The Role of Inhibitory Learning in the Development and Maintenance of Anxiety Disorders, OCD, and PTSDWritten by Hillary Gorin, PhD, LCP Exposure and response prevention (ERP) has historically encouraged using what is called habituation as a tool for and marker of symptom reduction in anxiety disorders (as cited in Abramowitz et al., 2019). Habituation generally entails repeated exposure to a feared situation or stimuli until the anxiety eventually subsides (i.e., getting habituated to the situation). In other words, overcoming a fear has generally been determined by how little anxiety someone feels at the end of treatment when engaging with the feared situation or stimuli.
For example, if some is afraid of having panic attacks in the grocery store, successful treatment would look like having little anxiety (and elimination of panic attacks) in the grocery stores by the end of treatment. However, Craske and colleagues (2014) have suggested that habituation is not the most important factor in the extinction of fears in the long term. Specifically, Craske expresses concern regarding the goal of habituation, or anxiety reduction, claiming that it reinforces a problematic belief that anxiety is intolerable and that it must be eliminated. Instead, researchers like Abamowitz (n.d.), emphasize what is referred to as the inhibitory learning perspective, which suggests that the goal of exposure and response prevention should be to learn that, even if a trigger/stimuli makes us anxious or is slightly dangerous/distressing, we can also develop beliefs that the stimuli are not dangerous enough to be avoided or that the stimuli are generally safe. The inhibitory learning perspective suggests that the goal of ERP should be to learn to tune out or inhibit the idea that a stimuli is dangerous while allowing development of the the belief that the stimuli is generally safe, despite any anxiety and/or distress that arises (Abramowitz; n.d.). This perspective also emphasizes that learning new information/new safety associations that supersede or combat previous fear associations is critical to overcoming a fear. In other words, part of exposure therapy requires sitting with a feared stimuli long enough to develop new beliefs about it, mainly that it is not as dangerous as it seemed. For instance, in the example above, if someone fears going into a store due to fear of having a panic attack and being unable to escape, exposure therapy using habituation would entail repeatedly going into the store and seeing that the panic will subside if they stay in the store long enough and that rationally, they always could escape the store. Per the inhibitory learning perspective, they will also learn that they can in fact still function even when experiencing panic and that panic is not a harmful emotion. In fact, it is an emotion that naturally protects us. Although repeated exposure to a grocery store will teach the person referenced above that they can handle grocery stores and that they are safe, research suggests that fears/danger associations can’t be unlearned (as cited in Abramowitz et al., 2019). According to certain theories and researchers, the fear of grocery stores may remain and in the future may resurface even after exposure therapy. However, if we collect enough new safety information, which allows us to see that whatever we were afraid of is actually not as dangerous as we thought, then we will be able to overcome our fears in the future if or when they resurface. This is supported by the inhibitory learning perspective, in which the goal of treatment is to learn new and more accurate safety associations so that the old threat associations are no longer controlling thoughts and behavior. From this perspective, it is not as critical that one habituates to a feared situation or object (becomes less anxious or triggered). Instead, the exposure should be repeated until a new belief related to general safety of the situation is believable, and what the person expects to have happen (e.g., disastrous consequences) does not happen. For instance, if you are starting treatment with a fear that you will contract or spread a deadly disease if you do not wash your hands with bleach before cooking meals, the goal of exposure and response prevention therapy would be to refrain from hand washing with bleach and to cook a meal anyway until you start to learn that a deadly disease will likely not spread through cooking dinner. The updated model of exposure therapy using inhibitory learning suggests that, during this exposure work, additional learning takes place: that the originally feared stimuli, the possibility of spreading a deadly disease without washing with bleach, is actually unlikely, that the act of cooking using standard non-bleach handwashing methods is safe, and that the fear/thought/possibility itself is tolerable. If a new belief has not formed during exposure therapy, Craske and colleagues (2014) suggest that a future relapse is likely. Craske and colleagues (2014) therefore suggest that a new non-threatening cognition must be developed during therapy and the patient must be able to easily access the safety-based cognitions in a variety of contexts. They believe that anxiety should not be controlled or resisted but instead exposure therapy should prioritize fear tolerance, because anxiety is universal, inevitable, and critical for our survival. Exposure therapy using the inhibitory learning model therefore does not encourage the use of a hierarchy, or slowly facing fears in a progressive way, from easiest to most difficult feared situation. Instead, it suggests that the patient commit to “desirable difficulties” (Bjork, 1994) in exposure therapy, or random choosing of exposure stimuli instead of utilizing a hierarchy. Craske and colleagues (2014) and Bjork (1994) believe that this approach assists with managing real life challenges because they will be able to retrieve newly learned information during surprise exposures in the future and learn that desirable difficulties aid in fear tolerance. They hope patients can start to see that when they feel fear, they can manage the distress. In other words, the end goal, according to the inhibitory learning perspective, is to learn that you did not increase the likelihood of developing or spreading a deadly disease because you refrained from bleach use. If your family survives the meal, you have gathered information that is inconsistent with your original belief and you may start to see that bleach is an unnecessary protection (even though it technically does kill germs). Every time you repeat this exposure, you will build up stronger and stronger new associations which suggest your old belief was inaccurate. Of note, we can never be 100% certain. The goal of therapy is also to be able to tolerate uncertainty and to let new information gathered during exposure work drive future behavior patterns, which thereby allows you to live life and welcome anxiety along the way. If you are interested in counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at Contact.OH@OakHeartCenter.com. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond. References Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd Ed.). The Guilford Press. Bjork, R. A. (1994). Memory and metamemory considerations in the training of human beings. In J. Metcalfe & A. P. Shimamura (Eds.), Metacognition: Knowing about knowing (pp. 185-205). Cambridge MA: MIT Press. Cras ke, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behavior Research and Therapy, 58, 10-23. Abramowitz, J. S. (n.d.). The Inhibitory Learning Approach to Exposure and Response Prevention (iocdf.org). Retrieved April 11, 2024 from https://iocdf.org/expert-opinions/the-inhibitory-learning-approach-to-exposure-and-response-prevention/ Alcohol Awareness MonthWritten by: Lee Ann Heathcoat, MSEd, LCPCApril kicks off alcohol awareness month for the Substance Abuse and Mental Health Services Administration (SAMHSA). I wanted to take some time to review information related to alcohol and bring awareness and understanding to alcohol use and misuse.
According to data from the 2022 National Survey on Drug Use and Health, among the 137.4 million respondents aged 12 and older self-reporting current use of alcohol, 44.5% reported binge drinking, with the most prevalent age category being 18-25 years old (29.5%). Among people 12-20 years old, 15.1% used alcohol in the past month. Estimates of binge alcohol use and heavy alcohol use in the past month among underage people were 8.2% and 1.7%, respectively. The Centers for Disease Control and Prevention estimate about 178,000 people die from excessive alcohol use in the U.S. each year (SAMHSA, 2024). Let's review how SAMHSA classifies a standard drink of alcohol:
Signs of Using Too Much Alcohol:
If reading the information provided above resonated with you and you may be struggling with alcohol use, reach out. I’d like to connect and find out more about how I can support you on your journey. References Alcohol Awareness Month. (n.d.). Alcohol Awareness Month. SAMHSA. Retrieved April 17, 2024, https://www.samhsa.gov/newsroom/observances/alcohol-awareness-month If you are interested in counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at Contact.OH@OakHeartCenter.com. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond. The Benefits of BoundariesWritten by Anna Perkowski, MSW, LCSWThe concept of boundaries has seemed to take off in the social media realm and in therapy offices alike. The Merriam-Webster Dictionary defines a boundary as “something that indicates or fixes a limit or extent.” Boundaries apply to things like property lines and city limits, and they also apply to both intrapersonal and interpersonal relationships. Boundaries are an opportunity to determine how and when we will utilize our innate and external resources such as emotional capacity, verbal and non verbal communication, time, and money, to name a few things, when we relate to ourselves and other people in our lives, for the purpose of creating and maintaining safe and satisfying relationships.
As a recovering people pleaser, I can attest that setting healthy boundaries is hard, but it’s not selfish. The furthest thing could be from the truth - boundaries are actually kind. Merriam-Webster defines kind as being “of a sympathetic or helpful nature.” Boundaries are also helpful. Here’s an exercise: Consider someone you personally know who you would describe as having healthy boundaries, and as being kind and helpful - ask them if they believe it is selfish to have and maintain boundaries. In regard to continuing to unlearn some misconceptions about boundaries, I like to envision them as a “gate” instead of a “fence.” This means that there is a pathway, an opportunity for the boundary to be responsive, to allow others in and out when appropriate, but it does not mean shutting the world out forever. A barrier I’ve also noticed for so many individuals in setting healthy boundaries is the fear of coming across as “mean” or “selfish.” This fear of negative perception maintains the boundaryless behavioral pattern until it’s no longer sustainable. What usually happens over time is that resentment will set in and all of a sudden, it’s “boundaries for everyone!” as an attempt to regain some peace. The only problem with this is that when boundaries are coming from a place of burnout and resentment, and it becomes tempting to isolate, they’re usually less effective. However, regardless if someone is setting a boundary proactively or somewhat reactively, they are still so important to have. Without them, we risk enabling poor behavior in ourselves and in others. Here are some signs and questions to ask to determine if boundaries are needed with self or others:
I hope you’re now wondering how to get ahead of burnout and resentment, and how to learn to set boundaries from a place of health and peace. One of my favorite ideas to think on is that instead of being responsible for other grown people, we are instead responsible to them; to do no harm. This distinction can help shift away from the tendency to engage in people-pleasing tendencies at the expense of one’s own needs and desires. How to set and communicate boundaries:
Lastly, I want to expand a bit more on this idea of having healthy boundaries with ourselves. The relationship we have with ourselves is one of the most, if not the most, important relationship we have, and yet I find this to be an area that often gets overlooked. Some examples of this could be forgetting to eat or sleep well, not advocating for what we need in our homes or relationships or workplaces, not doing what we say we will do, etc. Here are some examples of boundaries that someone can have with themselves:
Positive DefianceWritten by Adam Ginsburg, MA, LCPCWhen we think of what it is to be defiant or to display a level of defiance in our everyday lives, more times than not, this isn’t exactly viewed from the lens of being a desirable trait that one would possess in their arsenal. After all, when’s the last time a friend got back from a social engagement, perhaps a first date of sorts, and when pressed for details on what their counterpart was like, jubilantly exclaimed, “Oh, it was magical! They were so defiant!” Yeah, not so much *shrug emoji*
To take this a step further, according to the upstanding, grade A humans at Merriam Webster, of both dictionary and thesaurus notoriety, defiance and/or defy can be defined as: A.) The act or insistence of defying B.) Disposition to resist and/or a willingness to contend or fight C.) To confront with assured power of resistance D.) To resist attempts at E.) To challenge to do something impossible F.) To combat Well, yikes! Not an overflowing, overabundant amount of positivity in this term defiance, yet, what if I were to spill all sorts of tea everywhere, whether it be chamomile, jasmine, or hibiscus, and shared that there’s actually a defiance that’s, well, positive? What if I were to also be brazen enough to take it a step further and speculate that perhaps this level of, what we’ll call from here on out as positive defiance, is something that can be leveraged fully in your life to use as the very vehicle to guide you from the disappointments of the past and perhaps even present, towards the hope that emerges in the future? All sorts of outlandish, I know, but hear me out on this as there’s more to it than might meet the eye. I’m going to go rogue for a bit here, and make the perhaps emboldened claim, that at some point in your life, dearest and most beloved blog reader on the world wide web, there have been points in your life where negative thing have occurred. Chances are, they weren’t simply negative things, but heavy, emotionally dense things that dragged you to figurative waters that were so deep it was almost impossible to swim within. So what gives? You were dragged to the figurative deep waters but you didn’t drown; neck deep in hardship and circumstances yet still able to carry on, all the same. Chances are, at some level, there was an aspect of positive defiance that emerged against the hardship, where you made a determination that you simply weren’t going to give in. Think about every aspect of your life to this point, whether it was the hardships of an upbringing that saw a level of neglect, abuse or trauma, a situation that happened where something or someone you deeply cared for was ripped away from you, or even just the perpetual disappointments that happen day to day. You got through it. Take a moment to acknowledge that and receive that. You! Got! Through! It! As if that wasn’t enough, this is the potential that positive defiance has in this process, as it allows you to not just get through difficult things, but to actually use the very things that sought to overwhelm and destroy, as the very foundations for continued growth for yourself and others. So let’s take this negative upbringing example that was previously referenced; chances are very high that level of pain and discomfort shaped you, illustrating thoroughly what you’re not seeking for your life or the lives of those significant people that are around you. Positive defiance therein takes this experience, and makes a commitment to not pass along those hurts to others in a way that’s inconceivable, because you yourself can identify the pain, the brokenness and the hurt that emerged from that and couldn’t possibly fathom inflicted that on another. Think of this as the bizarro version of a generational curse, where one generation of a family experiences a particular behavioral pattern and passes it along to other generations in a vicious cycle that leaves a path of dysfunction and brokenness in its aftermath. Positive defiance ends that, all of it. Positive defiance plants a flag and makes the proclamation that one won’t be held to the hurts of the past, but instead will confront them head on, ensuring that others within their relational sphere will not have to encounter them personally. There’s a crux to all of this that’s a vital piece of this positive defiance puzzle: before any positive defiance can be exhibited, there has to be the understanding in place that everything that’s happened in your life has been necessary, as you don’t get the current version of yourself without first walking through the past versions, each & every past version. All of your experiences matter. Not just the ones we proudly speak to, even the ones we’d rather forget, bury deeply within ourselves and attempt to forge ahead in spite of them. Your past can be a prison or a pathway, the decision is yours to make and yours alone. On that pathway though, positive defiance awaits, with the ambition to reshape and repurpose those negative situations into something that stops the harm cycle and ushers in a healing cycle that’s beyond comprehension. So get after it, let’s get defiant with our past! If you are interested in counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at Contact.OH@OakHeartCenter.com. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond. ​The Role of Thought-Action Fusion in the Development and Maintenance of OCDWritten by Hillary Gorin, PhD, LCPEveryone has ‘intrusive’ thoughts that are odd and even disturbing, inappropriate, or taboo, at times (Grayson, 2014). Individuals without obsessive-compulsive disorder (OCD) recognize that intrusive thoughts, or thoughts we are not consciously producing that just pop into our heads, are not anything to be alarmed by and don’t need to be interpreted as potentially dangerous. They might think to themselves, “well that was a strange thought” and move on with their day. However, someone with OCD will be inclined to react to an intrusive thought with fear, panic, and shame and interpret the thoughts as potentially meaningful and dangerous. They might alternatively say “Oh my, that is awful, I need to get that out of my head, would I act on this thought? Why am I having this terrible thought? I must be a monster.” They then may assume that having this terrible thought MUST mean that they will act on the thought and that every thought will lead to action, and therefore they must do something to prevent the terrible thing from happening (i.e., compulsive behavior).
As referenced in a previous blog written by Johanna Younce, MA (see OCD and “Unacceptable” Intrusive Thoughts - You are Not Alone - OakHeart, Center for Counseling (oakheartcenter.com)), a study conducted on 777 students from 6 continents (13 different countries), found that 94 percent of people without OCD have the same of intrusive and unwanted thoughts, images and/or impulses that someone with OCD has (Moulding et al., 2014). So why is it that individuals with OCD have such a strong reaction to these intrusive thoughts when someone without OCD does not react really at all? Well, OCD is sometimes referred to as a thought phobia. In other words, individuals with OCD believe that their thoughts are very powerful and they fear having certain thoughts due to the belief that every thought is significant. Most of us tend to believe that thinking positively will result in positive outcomes and thinking negatively will result in negative outcomes. However, we do not think this in a literal sense. We believe that negative thinking isn’t great for our well-being. Conversely, someone with OCD might believe that negative, intrusive and disturbing thoughts (that are highly normative) will likely result in negative outcomes. In this sense, individuals with OCD tend to believe that whatever thought comes to mind will result in action or result in very real consequences. I think we all sometimes wish our thoughts were that powerful. Wishing for a billion dollars would then result in financial prosperity. Wishing for world peace would result in world peace. Unfortunately, individuals with OCD don’t just believe positive thoughts will result in positive outcomes. They also believe the alternative. I think we can all recognize that this belief would be challenging and quite distressing. If every intrusive thought that pops into someone’s head could lead to an actual outcome in the world, our world would be a scary place! For example, when we are running late and the car in front of us fails to see that the light turned green, many people likely experience anger followed by intrusive thoughts about the person in that car. Individuals with OCD tend to believe, because they had that bad thought, there is an increased likelihood that the person in the car ahead will actually experience harm. Thought-action fusion reflects the distorted thinking described above that is often characteristic of OCD: This distortion suggests, because I think it, it must be so (Grayson, 2014). Because we think many ridiculous thoughts throughout the day, this psychological phenomenon causes significant distress in individuals with OCD. For this reason, the most effective treatment for OCD is exposure and response prevention (ERP), which entails exposing someone to a scary thought (ones that they are already having) and then refraining from trying to undo the thought via a compulsion. Studies have been conducted to understand the neurobiology of thought-action fusion. Researchers have identified areas of the brain that are likely involved, including the inferior orbitofrontal gyrus, several prefrontal cortex regions, the insula, and the globus pallidus (Lee et al., 2021). Lee and colleagues (2021) found that the superior and middle frontal gyri (dlPFC), medial prefrontal cortex (PFC), and inferior parietal lobule were correlated with OCD symptoms. A recent meta-analysis showed that all of these regions were associated with OCD in functional imaging studies (Rasgon et al., 2017). For instance, individuals with OCD were found to have abnormalities in the insula (associated with disgust) and the unacceptable thought dimension of the dorsolateral and dorsomedial prefrontal cortex (PFC; associated with cognitive control; Rasgon et al., 2017; as cited in Lee et al., 2021). This neurobiology of thought-action fusion exhibits that OCD is a medical/ biological condition and therefore requires treatment that will assist with training the brain, which is the goal of exposure and response prevention treatment. ERP treatment aims to help you either reduce the frequency of intrusive thoughts or learn to recognize that most thoughts are just thoughts without much or any meaning. By intentionally provoking or “sitting with” your scary or distressing thoughts in exposure-based therapy, you can start to learn that intrusive thoughts do not lead to action and that thought-action fusion is simply a thinking error. This is a major goal of treatment. An additional goal in treatment is to realize that a thought is just a thought; it means nothing without intentional action. For instance, one exercise that I sometimes have my patients participate in is to have the thought “stand up” for one minute. I then tell them, “now actually stand up.” To actually stand up, requires intention. Intended action requires more than a thought. The goal of treatment is to see that you are more than your thoughts. We are here to help you too start to believe this. If you are interested in counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at Contact.OH@OakHeartCenter.com. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond. References Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd Ed.). The Guilford Press. Foa, E. B., Steketee, G. S., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of posttraumatic stress disorder. Behavior Therapy, 20, 155–176. https://doi.org/10.1016/S0005-7894(89)80067-X Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books. Krypotos, A-M., Effting, M., Kindt, M., & Beckers, T. (2015). Avoidance learning: A review of theoretical models and recent developments. Frontiers of Behavioral Neuroscience, 9(189), 1-16. https://doi.org/10.3389/fnbeh.2015.00189 Lee, S. W., Cha, H., Jang, T. Y., Kim, E., Song, H., Chang, Y., & Lee., S. J. (2021). The neural correlates of positive versus negative thought-action fusion in healthy young adults. Clinical Psychopharmacology and Neuroscience, 19(4): 628-639. https://doi.org/10.9758/cpn.2021.19.4.628 Moulding, R., Coles, M. E., Abramowitz, J. S., Alcolado. G. M., et al. (2014). Part 2. They scare because we care: The relationship between obsessive intrusive thoughts and appraisals and control strategies across 15 cities. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 280-291. https://doi.org/10.1016/j.jocrd.2014.02.006 Rasgon, A., Lee, W.H., Leibu, E., Laird, A., Glahn, D., Goodman, W., et al. (2017). Neural correlates of affective and non-affective cognition in obsessive compulsive disorder: a meta-analysis of functional imaging studies. Eur Psychiatry, 46, 25–32. https://doi.org/10.1016/j.eurpsy.2017.08.001. Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist’s manual. Department of Veterans Affairs. The Role of Habituation in the Treatment of Anxiety DisordersWritten by Hillary Gorin, PhD, LCPTreatment for an anxiety disorder generally involves two components:
1. Taking small steps towards facing a fear, psychologically and/ or behaviorally. 2. Taking the same small steps over and over again until you can take another step. In theory, if you keep taking small steps, eventually, you get to the final step and overcome your fear. Why would you need to repeatedly take the same step over and over again to get used to it? Well, simply stated, that is the only way we learn that we can do something difficult as human beings. If we do not think we can do something difficult, we need to go do that thing over and over again until we feel like we are actually capable of doing it and have collected enough instances of success to be confident in our abilities. Treating an anxiety disorder, in this sense, is similar to training as an athlete. How many baskets does an NBA player have to make to feel confident? Many. Exposure therapy, a therapy that entails facing and overcoming fears that are interfering with your happiness and success in life, is therefore effective because it entails repeatedly taking small steps towards overcoming your fears. Your therapist will explain a part of this process as habituation, or getting used to or desensitized to unhelpful or unrealistic anxiety (as cited in Abramowitz et al., 2019, p. 17). Habituation involves anxiety reduction/ getting used to anxiety both within and between sessions. In other words, during sessions, you will work on sitting with anxiety but in between sessions you will repeat the exercises for successful habituation. Why can’t you just complete the work in one session per week? Because habituation or desensitizing is a process that takes several repetitions and a large amount of time (Abramowitz et al., 2019). You would never go to the gym and expect results after only one gym session. Similarly, modifying your brain will take repetition. As mentioned in the previous blog in this series (see The Role of Avoidance Learning in the Development of Anxiety-Based Disorders, OCD, and PTSD), fear is promoted through operant conditioning, or the encouraging or discouraging of behavior by using reinforcement or reward. Therefore, unconditioning a fear requires habituation or many repeated exposures to the conditioned stimulus (the now feared situation that you did not fear before) presented without the unconditioned stimulus (feared outcome taking place) until fear starts to diminish. For example, if someone is afraid of riding a bike because they fell off of it previously, successfully riding the bike many times will eventually lead to habituation, or getting used to riding the bike again and confident you can continue doing so. With respect to neurobiology, during habituation (and eventually elimination of a fear), an area of the brain called the medial prefrontal cortex or the mPFC blocks output in what is called the amygdala, the part of the brain that regulates fear (Kwapis & Wood, 2014). The mPFC is responsible for decision making (Euston et al., 2012). More specifically, during exposure work, neurons, or cells in a portion of the medial prefrontal cortex called the infralimbic cortex (as cited in Kwapis & Wood, 2014) undergo changes that reduce activation in the amygdala (as cited in Kwapis & Wood, 2014). In other words, cells in our brain help us get used to being exposed to a fear (that originally activates the amygdala) and eventually our rational brain realizes that we no longer need to be afraid because a situation is not inherently dangerous. Psychologically, one additional component of habituation is learning that our anxiety will not last forever, as we start to learn that the feared stimuli is not actually dangerous. It has been theorized that fear extinction, or complete elimination of a fear, first requires habituation. In other words, getting used to the fear and seeing that it is not as dangerous or intolerable as once believed, allows you to form new associations and to stop avoiding the originally feared situation, object, thoughts, etc. Due to habituation, exposure therapy remains a highly effective intervention for treating anxiety disorders. If you are interested in counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at Contact.OH@OakHeartCenter.com. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond. References Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd Ed.). The Guilford Press. Euston, D. R., Gruber, A. J., & McNaughton, B. L. (2012). The role of medial prefrontal cortex in memory and decision making. Neuron, 76(6), 1057-1070. Foa, E. B., Steketee, G. S., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of posttraumatic stress disorder. Behavior Therapy, 20, 155–176. https://doi.org/10.1016/S0005-7894(89)80067-X Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books. Krypotos, A-M., Effting, M., Kindt, M., & Beckers, T. (2015). Avoidance learning: A review of theoretical models and recent developments. Frontiers of Behavioral Neuroscience, 9(189), 1-16. https://doi.org/10.3389/fnbeh.2015.00189 Kwapis, J. L., & Wood, M. A. (2014). Epigenetic mechanisms of fear conditioning: Implications for treating post-traumatic stress disorder. Trends in Neuroscience, 37(12), 706-720. Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist’s manual. Department of Veterans Affairs. The Role of Avoidance Learning in the Development of Anxiety-Based Disorders, OCD, and PTSD2/6/2024
The Role of Avoidance Learning in the Development of Anxiety-Based Disorders, OCD, and PTSDWritten by Hillary Gorin, PhD, LCPThe development of anxiety-based disorders, OCD, and PTSD, as understood at this time, involves complex interactions between genetic and environmental, behavioral, and psychological factors. In this blog, I will discuss a leading theory on one major behavioral/ psychological contribution to the development of and maintenance of these disorders: Avoidance. Unfortunately, avoidance generally prevents overcoming a fear response. Why? Because you can’t see that a feared situation, thought, or memory is actually not harmful until you repeatedly encounter that thing and see that it is not harmful.
Specifically, the avoidance learning theory on the development of fear suggests that fear responses develop through two processes. First, fear development is based on forming an association between two stimuli: A neutral thing and a scary or unpleasant thing (as cited in Krypotos et al., 2015). This is often referred to as classical conditioning. For instance, at an early age, we learn to associate a stove (neutral thing) with being hot (an aversive and scary stimuli), after we accidentally touch the stove or are warned by our parents that it will burn us. Therefore, we learn to avoid touching hot stoves and we develop a healthy fear of putting our hands on the burners when the stove is on. Similarly, unrealistic or anxiety-disordered fear associations develop when a previously neutral stimulus gets paired with an aversive or anxiety-provoking stimulus. For instance, if a dog is startled by the loud sound of a garbage truck every time the garbage gets picked up, the dog might start to fear garbage trucks, trucks/ cars in general, or even the garbage can. Although we know the garbage truck is not actually a dangerous stimuli, the repeated pairing of a previously neutral/ safe stimulus (garbage truck/ can) and aversive stimulus (loud noise) will generate a conditioned stimulus (truck/ can) and a conditioned response (fear). In the event that the garbage truck was actually dangerous, it would be adaptive for the dog to avoid seeing or being near the garbage truck or garbage can. However, because the garbage truck is not actually dangerous, the dog has now developed a maladaptive anxiety response and false narrative about garbage trucks being dangerous. After this maladaptive anxiety response is formed, disordered anxiety will be further maintained by avoidance, often termed operant conditioning. For instance, if the dog starts to run and hide every time the garbage truck arrives, he will not only maintain the fear but also strengthen the fear. Every time he hides, he is confirming that something about the garbage truck is dangerous and he feels a sense of relief while hiding under the bed. This process is often termed operant conditioning, or the encouraging or discouraging of behavior by using reinforcement or reward. In this way, operant conditioning plays a role in the maintenance of anxiety disorders. When something is pleasant, it is reinforcing/ feels good, and therefore the behavior continues. Conversely, when something is unpleasant/ feels bad, that thing will be avoided so the behavior discontinues. When the dog runs and hides, he feels a reduction in negative emotion (which is pleasant) and therefore the behavior is reinforced and the fear is maintained. Thus, the avoidance learning theory suggests that anxiety disorders are developed through classical conditioning and are maintained through operant conditioning. After one fear-provoking situation, our brains can trick us into believing something is dangerous, when it actually is not, and then avoidance fuels and strengthens unhelpful and unrealistic anxiety responses and beliefs over time. Understanding this theory is important for your treatment. Why? Because the most effective interventions we have to date for the treatment of anxiety-based disorders, OCD, and PTSD involve breaking these associations using exposure-based interventions and thought challenging strategies. Thus, there is good news! If avoidance maintains these disorders, then challenging it and reducing avoidance will serve as effective treatment for overcoming your fears. If you are interested in counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at Contact.OH@OakHeartCenter.com. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond. References Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd Ed.). The Guilford Press. Foa, E. B., Steketee, G. S., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of posttraumatic stress disorder. Behavior Therapy, 20, 155–176. https://doi.org/10.1016/S0005-7894(89)80067-X Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books. Krypotos, A-M., Effting, M., Kindt, M., & Beckers, T. (2015). Avoidance learning: A review of theoretical models and recent developments. Frontiers of Behavioral Neuroscience, 9(189), 1-16. https://doi.org/10.3389/fnbeh.2015.00189 Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist’s manual. Department of Veterans Affairs. Will You Peel My Orange? Bids for Connection in the Couple’s RelationshipWritten By: Erin Blair, MSYou may have seen the viral TikTok trends about oranges and birds only to wonder what that has to do with the strength of your relationship. “Orange peel theory” and “bird theory” are both real life examples of the famous research study by relationship expert,
John Gottman. After observing thousands of couples in his lab, he found that the couples with the greatest long-term success had one major thing in common: how they responded to bids for connection. A bid for connection can be something as simple as asking your partner to peel an orange or look at the interesting bird outside but often they are an indicator of much deeper aspects of the relationship like shared values, dreams, and desires. What Gottman noticed is that couples who were happiest (and stayed together) responded consistently to bids for connection from their partner and responded with genuine interest and curiosity. This showed each partner’s willingness to learn and understand more about their partner during regular day-to-day interactions. He called this “turning towards” the bid for connection. Couples who were less satisfied with their relationship often ignored bids (“turning away”) or responded with disinterest or even hostility (“turning against”). In his research, Gottman discovered that “master couples” (those who stayed together and were satisfied in their relationship) responded by turning towards their partner 86% of the time while “disaster couples” (those who experienced high conflict and eventually ended their relationship) turned towards the bid only 33% of the time. This research was groundbreaking because it highlighted that the majority of the work in the relationship happens in small, everyday moments. Not extravagant date nights, vacations or gifts but asking your partner whether they had a good day at work and actually listening to their response. It may seem simple and straightforward to respond when your partner asks a question or tries to engage you in a conversation. However, bids for connection require emotional attunement and vulnerability on both sides. Let’s look at some examples of turning against, turning away and turning towards. Turning Against Becca: Hey, I’m thinking about looking for a new job. You know how unhappy I’ve been at this one. Alex: Oh jeez, not again! I swear you can’t stay at a job for more than six months. Do you know how stressful it is for me when you’re constantly switching jobs? In this example, Becca is receiving the message that her partner is not a safe person to discuss her dreams and concerns with. She will likely internalize the concept that showing vulnerability is stressful to her partner and she should keep these thoughts to herself which prevents Alex from understanding his partner. Not only will Becca refrain from making bids for connection in the future but it’s likely she will make decisions without informing her partner which can lead to even more conflict. While Alex is able to clearly assert his needs in the situation (a desire for stability), the hostility he used to communicate will likely keep Becca from fully understanding his fears and create defensiveness instead. Because Becca will probably respond to Alex with a focus on defending herself, the original issue (looking for a new job) will remain unaddressed and both parties will leave the interaction feeling misunderstood. Turning Away Becca: Hey, I’m thinking about looking for a new job. You know how unhappy I’ve been at this one. Alex: Uh-huh… did you remember to get mustard at the store this week? In this example, Becca is not receiving hostility but the concerns about her current job are being ignored. While this might not create a conflict in the moment the way that “turning against” can, this type of response will lead to a build-up in resentment. Over time, Becca will internalize that her needs are irrelevant and her attempts at building intimacy are not worthwhile. Alex may not realize that he is ignoring an important interaction because he is distracted. We all experience moments where our partner is trying to connect with us and we have our attention elsewhere. This is where Gottman suggests utilizing a “repair bid” or a follow-up question from the partner who initially ignored the bid. Repair bids are an attempt to turn towards our partner when we missed the first request for connection and go a long way in reducing resentment over time. Turning Towards Becca: Hey, I’m thinking about looking for a new job. You know how unhappy I’ve been at this one. Alex: I know this job hasn’t turned out the way you’ve hoped. What kind of new jobs are you considering? It’s important to highlight a few aspects of what makes Alex’s response a good one:
Once we start to notice how we are responding to our partner’s bids for connection, we can begin turning towards them with more intention. Your partner might say, “Hey, did you see that bright red cardinal?” when they actually mean “Hey, are you paying attention to things that are interesting to me? Do my experiences matter to you? Do you see me and enjoy who I really am?” Learning to respond to these questions at the heart of the bid will strengthen the foundation of the relationship and ultimately lead to a happier, longer-lasting bond for both partners. If you are interested in couples counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at Contact.OH@OakHeartCenter.com. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond. Blue Blue ChristmasWritten by Bridgette Koukos, MA, LCPC, NCCWhen you think of the holiday season, I bet you automatically think of things such as holiday parties, ugly sweater contests, eggnog, making gingerbread houses, driving around to see all the holiday lights, and family celebrations. However, this is not always the case for everyone. For some, what should be a time of celebration, is a time of increased depression, and wanting to isolate in the safety of their own home ignoring the fa-la-la-la fun, which can feel like you are on the island of misfit toys.
According to the National Alliance on Mental Illness (NAMI), 64% of people with an existing mental illness report that the holidays make their condition worse. It is no secret that the holiday craziness of cooking, buying and wrapping presents, keeping children entertained, decorating your home, and cleaning up after family gatherings can exacerbate depressive symptoms, and make us feel more overwhelmed and exhausted. This can lead to some individuals feeling immense amounts of guilt for feeling low. While no one goes into the holiday season hoping to feel like a Scrooge, sometimes life situations, family members, or general mental health can trigger the Christmas Blues. If your family is similar to the Griswald’s and drives you crazy, or triggers bad memories that make us want to do anything to steer clear of attending the family holiday party. So how do you deal with a triggering family member? Well here are some helpful tips and tools.
Alternatively, suppose you have good family relationships but cannot spend the holidays with them. In that case, that can also trigger an individual to have increased depressive symptoms, isolate themselves, and exacerbate feelings of loneliness. Below are some helpful tools for this individual to manage a holiday season away from loved ones.
We may feel very Grinch-y this holiday season, but remember you are not the Grinch who lives a lonely life on the top of the mountainside, however, current holiday circumstances can make you feel like you are. But remember whether you are grieving the loss of a loved one this holiday, experiencing unhealthy family dynamics, or feelings an increase in depressive symptoms. Yes, you may find yourself longing for the happier holiday traditions of the past—making the present feel even more miserable. But it is important to remember that with each year, holiday plans, traditions, and experiences will change; yes, this is normal for change to occur. With that said, create your holiday traditions.
Most importantly, for those of us who live in an area such as the Midwest where there is sparse amounts of sunlight during the winter months. To put into perspective, holiday depression impacts approximately 1.5% of Floridians as compared to the approximate 10% in northern/midwestern states. So we need to make sure that we are taking extra steps to help ourselves manage throughout the holiday and winter seasons. This means; making sure you are taking better care of your body (eating healthy, quality sleep, keeping up with hygiene, increasing water intake, etc.). It's important to try and get as much sunlight as possible, so if possible make sure you take time to get outside in the middle of the day when the sun is brightest, or take vitamin D supplements. You can also get a sunlamp. While light therapy is not a cure, it has been shown to help reduce some symptoms of depression. If symptoms of depression continue to worsen and/or intensify please do not hesitate to seek our support here at OakHeart. Overcoming ADHD OverwhelmWritten By Erin Mitchell, MSW, LCSWHave you ever found yourself feeling overwhelmed by tasks, responsibilities, and expectations? Do you find yourself procrastinating until the last possible minute…even if you had a whole day to get it accomplished? Does the task (when you remember to take care of it) feel like there are just too many steps? This is the tip of the iceberg known as overwhelm, especially in the neurodiverse community.
Each person has different tolerances for being overwhelmed and different factors that can contribute For some, feelings of being overwhelmed may stem from physical stimuli (too loud, too many people, uncomfortable clothes, etc.). For others it may be the sheer amount of steps required and feeling like it will take “forever”. While many people with ADHD find that they make decisions very well during times of crisis, they may struggle in making similar decisions without the crisis present to push them along. Signs of Overwhelm:
Coping with Overwhelm:
Getting Tasks Done:
Not all of these things work for everyone at every time, but these can be a good starting point. You are not able to be productive all of the time and you do not need to expect yourself to be. Try things to work with your brain, instead of trying to do things the same way. Different is not bad, just different and you are not alone. If you are looking for more, I recommend checking out this article on ADHD paralysis on ADDitude Magazine: https://www.additudemag.com/slideshows/analysis-paralysis-and-adhd-trouble-making-decisions/ If you are interested in counseling, call OakHeart at 630-570-0050 or 779-201-6440 or email us at Contact.OH@OakHeartCenter.com. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond. |
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