Prevalence
Any Anxiety Disorder 28.8 18.1 75% onset

< age 21.5
Panic Disorder 4.7 2.7

PD without Agoraphobia 2.9 1.8 24
PD with Agoraphobia 1.7 0.9 20
Social Phobia 12.1 6.8 13
Specific Phobia 11.3 8.7 7
OCD 1.6 1.0 19 (33% < 12)
GAD (6 month criteria) 5.7 3.1 31
PTSD 6.8
www.drbrianott.net 3.5
Panic and Health Care Utilization
5% of All Emergency Room Visits
20-33% of ED Visits for Chest Pain
7 times the visits to MDs

8.00
7.00
6.00
in 6 months prior to diagnosis 5.00

4.00
than non-panic population 3.00

2.00
1.00
0.00
1 2
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Outcome Research on CBT Protocols
Exposure and Response Prevention

Across Meta Analytic Studies / Diagnostic Groups
Effect Sizes for ERP

Effect Sizes : 1.0 to > 2.0 for ERP
2
1.5
Effect Size
0.5
0
Specific Panic OCD PTSD Social GAD
Phobia Disorder Phobia
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Outcome Research on CBT Protocols
Exposure and Response Prevention

Across Meta Analytic Studies / Diagnostic Groups
 Percent initially sub-diagnostic: 70 to 80%
 Two year follow-ups show gains are maintained

in more than 80%
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Why does suffering continue?
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EVERYTHING IS NOT FINE!
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One-Two Punch
1 No one speaks to their experience

and helps make sense of it.
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One-Two Punch
1 No one speaks to their experience

and helps make sense of it.
2 Distortion of available, effective

treatments
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They run away.
Overall attrition rate of 18.7% for ERP
Ong, C. W., Clyde, J. W., Bluett, E. J., Levin, M. E., & Twohig, M. P. (2016). Dropout rates in
exposure with response prevention for obsessive-compulsive disorder: What do the data really
say?. Journal of anxiety disorders, 40, 8-17.
The average nonadherence rate is

24.8% for medical interventions
DiMatteo, M. R. (2004). Variations in patients' adherence to medical recommendations: a
quantitative review of 50 years of research. Medical care, 200-209.
Solution: Education and Socialization
1. Provide an etiological Model explains

WHY the panic attacks are occurring
2. Provide a detailed plan of WHAT to
do about them
3. Use EVERYDAY LANGUAGE that

speaks to their experience
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High
Minimal
Intensity
Arousal
CS
Stay Put
Moderate
Inhibitory Intensity
Learning CS
Low
Run Away Intensity
Neutralize CS
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Orientation Points
Theory 1. Biology/Neurology of ANS Arousal
2. Classical Conditioning of Emotional Responses
3. Recursive Cycle of Anxiety Avoidance and Retriggering
4. Extinction of Classically Conditioned Anxiety Responses
5. Paradoxical Approach
Preparation 1. Behavioral / Functional Analysis

2. Conditioned Stimuli vs. Unconditioned Stimuli
3. Hierarchy Construction
4. Selection of Initial Exposure Step
Exposure 1. Experience All Aspects of the CS in All Contexts

Trials 2. Focus Attention
3. Prolonged Exposure
4. Repeat Trials
5. Recalibrate Hierarchy and Repeat
Integration 1. Part of a Treatment Plan

2. Kind and Competent Behavioral Therapist
3. ERP AWOL www.drbrianott.net
Orientation Points
Theory
1. Biology/Neurology of ANS Arousal
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Biological/Neurology of ANS Arousal
Teaching Method
Stories and Pictures
Simplified, Not Simplistic

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ID’s the Situation
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ID THE SITUATION
1 - There is an object about 25 feet away.
2 - 10 feet high and 10 feet wide
3 - Yellow
4 - Has wheels
5 – Full of screaming and jumping kids
6 - The driver looking at kids and waving his arms
7 – Object traveling at ~ 30 miles an hour
8 - The object is pointed at me
9 – I see the letters S-C-H-O-O-L-B-U-S
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Makes Meaning
OMG !
Holy Shit !!
I’m Gonna’ Die !!!
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• Muscles
• Heart
• Breathing
• GI System
• Hypersensitivity
to Signal Stimuli
• Hyperreactivity
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ANS Arousal
helps you escape an immediately

dangerous situation…
…or confront one if escape is not feasible…
…and prepares us for danger
before it arrives…
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The next day…
And the next day…
…and so on
Orientation Points - Language
Biology/Neurology of ANS Arousal

• What you feel is real.
• The body’s natural emergency response system
• Hard wired because you need it
• Can’t get rid of it – no surgery or medication.
• Wouldn’t want to because it may save your life.
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Question: If it’s such a damn good thing, why is
it popping out when I don’t need it?
Orientation Points - Theory
Theory
2. Classical Conditioning of Emotional

Responses
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Question: If it’s such a good thing, why is it
popping out when it isn’t doing any good?
Answer:
Classical Conditioning Model
US UR (CR)
May be
direct
or
vicarious
NS (CS)
Prepared vs Threat
Irrelevant NS
Talk some sense into me!
Question: So what does all this
stuff about dogs and saliva
have to do with me?
Thalamus Primary
Sensation
MGN and
Cochlea Secondary
LGN Association
Retina Areas of
Cortex
PIN
Prefrontal Cortex Hippocampus

[ P (CS/US) ] [ Context ]
AL Lateral
Body
CS - CR
CS/US Central Amygdala
Acquired
Nucleus
Alternate
Behavioral
Patterns
ANS Arousal
Nucleus
Hypothalamus Brainstem
Accumbens
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Traffic
Control
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Classical Conditioning of
Emotional Responses
• Brain there “to serve and protect” by creating warning signs for danger
• Warning signs are often ineffective:

o A healthy response popping out when you don’t need it.
o Learned to react to a low threat situation with a high threat response
o A car alarm sounding when no one is around.
o Your radar detector going off when no police are around.
• Can’t talk yourself out of a CC trigger.
www.drbrianott.net
BUT…
if you are like most people, you do some
pretty logical and sensible things to control
the feelings.
And they don’t work.
Why don’t they work?
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Theory
3. Recursive Cycle of Anxiety

Avoidance and Retriggering
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Why can’t I control this?
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Recursive Cycle of Anxiety

Avoidance and Retriggering
• Battling a powerful biological process that must run its
course.
• Harder you battle, more you fail. More you fail, the worse
you feel.
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“SO I’M STUCK WITH THIS?”
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Orientation Points
Theory
4. Extinction of Classically
Conditioned Anxiety Responses
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So how do we help?
How do we stop pooch drooling?
How do we stop Brian Ott drooling?

Extinction
A decrease in intensity of CR during

repeated prolonged exposure to the
CS without further CS-US pairings
US UR (CR)
NS (CS)
Extinction
A decrease in intensity of CR during

repeated prolonged exposure to the
CS without further CS-US pairings
(CR)
(CS)
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Thalamus Primary
Sensation
MGN and
Cochlea Secondary
LGN Association
Retina Areas of
Cortex
PIN

AL Lateral
Body
CS - CR
CS/US Ace Amygdala
Acquired Central
Nucleus
Alternate
Behavioral
Patterns
ANS Arousal
Nucleus
Accumbens
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Thalamus Primary
Sensation
MGN and
Cochlea Secondary
LGN Association
Retina Areas of
Cortex
PIN

AL
Lateral Body
Extinction
Trial CS/US Ace Amygdala
Central
CS/NoUS Nucleus
Alternate
Behavioral
Patterns
ANS Arousal
Nucleus
Accumbens
www.drbrianott.net
Thalamus Primary
Sensation
MGN and
Cochlea Secondary
LGN Association
Retina Areas of
Cortex
PIN

AL Ratio
Lateral Body
Stimulation
or CS/US
+ Ace Amygdala
Inhibition
of CR
CS/NoUS - Central
Nucleus
Alternate
Behavioral
Patterns
ANS Arousal
Nucleus
Accumbens
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Traffic
Control
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Traffic
Control
Traffic
Control
Traffic
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Control
Traffic
Control
Traffic
Control
Traffic
Control
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Shape of Extinction Curves Across Trials
NOTE
Can get clinical improvement

long term even when don’t get
physiological changes /
habituation within session
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Theory
www.drbrianott.net
“Courage is being scared to
death and saddling up
anyway.”
John Wayne
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Paradoxical Approach
• Do what doesn’t come naturally.
• Leave logic at the door and hang a 180.
• Experience, don’t avoid, the anxiety.
• Two roads to the emergency response and only

one operates on logic and reason
www.drbrianott.net
Time to move on?
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Orientation Points
Preparation
1. Behavioral / Functional Analysis
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Do identical twins have
identical finger prints?
Jaina, A., Prabhakarb, S., Pankantic, S., Jaina, A., & Anil K. Jaina (2002). On the similarity of identical twin
Fngerprints. Pattern Recognition, 35, 2653 – 2663
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Orientation to the CBT Model of Anxiety
Exoceptive vs. Interoceptive Conditioned Stimuli
Behavioral / Functional Analysis
S Stimulus
O Organismic
R Response
C Consequence
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S Who, what, when and where?
O What are you expecting?
R How do you know you’re anxious?
C What do you do about it?

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Key Question?
Temptation to ask:
What would make it better?
If know that they wouldn’t need us
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Key Question:
What would make it worse?
“Take the trigger out for a spin.”
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Behavior Analysis of CS
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Orientation Points
Preparation
2. Conditioned Stimuli vs.

Unconditioned Stimuli
www.drbrianott.net
Is it Exposure and Response Prevention?
Conditioned
Stimuli
vs.
Unconditioned
Stimuli
www.drbrianott.net
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An emergency situation is
the perfect time for an
emergency response.
TIME
TO
PANIC

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US UR
(CR)
?
NS (CS)
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Is it Exposure and Response Prevention?
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Orientation Points
Preparation
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They run away.
Construction of the Anxiety Hierarchy
Conditioned (Phobic) Stimulus ________________
CS Dimension 1 CS Dimension 2 CS Dimension 3 CS Dimension 4 SUDS
10
9
8
7
6
5
4
3
2
1
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Orientation Points
Hierarchy Construction
• Build a series of movie scenes
• At each set, change some dimensions, hold others
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Conditioned (Phobic) Stimulus __THE MALL__
Location People Kids Floor
Inside 50 Yes 3 10
Inside 50 No 3 9
Inside 30 Yes 3 8
Inside 30 Yes 2 7
Inside 12 No 2 6
Inside 12 Yes 1 5
Inside 6 No 1 4
At Door 6 Yes 1 3
Curb 6 Yes 1 2
Curb 0 No 1 1
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Factors Affecting E/RP Effectiveness
Exposure Optimization Strategies

MULTIPLE CONTEXTS
New learning won’t automatically generalize across

contexts
HIERARCHIES SHOULD BE BUILT FOR EACH

RELAVANT CONTEXT IN WHICH THE
CONDITIOINED ANXIETY RESPONSE OCCURS

Craske, M., Treanor, M., Conway, C., Zbonzinek, T., & Vervliet, B. (2014). Maximizing exposure therapy:
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an inhibitory learning approach. Behavior, Research and Therapy, 5, 10-23.
Orientation Points
Preparation
www.drbrianott.net
The Truman Show
When confronted with an life threatening
situation…
we do what comes naturally

High
Minimal
Intensity
Arousal
CS
Stay Put
Moderate
Inhibitory Intensity
Learning CS
Low
Run Away Intensity
Neutralize CS
www.drbrianott.net
Where on the hierarchy to start…
Inside 50 Yes 3 10
Inside 50 No 3 9
Inside 30 Yes 3 8
Inside 30 Yes 2 7
Inside 12 No 2 6
Inside 12 Yes 1 5
Inside 6 No 1 4
At Door 6 Yes 1 3
Curb 6 Yes 1 2
Curb 0 No 1 1
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Inside 50 Yes 3 10
Inside 50 No 3 9
Inside 30 Yes 3 8
Inside 30 Yes 2 7
Inside 12 No 2 6
Inside 12 Yes 1 5
Inside 6 No 1 4
At Door 6 Yes 1 3
Curb 6 Yes 1 2
Curb 0 No 1 1
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Inside 50 Yes 3 10
Inside 50 No 3 9
Inside 30 Yes 3 8
Inside 30 Yes 2 7
Inside 12 No 2 6
Inside 12 Yes 1 5
Inside 6 No 1 4
At Door 6 Yes 1 3
Curb 6 Yes 1 2
Curb 0 No 1 1
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Deepened Extinction
Each level of the hierarchy should contain

new and old items

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Inside 50 Yes 3 10
Inside 50 No 3 9
Inside 30 Yes 3 8
Inside 30 Yes 2 7
Inside 12 No 2 6
Inside 12 Yes 1 5
Inside 6 No 1 4
At Door 6 Yes 1 3
Curb 6 Yes 1 2
Curb 0 No 1 1
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Variability
Both in inter-session intervals and

selection of step on the hierarchy
OK to shift around a little.
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What if I have a panic attack?
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Occasional Reinforced Extinction
Having a panic attack may help delay

reacquisition

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Conducting Exposure Trials
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Orientation Points
4. Repeat Trials
Exposure Trials
1. Experience All Aspects of the CS

in All Contexts
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Hold the
conditioned
Not so much.
stimulus
constant.
Drive the Tour Bus
Exposure to All Aspects of Discrete Stimulus and Context
www.drbrianott.net
Orientation Points
• Describe the Outside - Triggers
• Describe the Outside - Location
• Describe the Inside - What the Anxiety Feels Like
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…the experience of anxiety
Affect Labeling
Katharina Kircanski, K., Lieberman, M., & Craske, Michelle (2012)

Feelings into words: contributions of language to exposure
therapy. Psychological Science, 23, 1086-1091.
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Become a trigger gourmet
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Removal of Safety Signals
No pills or cell phones

www.drbrianott.net

Retrieval Cues
Bring an object that will serve as a

cue for past inhibitory learning

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NO YES
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Orientation Points
4. Repeat Trials
Exposure Trials
2. Focus Attention
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Observation:
Some people take fairly regular airplane
trips and continue to experience
phobic anxiety.
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Question:
How can this be explained without

abandoning the inhibitory learning
model theory?
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Answer:
Inadequate Exposure
“On the plane, but not on the plane.”
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Response prevention refers to the voluntary
termination of avoidance behaviors that
interfere with natural extinction processes
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Keep Your Eye
(and ear, and nose, and tongue, and skin)
on the Ball
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Eliminate Neutralizing / Avoidance Behaviors
Stare it down.
Orientation Points
4. Repeat Trials
Exposure Trials
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Prolongued Exposure
How long is long enough?
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Prolongued Exposure
Produce an
Expectancy Violation
How long will it take for

the worst to happen?
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Be a Long Distance Runner
Continue
exposure after
the anxiety
response has
come back down.
“Surf it in.”
“Stay until you

are bored.”
Orientation Points
4. Repeat Trials
Exposure Trials
4. Repeat Trials
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“Repeat the trials until the level of
arousal at the start of the
exposure trial triggers a level of
anxiety that the patient agrees is
tolerable.
“I can stand it.

I don’t need to run away.”
Orientation Points
4. Repeat Trials
Exposure Trials
www.drbrianott.net
Recalibrate and Repeat
Recheck ratings on ladder and
select new step
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Inside 50 Yes 3 10
Inside 50 No 3 9
Inside 30 Yes 3 8
Inside 30 Yes 2 7
Inside 12 No 2 6
Inside 12 Yes 1 5
Inside 6 No 1 4
At Door 6 Yes 1 3
Curb 6 Yes 1 2
Curb 0 No 1 1
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Recalibrate and Repeat
It may be of benefit to
“jump around” the hierarchy
www.drbrianott.net
Orientation Points - Integration
3. ERP AWOL
Integration
1. One Part of a Treatment Plan
www.drbrianott.net
Outcome Research
Data suggests that that

both ERP and Cognitive
Restructuring account for
unique variance.
Anxiety Disorders have
BOTH
Conditioned Anxiety
Responses
AND
Anxiety Triggering Thoughts

One Part of the Treatment Plan
Use Cognitive Restructuring
WHEN YOU’RE NOT

USING ERP
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Outcome Research
Addition of medication to intervention

package initially improves the response
rate, but later results in increased
relapse rates
Medication -References - D-cycloserine (DCS)
Wilhelm, S., et al. (2008).
Part of the Treatment Plan
ANS Regulation Techniques
www.drbrianott.net
One Part of the Treatment Plan
Use ANS Regulation
WHEN YOU ARE

FEELING GOOD
www.drbrianott.net
One Part of a Overall Plan

• Use Everything – But Not at the Same Time
• Take Turns – Use Elements in Tandem
• Don’t Mix - Oil and Water
www.drbrianott.net
3. ERP AWOL
Integration
2. Kind and Competent

Behavioral Therapist
www.drbrianott.net
Kind and Competent

Behavioral Therapist
www.drbrianott.net
Kind and Competent Experts
"You never really understand a person until you

consider things from his point of view - until
you climb into his skin and walk around in it.“
(spoken by) Atticus Finch
To Kill a Mockingbird
Harper Lee
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3. ERP AWOL
Integration
3. ERP AWOL
www.drbrianott.net
Relapse Prevention
What are the three most important factors in
buying a house?
Location! Location! Location!

What are the three most important factors in
maintaining effective responses to anxiety
triggers?
Practice! Practice! Practice!
(Especially when you are feeling GOOD)

Jump on Thin Ice
Taunt Sleeping Dogs
Shake the Apple Cart

www.drbrianott.net
ERP - AWOL
Do it All, Do it Right, Do It Every Day

www.drbrianott.net
Official
Shameless
Promotion
Drbrianott.net/StaringDownPanic
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Staring Down Panic

Communicating the Elements of Exposure

Brian D. Ott, Ph.D.

William James College

ANXIETY Lifetime 12 Month Onset

Any Anxiety Disorder 28.8 18.1 75% onset

Panic Disorder 4.7 2.7

Specific Phobia 11.3 8.7 7

OCD 1.6 1.0 19 (33% < 12)

GAD (6 month criteria) 5.7 3.1 31

5% of All Emergency Room Visits

20-33% of ED Visits for Chest Pain

7 times the visits to MDs

in 6 months prior to diagnosis 5.00

than non-panic population 3.00

Exposure and Response Prevention

Effect Sizes for ERP

Exposure and Response Prevention

 Percent initially sub-diagnostic: 70 to 80%

 Two year follow-ups show gains are maintained

1 No one speaks to their experience

1 No one speaks to their experience

2 Distortion of available, effective

The average nonadherence rate is

1. Provide an etiological Model explains

3. Use EVERYDAY LANGUAGE that

Preparation 1. Behavioral / Functional Analysis

Exposure 1. Experience All Aspects of the CS in All Contexts

Integration 1. Part of a Treatment Plan

1. Biology/Neurology of ANS Arousal

Stories and Pictures

Simplified, Not Simplistic

helps you escape an immediately

Biology/Neurology of ANS Arousal

• The body’s natural emergency response system

• Hard wired because you need it

• Can’t get rid of it – no surgery or medication.

• Wouldn’t want to because it may save your life.

2. Classical Conditioning of Emotional

Prefrontal Cortex Hippocampus

• Warning signs are often ineffective:

• Can’t talk yourself out of a CC trigger.

And they don’t work.

Why don’t they work?

3. Recursive Cycle of Anxiety

Recursive Cycle of Anxiety

How do we stop pooch drooling?

How do we stop Brian Ott drooling?

A decrease in intensity of CR during

A decrease in intensity of CR during

Prefrontal Cortex Hippocampus

Prefrontal Cortex Hippocampus

Prefrontal Cortex Hippocampus

Can get clinical improvement

• Leave logic at the door and hang a 180.

• Experience, don’t avoid, the anxiety.

• Two roads to the emergency response and only

1. Behavioral / Functional Analysis

Exoceptive vs. Interoceptive Conditioned Stimuli

S Who, what, when and where?

O What are you expecting?

R How do you know you’re anxious?

C What do you do about it?