Department of Psychiatry

Penn Behavioral Health

How We Treat These Disorders

What is Cognitive Behavioral Therapy?

Cognitive-behavioral therapy, or CBT, helps the client overcome avoidance by gradually facing what is feared with lots of praise and positive reinforcement for doing so. Further, the therapist and clients will examine all elements that maintain a problem, including their thoughts, feelings, and behaviors. Often clients will be asked to practice the techniques in between sessions, as active participants in their own therapy. Parents, teachers, and other adults around the child can be very helpful in this process. Once the skills are learned and practiced, clients can keep using what they have learned in therapy to approach other problems in their life.

CBT has been extensively investigated in rigorous clinical trials and has demonstrated effectiveness in treating anxiety in children and adults. Cognitive-behavioral therapy can be used alone or in conjunction with medication, depending on the severity and nature of each client’s problem.

CBT for OCD - Exposure and Ritual Prevention

Currently, the most effective psychotherapy for OCD is called Exposure and Ritual (or Response) Prevention. Exposure therapy involves systematic exercises, designed by the therapist and the patient, to help patients confront situations and objects that elicit the unwanted thoughts or ideas, worries and fears. Through the exposure exercises the patients learn that over time the fear and distress associated with thoughts decreases. Many children with OCD are afraid that something bad will happen as a result of confrontation with the situations or objects that elicit obsessional distress. Repeated exposures without rituals will teach the patients that their fears are exaggerated.

Individuals with OCD have developed strong habit of reducing their anxiety and distress by repeatedly using rituals. Common examples include washing, checking, ordering or mental rituals such as seeking reassurance from mom, thinking about certain numbers or words. Most times the rituals successfully reduce the distress temporarily. However this temporary reduction prevents the patients from learning that the distress would have decreased even without the rituals. As long as they perform their compulsive rituals, patients will continue to believe that the rituals protect them from bad things such as illness, death, or making serious mistakes. The best way for patients to learn that the rituals do not really protect them is to refrain from performing the rituals after they do their exposure exercises. Thus, ritual prevention is designed to help correct the patients' beliefs that rituals prevent disastrous consequences from occurring or that they can't handle the distress and anxiety if rituals are not acted upon. By purposely becoming anxious through the exposure exercises, but resisting the urges to perform compulsive rituals, patients learn that these urges to ritualize and the anxiety/discomfort will dissipate on their own.

What is Habit Reversal Therapy?

Our Center utilizes a form of cognitive-behavioral therapy known as Habit Reversal Therapy (HRT) to treat Chronic Tic Disorders including Tourette's syndrome. The efficacy of this treatment has been illustrated in several adult and adolescent studies.

Treatment begins with awareness training. During this phase, the aim is to orient the patient toward detection of his or her tic beginning at its earliest expression. The patient is instructed to describe the tic in as much detail as possible to the therapist and may even be recorded making the tic or watch his/herself in a mirror. Secondly, the patient notes situational triggers that affect tic expression. Noting when, where and how one’s tic occurs facilitates awareness.

Next, relaxation techniques including deep breathing, muscular relaxation and visual imagery are taught. Such techniques help to ease the patient’s urge to tic. Lastly, together with the therapist, the patient develops a "competing response," an action that is incompatible with the expression of their tic but is less noticeable to others. For example, a competing response to a head jerk tic may be to tense one's neck, or a competing response to a nose-sniffing tic may be a breathing exercise. This response acts as a replacement strategy for the tics.

Family instruction is another important component of program. Family members and significant others are taught favorable ways to discuss the tics and the patient's improvement. Lastly, the patient is taught to practice these control techniques in different settings.

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