Corrective breathing consists of diaphragmatic breathing methods. One way to teach this is to say to your patient, “First, get as comfortable as possible within your current surroundings. Then, close your eyes and begin to breathe deeply through your nose or mouth, whichever feels better for you. Take in deep breaths, and during each exhalation, let yourself unwind; notice your muscles loosening and tension draining away. Now, see if you can notice your belly rising as you inhale and falling as you exhale. This ‘belly breathing’ is what is meant by ‘diaphragmatic breathing.’ By doing this for just a few minutes, your physiology can return to a more balanced state, helping your body relax and your mind grow calm.”
Finally, in the interoceptive exposure phase, you help the patient induce the feelings of having a panic attack. You can do this in various ways. The most common technique is to have a patient spin in a swivel chair for about 30 seconds while hyperventilating into a paper bag. This often produces some of the sensations of panic, such as dizziness and increased heart rate. Usually, demonstrating this method before having the patient do it is most beneficial (partly because watching the therapist deliberately induce generally unpleasant sensations causes a degree of anticipatory anxiety in the patient, thus “priming the pump”). I also find it helpful to model a few moments of diaphragmatic breathing after the interoceptive demonstration.
According to continued expert consensus, the most evidence-based method for treating OCD is a form of CBT that includes exposure and response (or ritual) prevention (ERP). (See, for example, Lack CW, World J Psychiatry 2012;2(6):86–90. doi:10.5498/wjp. v2.i6.86.) Other therapies might also be effective but have not yet been adequately tested in controlled trials.
ERP is based on the idea that OCD behaviors are counterproductive efforts to prevent anxiety. It’s helpful to break down the patient’s anxiety prevention efforts into three categories: avoidance, escape, and reassurance-seeking. Avoidance means simply not exposing oneself to the anxiety-producing situation (for example, not using public restrooms). Escape is performing a ritual, which is a behavior done to neutralize the anxiety, such as washing, checking, or arranging. Reassurance-seeking involves repeatedly asking questions to confirm that nothing bad has happened (for example, a patient calling his parents multiple times a day to make sure they are alive, due to his fear that he had left the stove on the last time he visited).
The ERP technique involves encouraging patients to expose themselves to the trigger, and to learn how to neutralize the anxiety without resorting to rituals. For example, if a patient has contamination fears, the therapist might first model desirable responses by touching something the patient avoids and then not washing (eg, a doorknob, toilet flusher, rim of a trash can, etc). After modeling the nonavoidant and nonritualistic behavior, the patient is encouraged to perform it. Once the patient reports feeling “contaminated” and the patient’s subjective distress is gauged (usually on a 10-point SUDS—subjective units of distress—scale), the therapist asks the patient to periodically reassess the SUDS score until the anxiety has significantly diminished or completely resolved.
Conducting this type of therapy well usually requires significant experience and expertise, meaning you will likely need to refer patients to therapists for this treatment. Two websites that can help you locate such therapists are the sites for the Association for Behavioral and Cognitive Therapies (http://ABCT.org) and the International OCD Foundation (https://iocdf.org).
According to the latest Cochrane review, the three most evidence-based therapies for PTSD are exposure therapy, eye movement desensitization and reprocessing therapy (EMDR), and cognitive processing therapy (Bisson JI et al, Cochrane Database of Systematic Reviews 2013;12(CD003388). doi:10.1002/14651858.CD003388.pub4).
Exposure therapy is the most well-established technique. You start by teaching patients some basic relaxation exercises, then you have them recount the traumatic experience out loud several times. Often, patients record the sessions so they can listen to the narrative later as homework. This repetition gradually extinguishes the fear response triggered by the memories. The technique is highly effective if patients can stick to it, but there’s a fairly high dropout rate since the process is emotionally painful and not everyone can tolerate it.
EMDR involves having patients move their eyes back and forth while recounting the traumatic event and repeating various functional or dysfunctional beliefs, images, sensations, and emotions. The theory is that eye movements (or hand taps or sounds in lieu of eye movements) activate and facilitate the brain’s information processing system. However, there’s controversy about whether the eye movements are a necessary part of the therapy.
In cognitive reprocessing therapy, you help patients identify how a traumatic event has affected their view of the world, and how this view may be negatively affecting their life. For example, patients may believe that the world is a dangerous place and therefore avoid work or other activities. Other patients may blame themselves for the trauma, leading to depression. The therapist helps patients evaluate these beliefs and replace them with more accurate and functional ones.
The best psychological treatment for insomnia is an approach called cognitive behavior therapy for insomnia, or CBT-I. See this month’s Q&A with one of CBTI’s major innovators, Michael Perlis, for more information on this technique.
Although medications are the mainstay of treatment for bipolar disorder, a recent review found that several bipolar-specific therapies are helpful as an adjunct (Swartz HA and Swanson J, Focus (Am Psychiatr Publ) 2014 Summer;12(3):251–266. doi:10.1176/ appi.focus.12.3.251). Psychoeducation, for example, is useful for any phase of the disorder. Talk to your patient about factors that tend to trigger an episode, such as increased work stress, less sleep, arguments with family members, substance abuse, and so forth. Then, based on that discussion, come up with a relapse prevention plan, which should be put in writing.
Typical CBT can be very effective for treating depression in bipolar disorder. This involves behavioral activation (as described previously); activity scheduling and pleasure predicting; thought journaling; and reevaluation of irrational beliefs (eg, overgeneralizing, catastrophizing, all-or-none thinking, and so on.). Another type of psychosocial treatment is interpersonal and social rhythm therapy (IPSRT). The premise is that recurrences of mood episodes are often triggered by changes in routines, changes that are frequently caused by interpersonal conflicts. These changes in routine (called “rhythm dysregulation”) can then disrupt the sleep cycle, and sleep problems are often linked to mood issues. Your job as the therapist is to help patients identify connections between times when their days are thrown off kilter and mood episodes. Then, you coach your patients in how to manage their life in a somewhat regimented way to maintain a consistent sleep, meal, work, and exercise schedule.
Finding the right therapist for your patient
A helpful referral resource is the Association for Behavioral and Cognitive Therapies (ABCT); it has a useful “Find a CBT Therapist” function on its website (http://ABCT.org). Most of ABCT’s members are trained and experienced cognitive behavior therapists, which can help in making reasonably confident referrals.