von den grundlagen zur anwendung: die erfolgsgeschichte der expositionstherapie · 2016-11-22 ·...

© S. Schneider 2014, Folie 1

Von den Grundlagen zur Anwendung: Die Erfolgsgeschichte der Expositionstherapie

Silvia Schneider Forschungs- und Behandlungszentrum für psychische Gesundheit Fakultät für Psychologie, Ruhr-University Bochum, Germany


Leitlinien •  Deutsch

–  AWMF: •  Angststörungen bei Kindern und Jugendlichen (wird überprüft) •  Angststörungen bei Erwachsenen (für 2014 angekündigt)

–  Fachgruppe Klinische Psychologie und Psychotherapie der DGPs: •  Psychotherapie der Panikstörung und Agoraphobie •  Psychotherapie der Sozialen Angststörung

•  International –  NICE (UK):

•  Common Mental Disorders •  Social Anxiety Disorder

–  Weitere Leitlinien aus USA, Australien


Leitlinien: Typische Empfehlungen (NICE)


Leitlinien: Typische Empfehlungen (Fachgruppe Klinische Psychologie und Psychotherapie der DGPs)

Typischerweise KVT als

erste Wahl


Isaac M. Marks

Das „Expositions Prinzip“

“Exposure therapy is one of the biggest success stories in

mental health”

Marks et al. 1987


Expositionsbehandlung

Dresden, “Blaues Wunder”

Dresden, Kreuzkirche

Wiederholte, systematische Exposition mit gefürchteten

Reizen

In vivo: Situationen, Objekte, Plätze, Menschen In sensu: Bilder und Erinnerungen Interozeptiv: Empfindungen Therapeuten- vs. Selbst-geleitet Graduiert vs. intensiv (Flooding)


Long-term outcome of exposure treatment of Panic Disorder/Agoraphobia

100

80

60

40

20

0 Pre Post 3 years 22 years

Exposure

Combined

Cognitive

Wait list

100%

64%

100%

22 years after Cognitive-Behavioral Treatment (of 56 patients completing treatment, 25 have been studied,

20 are still being traced, 2 have died, 2 declined participation, 7 are untraceable

Percent panic-free patients


Langzeiterfolg von Expositionsbehandlung bei Störung mit Trennungsangst

%

Schneider et al. (2011). Psychotherapy and Psychosomatics. Schneider et al. (2013). J Consulting and Clinical Psychology

TAFF 2-Jahres FU (N=62, 84%) 4-Jahres FU (N=59, 80%)

Coping Cat 2-Jahres FU (N=23, 70%) 4-Jahres FU (N=24, 73%)


Langzeiterfolg von Expositionsbehandlung bei Störung mit Trennungsangst

%

0

5

10

15

20

25

30

2-year FU 4-Year FU

Andere Diagnosen (%)

TAFF

Coping Cat

Schneider et al. (2011). Psychotherapy and Psychosomatics. Schneider et al. (2013). J Consulting and Clinical Psychology


• 1

1

Grawe et al. 1994

15

2

34

78

73

40

47

4

1

2

3

6

10

10

10

16

0 10 20 30 40 50 60 70 80 90

Gestalt Psychodrama

Rogerian psychotherapy

Psychoanalysis Psychoanalysis short.

CBT System. Desensitization

Exposure Cognitive Therapy

Social Competence Training

Biofeedback

Negativ

Signifikant

Nicht signifikant

1

General Meta Analysis: Significant pre-post-changes of main symptoms

1


Meta-Analyse für Panik mit Agoraphobie (Katamnese: 7-24 Monate)

Ruhmland & Margraf (2001)

Psychotherapy: Overall mean

Exposure (N=103)

CBT (N=229)


A meta-analysis for anxiety disorders in children: (10 studies, N=676)

0,22

0,32

0,2

0,830,85

0,7

1,13

1,66

0,97

00,20,40,60,8

11,21,41,61,8

Anxiety Phobia DepressionWaitlist Post-Treatment Follow-up to 12 M.

In-Albon,T. & Schneider,S. (2007). Psychotherapy and Psychosomatics

Pre-post effect size Only CBT studies qualified

91% studies included exposure


Verhaltenstherapie vs. andere „Bona fide“-Therapien: Therapieende und Katamnese

VT vs. alle anderen Psychotherapien

D.F. Tolin, Clinical Psychology Review, 2010, 30, 710-720.

Katamnese 1 Jahr

0.22

Therapieende

0.28 0.34

0.55

VT vs. psychodynamische Therapien

Effektstärke (Hedge´s g)

Besondere

Langzeitwirkungen?


%

Dresden CBT Outpatient Clinic Hahlweg et al.(2001) JCCP, 69, 375-382

Exposure Can be Transferred to Routine Clinical Care (“Effectiveness”)

Very much better

Much better

Somewhat better

Unchanged

Somewhat worse

Much worse

Very much worse

Outcome for 416 patients treated with high-density exposure

End of treatment

0 5 10 15 20 25 30 35 45 40

5.6

0

1.1

1.7

33

41.3

17.3 1-year

follow-up 3.9

0

1.4

0.7

42.6

33.7

17.7

Pre-FU effect-size: .92 (BDI) – 1.70 (MI-A)


Exposure treatment: drop outs

•  Drop out rate: 13% •  Reasons:

–  doubts regarding rationale (35%) –  Improvement of symptoms during preparation phase

(16%) –  Treatment to difficult (9%)

• Folie 15 Hahlweg et al.(2001) JCCP, 69, 375-382


Treatment effects across generations: Outcome of children of patients with panic disorder

Comparison of children of parents with vs. without treatment (followed prospectively for seven years)

Effect sizee (Cohen´s d)

medium small large effect 0 1 2

Depression

Anxiety sensitivity

Agoraphobia

Self efficacy

Schneider, S.. et al. (2013) Psyxchotherapy and Psychosomatics

Children of parents with successful treatment (N= 33) >

Children of parents treated without success (N=7)


Isaac M. Marks

Yes, the „Exposure Principle“ works!

“Exposure therapy is one of the biggest success stories in

mental health”

Marks et al. 1987


John B. Watson

Avoidance behavior is maintained by immediate anxiety reduction (negative reinforcement)

„Shuttle Box“ Miller and Mowrer Neal E.

Miller

„Little Albert“

Phobic stimuli become aversiv through association with negative event (classical conditioning)

What is the secret behind the success? Exposure treatment - a result of experimental lab work

Grawe et al. 1994


Step 1: From lab to clinic – a translational study

1924: Mary Cover Jones & Little Peter

Peter‘s degrees of toleration of the rabit across time:


Step 2: Joseph Wolpe: Systematic Desensitization

Ø  Wolpe coined and perfected Jones idea

Ø  Counter conditioning / reciprocal inhibition

Three steps: 1.  Anxiety stimulus hierarchy 2.  Learning of coping mechanism or

incompatible response (e.g. relaxation)

3.  Connecting feared stimulus to incompatible response or coping method

Wolpe, J. (1954) Reciprocal inhibition as the main basis of psychotherapeutic effects. Arch Neurol & Psychiatry, 1954;72:205-226 Wolpe, J.(1958) Psychotherapy by Reciprocal Inhibition. California: Stanford University Press.


Step 3: Dismantling studies •  Hierarchy not essential •  Relaxation failed to reduce fear unless it was combined

with exposure •  Modelling worked only if exposure, but not if relaxation

was observed


Step 4: Isaac Marks: The exposure principle

•  Concentration on exposure, elimination of redundant components such as relaxation

•  Exposure as the “pure, potent crystal” like insulin for diabetes

Ø Next stage: “find out precisely which mechanism underlies response decrement during exposure”

Marks et al. 1987


Step 5: Understanding mechanism and optimizing intervention

Habituation oder Extinktionslernen oder beides?

CS

CX

US CS

US

Angs

t

Zeit Erste Übung

Nachfolgende Extinktion

Letzte Übung

Gedächtnis nach Konditionierung

Gedächtnis nach Extinktion

Bouton, 1993


Mechanismen der Angstbehandlung

•  Augmentierungsstudien erhellen Mechanismen -  „klassische Kombinationstherapie“ -  „translastionaler Paradigmenwechsel“


52%

Additiver Effekt? Das Beispiel Paniktherapie % Responders nach Absetzen der Medikamente (40% Abnahme in der Panic Disorder Severity Scale, Intention to treat-Analyse)

Barlow DH, et al. JAMA. 2000;283:2529-2536; KVT = Kognitive Verhaltenstherapie

32%

9%

20%

Placebo KVT + Placebo

KVT KVT + Imipramin

Imipramin 0 5

10 15 20 25 30 35 40 45 50

41%

41%

25%


Klassische Kombinationstherapie mit Antidepressiva oder Anxiolytika •  Mögliche Anfangserfolge werden durch schlechtere

Langzeitergebnisse zunichte gemacht –  Besonders negativ bei Benzodiazepinen –  Schwächerer, aber ähnlicher Befund bei Trizyklika + SSRI´s

•  Insgesamt nur wenige Studien, häufig mit methodischen Mängeln oder Fragen –  Auffallend geringere Effektstärken der KVT in Pharmastudien –  „Main effect research“ – Gruppenanalysen mit Vernachlässigung

individueller Unterschiede

•  Eventuell sinnvoll: Sequentieller Ansatz, z.B. Medikamente dann, wenn KVT nicht ausreichend erfolgreich war

1Kampman M, Keijsers GP, Hoogduin CA, Hendriks GJ. J Clin Psychiatry. 2002 Sep;63(9):772-7.


Translationaler Paradigmenwechsel in der Augmentierung

•  Weg von unspezifischer Anxiolyse und einfachen additiven Konzepten

•  Hin zu gezielter Beeinflussung der angenommenen Wirkmechanismen: –  Konfrontationstherapie beruht auf Extinktionslernen1-3

–  Entwicklung spezifischer Augmentierungsstrategien geleitet durch Ergebnisse der Extinktionsforschung (Gedächtniskonsolidierung)1

–  Fokus auf Konsolidierung des Extinktionslernens1

1Myers KM, Davis M. Mol Psychiatry. 2007;12(2):120-50 2Anderson KC, Insel TR. Biol Psychiatry. 2006;60(4):319-21

3de Quervain D, Margraf J. Eur J Pharmacology. 2008;583, 365-37


•  Sport –  verbessert Gedächtniskonsolidierung

•  D-Cycloserin –  verbessert Extinktionslernen –  verbessert Gedächtniskonsolidierung

Effektive Augmentatierungstrategien

•  Methylenblue –  verbessert Gedächtniskonsolidierung

Dopamin

Serotonin Noradrenalin

•  Gluccocorticoids (Cortisol) –  verbessert Extinktionslernen –  verbessert Gedächtniskonsolidierung

•  Sleep –  verbessert Gedächtniskonsolidierung


Improving acquisition, consolidation and retrieval of inhibitory association Strategy Description Catch-phrase

Expectation violation Design exposure to violate specific expectations Test it out

Deepened extinction Present two cues during the same exposure after conducting initial extinction with at least one of them

Combine it

Reinforced extinction Occasionally present the US during exposure Face your fear

Variability Vary stimuli and contexts Vary it up

Remove safety behaviors

Decrease the use of safety signals and behaviour

Throw it out

Attentional focus Maintain attention on the target CS during exposure

Stay with It

Affect labeling Encourage the patients to describe their emotional experience during exposure

Talk it out

Mental reinstatement/ retrieval cues

Use a cue present during extinction or imaginally reinstate previous successful exposures

Bring it back

Craske et al. (2014). Behaviour Research and Therapy, 58, 10-23


• B

Strategien bewirken zusätzliche Verbesserung

von Exposion


• B Aber...


Germany, patient report, representative sample of N=3000 Overall treatment rate only 40%

Margraf & Poldrack, Z Klin Psychol 2000

%

The biggest problem of exposure treatment: exposure only in research, not in routine care!

= 7.4% of all anxiety cases

Only 0.4% received exposure


Das Problem der Disseminierung…

• Folie 33

“Most clinical psychologists select their methods like kids make choices in a candy store: They look around, maybe sample a bit, and choose what they like, whatever feels good to them.”

(Walter Mischel)


What can CBM learn from exposure? •  Exposure treatment and CBM share their basis in

experimental lab work •  Close link to experimental work is an important condition

for success and continues development •  Understanding mechanism is essential for optimizing

interventions •  Translation of basic knowledge of learning and memory

consolidation processes into clinical application •  Different from exposure: CBM is less vulnerable to

psychotherapists idiosyncratic ideas and preferences - a big advantage!


From lab to clinic: The success story of exposure treatment

Silvia Schneider Center for the Study and Treatment of Mental Health Faculty of Psychology, Ruhr-University Bochum, Germany

von den grundlagen zur anwendung: die erfolgsgeschichte der expositionstherapie · 2016-11-22 ·...

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