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Optimierung expositionsbasierter Therapie

Ein Ansatz des inhibitorischen Lernens

Maximizing exposure therapy

An inhibitory learning approach

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Zusammenfassung

Exposition ist eine wirksame Behandlung bei Angststörungen, jedoch zeigt eine substanzielle Anzahl von Klienten keine signifikante Symptomreduktion oder ein Wiederkehren der Angst. Es wird angenommen, dass ängstliche Personen Defizite in grundlegenden Mechanismen der Expositionstherapie, wie dem inhibitorischen Lernen, aufweisen. Ein gezieltes Ansprechen dieser Defizite könnte demnach die Wirksamkeit von Exposition optimieren. Allerdings fehlen bisher Vorschläge zur konkreten Umsetzung in der Praxis. Dieser Beitrag verdeutlicht anhand verschiedener Strategien, wie das Modell zur Optimierung der Behandlung von Angststörungen praktisch umsetzbar ist. Die vorgeschlagenen Strategien unterscheiden sich hierbei von einem reinen habituationsbasierten Ansatz oder kognitiven Ansätzen zur Widerlegung von Überzeugungen. Die Strategien umfassen: 1) das Widerlegen angstbezogener Erwartungen, 2) vertiefte Extinktion, 3) Extinktion mit gelegentlicher Verstärkung, 4) Entfernen von Sicherheitssignalen, 5) Variabilität, 6) Erinnerungsreize, 7) multiple Kontexte und 8) affektives Labeling. Durch Fallbeispiele wird die Anwendung dieser Strategien bei verschiedenen Angststörungen illustriert.

Abstract

Exposure is an effective approach for treating anxiety disorders, although a substantial number of individuals fail to benefit or experience a return of fear. Research results suggest that anxious individuals show deficits in the mechanisms underlying exposure therapy, such as inhibitory learning. Targeting these processes may help improve the efficacy of exposure; however, there has been little discussion of how to implement this model in clinical practice. The primary aim of this paper is to provide examples to clinicians for how to apply this model to optimize exposure therapy, in ways that distinguish it from a fear habituation approach and a belief disconfirmation approach. Optimization strategies include (1) expectancy violation, (2) deepened extinction, (3) occasional reinforced extinction, (4) removal of safety signals, (5) variability, (6) retrieval cues, (7) multiple contexts and (8) affect labeling. Case studies illustrate methods of applying these techniques with a variety of anxiety disorders.

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Notes

  1. Es sollte betont werden, dass in einer neuen Metaanalyse zur Ablenkung während der Exposition bei spezifischen Phobien eine Exposition ohne Instruktionen bessere Effekte auf Verhaltensebene erzielte als Exposition mit Ablenkung. Jedoch zeigte unter spezifischen Bedingungen von interaktiver Ablenkung und wiederholten Expositionsdurchgängen Exposition mit Ablenkung bessere verhaltens- und Angstergebnisse im Vergleich zu fokussierter Exposition.

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  1. Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden, 01062, Dresden, Deutschland

    Andre Pittig Dipl.-Psych

  2. Universität zu Köln, Köln, Deutschland

    Stephan Stevens

  3. Center for Excellence on Generalization in Health and Psychopathology, KU Leuven-University of Leuven, Leuven, Belgien

    Bram Vervliet

  4. University of California, Los Angeles, CA, USA

    Michael Treanor, Christopher C. Conway, Tomislav Zbozinek & Michelle G. Craske

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Andre Pittig, Stephan Stevens, Bram Vervliet, Michael Treanor, Christopher C. Conway, Tomislav Zbozinek und Michelle G. Craske geben an, dass kein Interessenkonflikt besteht. Die Publikation entstand teilweise im Projekt P7 (Förderkennzeichen 01EE1402B; PI Jürgen Hoyer, Technische Universität Dresden) im Forschungsverbund PROTECT-AD („Providing Tools for Effective Care and Treatment of Anxiety Disorders: Outcomes, Mediators and Moderators of Enhanced Extinction Learning“; PI: Hans-Ulrich Wittchen). PROTECT-AD ist einer von neun nationalen Forschungsverbünden zu verschiedenen Störungsbildern psychischer Störungen, die vom Bundesministerium für Bildung und Forschung (BMBF) in dem Programm „Forschungsnetz für psychische Erkrankungen“ (2015-2019) gefördert werden.

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Deutsche Übersetzung des Beitrags Craske MG, Treanor M, Conway CC et al. (2014) Maximizing exposure therapy: an inhibitory learning approach. Behav Res Ther 58: 10–23. DOI 10.1016/j.brat.2014.04.006. Erstveröffentlichung beim Elsevier-Verlag, dem wir für die Abdruckgenehmigung herzlich danken.

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Pittig, A., Stevens, S., Vervliet, B. et al. Optimierung expositionsbasierter Therapie. Psychotherapeut 60, 401–418 (2015). https://doi.org/10.1007/s00278-015-0042-7

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