Saavedra and Silverman Button Phobia Lecture Notes PDF

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Saavedra and Silverman Button Phobia Clinical Case Study Background--Theory: Classical Conditioning- (Pavlov, 1890) A type of learning that occurs when an individual learns to produce an involuntary emotional or physiological response similar to an instinctive or reflexive response. - Neutral Stimulus (NS) = a stimulus (like a bell) that in itself does not elicit a response → Becomes the Conditioned Stimulus. - Unconditioned Stimulus (UCS) = a stimulus that naturally and automatically triggers a response (food). - Unconditioned Response (UCR) = the unlearned. naturally occurring response to the Unconditioned Stimulus (such as salivation to food). - Conditioned Stimulus (CS) = through repeated pairing and association, the Neutral Stimulus + the Unconditioned Stimulus now elicits the response (bell). - Conditioned Response (CR) = the learned response to a previously neutral stimulus (salivating to the bell). Little Albert Study- Watson and Raynor (1920) believed that we would naturally acquire phobias and used classical conditioning to instill the fear of a white rat in 11-month-old Little Albert. - NS- white rat. - UCS- loud noise (of steel bars being hit) - UCR- crying to the loud noise. - NS + UCS- conditioning phase of showing the white rat and hitting the steel bars. - CS- white rat. - CR- crying to the white rat. Since these “classical” studies, psychologists have gone against pure behaviorists notions and have included cognitive processes into the work with the new subtypes of the theoretical basis; - Expectancy Learning- when a previously neutral or non-threatening object/stimulus/event becomes associated with a potentially threatening outcome. - The person now expects the negative outcome and thus experiences fear in the presence of the previously non-threatening situation. - Think of a test in a class- before the class was neutral/non-threatening, but the idea of failing the semester exam and hurting your chance of getting into your preferred college now elicits fear of taking the test. - Evaluative Learning- attitudes towards a stimulus are considered to be the product of complex thought processes and emotions that lead someone to perceive or evaluative a previously neutral stimulus negatively. - Whereas expectancy learning depends on the person expecting the association of

the stimulus and outcome (fear of failing), in evaluative learning, the person would negatively evaluate the stimulus itself (the exam). - Basically, this elicits disgust for the stimulus (exam) rather than fear (of failing the exam). - For “button boy”, it is then suggested to treat not just the fear of buttons, but the disgust for them too. Previous studies set the basis to treat BOTH the fear and disgust. - Hepburn & Page (1999)- in treating 47 patients who showed disgust and fear of blood after an injury, addressing both of these issues showed the progress in reducing both fear of blood and faintness to blood. - De Jong et al. (1997)- treated children with arachnophobia- focused on the fear of spiders only, but found that their disgust for spiders also diminished. Background- Phobias Phobia- a persistent fear of an object or situation in which one would do anything possible to avoid the feared object or situation. - This differs from ordinary fears in the severity and in the discomfort faced by the sufferer - For example, a “common” fear of spiders may cause you to do the “spider dance” when walking through a cobweb, but arachnophobia could cause you to not leave the house or break down and cry at the sight of a cobweb, but arachnophobia could cause you to not leave the house or break down and cry at the sight of a cobweb, thus having a greater, negative impact on your everyday actions. - In general, phobias are considered to be an Anxiety Disorder that typically is characterized by “a general feeling of dread or apprehensiveness accompanied by various physiological reactions such as increased heart rate, sweating, muscle tension, and rapid, shallow breathing.” - A few key aspects of a phobia rather than a simple fear - The fear/anxiety is out of proportion to the actual danger. - The fear/anxiety causes clinically significant distress. - The sufferer fears and/or avoids potential situations of the phobic stimulus. The DSM-IV criteria for specific or simple phobias. - Marked fear an/or anxiety about a specific object or situation (buttons in this case) - The object always produces immediate fear/anxiety (distress over stimuli with buttons) - The object is avoided or endured with fear (not buttoning clothes, avoiding clothes with buttons, etc.) - The fear is out of proportion to the actual danger (no reports of buttons coming to life so far….) - Typically lasts 6 months or longer (had for 4 years when beginning treatment sessions) - Causes significant distress or impairment. - Not better explained by some other mental disorders (child did not “qualify” for OCD)

The DSM-IV classifies 5 subtypes of specific phobias - Animal- including spiders, insects and dogs. - Natural Environment- heights, storms, waters. - Blood-injection or injury- fear of needles, blood, or any invasive procedures. - Situational- airplanes, elevators and enclosed spaces. - Other- choking, committing, clowns, or other costumed characters. Prevalence and course - 12 month prevalence in the US is 7-9%. - 5% for children and 16% for 13-17 year olds, then back down to 3-5% for older adults. - Females 2x more likely in most phobias (but 1:1 in blood phobias) - Most specific phobias develop in early childhood before age 10. Aim and Sample Aim- to bring evaluative learning and disgust to the forefront of child psychiatric literature while treating the phobia of buttons of a 9-year old boy. - In doing so, Saavedra and Silverman wanted to see if using imagery exposure therapy would reduce disgust and distress associated with buttons. Type of study- case study - Case study (longitudinal over 11 sessions) --no mention of time between sessions. Sample- A 9-year old Hispanic-American boy who came to the Child Anxiety Phobias program at FI and met the DSM-IV criteria for “specific phobias”. - Boy and his mother consented to the assessment and intervention procedures. Button Boy-Background Button Boy’s phobia began at age 5 in kindergarten. - Working on an art project at school and he accidently knocked over a bowl of buttons that fell on him in front of the teacher and the class. - This seemed to be the triggering event as reported by him and his mother. At first, his avoidance of buttons did not cause difficulties in day-to-day activities, but this soon progressed and impacted his life (aside from the increased fear and disgust of buttons). - He could no longer dress himself if his clothes had buttons. - He would focus his attention on not touching his school uniform (or anything that came into contact with it) instead of paying attention in class. - Outside of school he would not wear any clothing that had buttons in it and he couldn’t even hug his mom if she was wearing buttons as well. Diagnosing specific phobias - Saavedra and Silverman ruled out physical or sexual abuse, accidents, and other traumas as being a cause of the phobia. - Button boy did NOT show signs of Obsessive-Compulsive Disorder (OCD) by the DSM-

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He did not have recurrent and persistent thoughts, impulses, or images that may be intrusive. - Did not report fears of aforementioned content hurting others leading to problems. - If so, OCD may have been a better diagnosis. With OCS being ruled out, his marked and persistent avoidance of buttons at school and at home, combined with the fear and disgust of buttons, led to the specific phobia diagnosis. - Use of the ADIS-C/P Anxiety Disorders Interview Schedule- Child and Parent Versions (for DSM-IV).

Treating Button Boy Before starting the treatment - Saavedra and Silverman had to have an understanding on the severity of certain aspects of the phobia. - This led to the creation of the hierarchy of feared stimuli, as represented with the kid-friendly Feelings Thermometer. - Distress rating of 0 (least distress feeling) to 8 (most distress feeling) on a 9-point scale. Treatment-Behavioral Approach Overall, there were 11, exposure-based treatment sessions (4 contingency & 7 imagery) - Contingency Management Treatment- focusing on the behavioral approach through a form of positive reinforcement, Button Boy would be rewarded for showing less fear and actually handling the buttons (known as in-vivo exposure) - These sessions lasted 30 mins with Button boy himself and an additional 20 minutes with the mother present as well. - No mention of what the reward was. - As Table 1 shows, Button Boy was able to increase the # of buttons that he would hold/touch, BUT his distress levels increased and he was more distressed about wearing and handling buttons afterwards. - This increase in disgust was consistent with evaluative learning that despite the in-vivo exposure, his evaluative reactions increased. - This unusual outcome to the treatment helped lead to another treatment. Treatment-Cognitive Approach -

As the contingency management sessions did not calm his phobia and instead increased it, a further cognitive approach was used (which became the main focus of the therapy).

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Additionally, interviews revealed that he “found buttons disgusting upon contact with his body… (and) he also expressed that buttons emitted unpleasant odors” (Disgust-related) Imagery Exposure- unlike in-vivo exposure, this was based on discussing “various things about buttons that he found disgusting..and using specific selfcontrol/cognitive strategies”. - For example, imagining buttons falling on him and describing how they looked, felt, and smelled and then how this made him feel. - Progressed from larger to smaller buttons (least to most severe ratings). - Treatment included cognitive restructuring for the more difficult ones. Saavedra and Silverman discussed that the disgust-related imagery exposure and cognitions helped to reduce Button Boy’s distress levels of buttons (but only 2 examples are reported). - Buttons falling all over his body - Distress level of 8 (starting point) decreased to a 5 (midway through imagery exposure) than eventually a 3 (after the exposure treatment). - Hugging his mother who is wearing “a shirt full of buttons”. - Distress level of a 7, decreasing to a 4, then settling down to a 3.

Treatment- Follow Ups -

6 and 12 month follow up DSM-IV phobia assessment were completed to gauge the success of the treatments. Button Boy reported”minimal distress” about buttons and he no longer met the DSM-IV criteria for a specific phobia. He would wear small, clear plastic buttons (previously rated an 8) with his school uniform on a daily basis.

Conclusions Saavedra and Silverman concluded that the treatment (mainly the imagery exposure) was successful in calming Button Boy’s phobia as he no longer met the DSM-IV criteria. - In particular, they argue two main points: - Emotions and cognitions relating to disgust are important when learning new responses to phobic stimuli. - Imagery exposure can have a long-term effect on reducing the distress associated with specific phobias as it addresses negative emotions. Discussion -

Though this not a “groundbreaking” case study, it helps to provide research into childhood phobias and treatments. - Saavedra and Silverman suggest that clinicians should “remember” disgust and

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evaluative learning when treating certain types of childhood phobias. It is suggested that future research should: - Focus on phobias where disgust plays a large role (not just fear) - How different treatments focusing on the disgust side of a phobia can be efficacious. - Examine the use of evaluative learning processes.

Evaluation- Strengths of the Study Case study - Enabled an in-depth understanding of a child with a phobia of buttons. - This seems to be the first reported case for a child with disgust playing a major role. High standardization - Use of DMZ-IV for specific phobia diagnosis, use of Feelings Thermometer throughout the study and during follow ups. Quantitative data - Helps to be more “sciency” given that it is a case study. - Can be considered a generative study. - Suggestions for addressing phobias and research into treatment effectiveness. Evaluation- Weaknesses of the Study Issue of generalizability - Case study examined only one 9 year old boy; Hispanic; specific phobia of buttons. - The nature of the qualitative data and the subjectivity of it. - Ethical issues and the use of children. - Possible issues of ecological validity--the subjective nature of self-report interviews, professional interpretation of responses and diagnosing, etc. - Demand characteristics possible with Button boy and his mom providing desirable responses. - Possible researcher bias with any case study. Evaluation- Ethics -

RTW- no specific mention, but certainly available by not coming back to sessions. Informed consent and confidentiality provided. Privacy was promised and there were no worries of harm....