Cognitive Drill Therapy
Cognitive Drill Therapy (CDT).[1] is a form of exposure therapy specifically being developed for Obsessive-Compulsive Disorder (OCD) and Phobia by Rakesh Jain, Ph.D. Clinical Psychologist, Institute of Mental Health and Hospital, Agra, India[2]. Cognitive Drill Therapy (CDT) derives its theoretical input from Emotional Processing Theory[3] and Inhibitory Learning Theory[4] and Cognitive Appraisal for management of anxiety disorders. CDT relies heavily on verbal exposure which has received minimal attention in existing methods of exposure therapy. In a typical exposure therapy, a patient is repeatedly exposed to fear evoking stimuli and the thoughts of perceived danger to achieve habituation or expectancy violation[4]. Exposure can be done in vivo or in imagination[5]; also it can be graduated or intense (flooding). Exposure can also be introceptive[4]
OBSD Framework
In Cognitive Drill Therapy, the problem of OCD and Phobia is partitioned into four components which is called as OBSD Analysis[6].[7][8][9](acronym).
- O represents objects of fear exposure to which elicit a fear reaction such as crowd, lizard, dirty things, speaking on stage, closed places, obscene thoughts
- B also termed as BMR represents Body-Mind Reactions elicited by exposure to an object of fear and includes sympathetic arousal.
- S represents safety behaviors of avoidance, compulsive acts, or any covert and overt methods used by the patients to mitigate the fear reaction.
- D represents danger ideation, also called as imagined feared consequences or threat perception.
The patients of OCD and phobia deal with their objects of fear (O) by taking safety measures (S) which reduces the fear temporarily and act as negative reinforcer which maintain the fear reaction[10][11][12]. The fears seen in phobia and OCD are considered as irrational fears[12]. The feared stimuli in phobia and OCD are harmless or contains minimal threat but the patients overestimate the threat probability in neutral or little harmful stimuli[13][8][14]. Threat perception towards objects of fear is reflected in thoughts of danger reported by the patients. In the perspective of the theory of cognitive appraisal, it is hypothesized that the threat perception triggered by fear cues is the primary determinant of the irrational fears[15]. Hence, the goal of treatment is to normalize the threat perception by replacing it with safety associations so that the objects of fear becomes associated with no or normal level of threat perception[4]. This normalization of threat perception can be accomplished by providing a safe environment to the patient in which he/she could test the validity of threat probability triggered by exposure to feared cues. When the patient has experiential realization that there are no evidence of objective threat, the irrational fear begin to resolve.
Future Orientation in Threat Perception
In a time reference from past, present to future, threat perception contain future time frame. For example, in claustrophobia, a person thinks that in closed places he may have suffocation. In CDT, the thoughts of threat perception are identified and listed[1][7][8][10]. In a person with social anxiety disorder, the list of the thoughts of threat perception triggered by social situations might be as follows[16]:
- I might be judged
- I might be ridiculed
- I might be humiliated
- I might be rejected
- I might be embarrassed
Changing Time Frame
In CDT, the time frame of the thoughts of threat perception is changed to present or past[1][6][7][8][9][10][11][17][18]. In case of social anxiety disorder, the thoughts of threat perception after a change in time frame would be as follows:
- I am being judged
- I am being ridiculed
- I am being humiliated
- I am being rejected
- I am being embarrassed
Hypothesis of Neural Correlates of Time Reference
It is hypothesized that three time reference, past, present and future, have different neural pathways[8].[17] When the thoughts of changed time reference from future to past or present are repeated, there is a shift in neural pathways of future time to the neural pathways of present or past. To clearly understand this hypothesis, notations can be used. A for past time reference, B for present time reference, and C for future time reference. 'A' time reference will trigger neural pathways of past, B will trigger neural pathways of present and C will trigger neural pathways of the future[8][17]. Carelli & Olsson (2015)[19] presented evidence from fMRI study for neural correlates of time perspective.
Time Reference and Threat Perception
Threat perception is associated with future time reference. When time reference of the thoughts of threat perception is changed and the patient is required to verbally repeat the same, it will initially trigger a fear reaction because of previous conditioning[disambiguation needed]. If he/she continues to verbally repeat the time reference modified statements, an experiential realization will take place that the overestimation of danger probability in the thoughts of threat perception is not valid. With this realization the irrational fear will begin to dissolve[1][6][7][8][10][11].
Cognitive Drill
Cognitive drill is the act of verbal repetition of time reference modified statements in bulk until realization of the validity of the threat perception. The protocol of drill is 'imagine objects of fear and verbally repeat time reference modified thoughts of threat perception'. For example, in case of social anxiety disorder, imagine yourself in a socially phobic situation such as on podium and repeat in following manner[1][8][10][17]:
- I am being judged, I am being judged, I am being judged...
- I am being ridiculed, I am being ridiculed, I am being ridiculed...
- I am being humiliated. I am being humiliated, I am being humiliated...
- I am being rejected, I am being rejected, I am being rejected....
- I am being embarrassed, I am being embarrassed, I am being embarrassed...
Moderation of Fear Activation during Cognitive Drill:
Cognitive Drill will elicit fear reaction which may rise from low, medium to high. When during drill, the fear reaction escalates to high level, a brief pause of some seconds could be given[1][8][9]. Fear activation contains arousal and high arousal interferes in new learning[20][21]. Brief pause will reduce the arousal level and facilitate cognitive processing required for new learning that overestimation of danger probability is not valid.
Enhancing Generalization
Cognitive drill produces habituation in fear reaction as well as 'experiential realization' of unrealistic overestimation of danger in the context of feared cues[1][8][10][11][22]. During the course of the disorder, a range of similar objects and situations acquire the properties of feared cues and trigger threat perception. For promoting generalization of acquired gains of cognitive drill, it has to be promoted to as many real life situations as possible with Drill & Daring. In daring, a patient is required to expose himself to as many cues as he/she could come across and use drill on the fly. With drill & daring, the patient would be able to feel safe in diverse situations and contexts which will enhance maintenance and generalization of therapeutic gains[1][9].
Areas of Research
Cognitive drill therapy is a novel form of exposure treatment which has extensive potentials for research into the management of phobia and OCD[1][11]. The simplest level is of case studies on the efficacy of cognitive drill. Kumar et al. (2012)[17] reported a series of five case studies of OCD patients. Four patients had clinically significant improvement. Dwivedi & Kumar (2015)[18] reported significant improvement in a case of Agroaphobia and Panic Disorder. Arya, Verma & Kumar (2017)[6] found it effective in a case of specific phobia. Similar case studies could be done in any type of OCD and phobia. Apart from case studies, efficacy studies following pre-post and follow up group designs would provide better evidence. Comparative studies of two or more treatments like CDT vis-a-vis Cognitive Behavior Therapy (CBT), exposure therapy based on Emotional Processing Theory and Exposure therapy based on Inhibitory Learning Theory would help in estimating relative efficacy of Cognitive Drill Therapy in anxiety disorders. An important area of investigation would be to study neural pathways involved in time reference of past, present and future[8][9].
Criticisms
Cognitive drill therapy is based on existing theories of exposure treatment such as Emotional Processing Theory and Inhibitory Learning Theory except adding two new dimensions (a) Verbal Exposure and (b) Integration of time reference. The role of these two components and the hypothesis as yet are not fully studied. Researches are needed to establish if these two components differentially contribute to the exposure therapy as applicable in anxiety disorders or they are simply redundant additions[8]. CDT can potentially trigger a dissociative reaction as observed in a case of OCD with Dissociation[23]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Jain, R (2016). Cognitive Drill Therapy. CreateSpace Independent Publishing Platform. ISBN 978-1539554219. Search this book on
- ↑ "Institute of Mental Health and Hospital, Agra, India".
- ↑ B., Foa, Edna (2007). Prolonged exposure therapy for PTSD : emotional processing of traumatic experiences : therapist guide. Hembree, Elizabeth Ann., Rothbaum, Barbara Olasov. Oxford: Oxford University Press. ISBN 9780195308501. OCLC 72774389. Search this book on
- ↑ 4.0 4.1 4.2 4.3 Craske, Michelle G.; Treanor, Michael; Conway, Chris; Zbozinek, Tomislav; Vervliet, Bram. "Maximizing Exposure Therapy: An Inhibitory Learning Approach". Behaviour research and therapy. 58: 10–23. doi:10.1016/j.brat.2014.04.006. ISSN 0005-7967. PMC 4114726. PMID 24864005.CS1 maint: PMC format (link)
- ↑ Jones-Smith, Elsie (2011). Theories of Counseling and Psychotherapy: An Integrative Approach. SAGE Publications, Inc; Psc edition. p. 137. ISBN 9781412910040. Search this book on
- ↑ 6.0 6.1 6.2 6.3 Arya, B., Verma, S., & Kumar, R. (2017) "Efficacy of Cognitive Drill Therapy in Treatment of Specific Phobia: EBSCOhost". web.b.ebscohost.com. Retrieved 2017-07-14. SIS Journal of Projective Psychology and Mental Health, 24: 48-51
- ↑ 7.0 7.1 7.2 7.3 Kumar, R. (2017) Cognitive Drill Therapy. National Workshop on Psycho-Yogic Therapies, Department of Psychology, CCS University, Meerut, India, 22-28 March 2017
- ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 Kumar, R (2017). "Verbal Exposure for Irrational Fears: New Directions in Research and Applications" (PDF). Clinical and Experimental Psychology. 3: 157.
- ↑ 9.0 9.1 9.2 9.3 9.4 Kumar, R (2017). "HN Murthy Oration: Experiences in Verbal Exposure for Stimulus Bound Anxiety". Indian Journal of Clinical Psychology. 44: 14–20.
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 Kumar, R. (2016) Cognitive Drill Therapy, Invited Address 2nd International Conference of Indian Academy of Health Psychology (December 16-18, 2016) http://iahp.net.in/Document/Abstract%20Book%20ICIAHP-2016.pdf#page=27
- ↑ 11.0 11.1 11.2 11.3 11.4 Kumar, R; Deubey, BL (2016). "Cognitive Drill Therapy: A Potent Application of the Principles of Psychology for OCD and Phobia" (PDF). SIS Journal of Projective Psychology & Mental Health. 23: 125–26. Retrieved 24 August 2017.
- ↑ 12.0 12.1 Milosevic, Irena; McCabe, Randi E. (2015). Phobias: The Psychology of Irrational Fear. Greenwood. p. 217. ISBN 9781610695756. Search this book on
- ↑ WHO (2002). The ICD-10 Classification of Mental & Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization. p. 112. ISBN 9788174731555. Search this book on
- ↑ Mavromoustakos, Elena; Clark, Gavin I.; Rock, Adam J. (2016-08-24). "Evaluating Perceived Probability of Threat-Relevant Outcomes and Temporal Orientation in Flying Phobia". PLOS ONE. 11 (8): e0161272. doi:10.1371/journal.pone.0161272. ISSN 1932-6203.
- ↑ Oxford handbook of anxiety and related disorders. Antony, Martin M., Stein, Murray B., 1959-. Oxford: Oxford University Press. 2009. p. 216. ISBN 9780195307030. OCLC 183831268. Search this book on
- ↑ Leary, MR (1983). "A brief version of the Fear of Negative Evaluation Scale". Personality and Social Psychology Bulletin. 9: 371–376.
- ↑ 17.0 17.1 17.2 17.3 17.4 Kumar, R., Ahmad, S., & Singh, B. (2012) "Preliminary Test of Cognitive Drill as an Intervention". Indian Journal of Clinical Psychology. 39 (1): 67–74. ISSN 0303-2582.
- ↑ 18.0 18.1 Dwivedi, S. & Kumar, R. (2015) "Efficacy of Cognitive Drill Therapy in Agoraphobia with Panic Disorder: A C...: EBSCOhost". web.a.ebscohost.com. Retrieved 2017-07-14.
- ↑ Carelli, Maria Grazia; Olsson, Carl-Johan (2015). Time Perspective Theory; Review, Research and Application. Springer, Cham. pp. 231–242. doi:10.1007/978-3-319-07368-2_15. Search this book on
- ↑ Fisk, John E.; Warr, Peter. "Age-related impairment in associative learning: The role of anxiety, arousal and learning self-efficacy". Personality and Individual Differences. 21 (5): 675–686. doi:10.1016/0191-8869(96)00120-1.
- ↑ Khan, Zaved Ahmed (2010-05-18). "The Effects of Anxiety on Cognitive Processing in English Language Learning". English Language Teaching. 3 (2): 199. doi:10.5539/elt.v3n2p199. ISSN 1916-4750.
- ↑ Kumar, R; Dubey, BL (2017). "Cognitive Drill Perspective on the Nature of Stimulus in Anxiety Disorders" (PDF). SIS Journal of Projective Psychology and Mental Health. 24: 135–136.
- ↑ Gupta, P; Sahu, A (2016). "Efficacy of psychodynamic understanding over cognitive and behavior therapies in OCD with dissociation" (PDF). The Odisha Journal of Psychiatry: 75–82.
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