four day cognitive behavioral treatment of a rat phobic

FOUR DAY COGNITIVE BEHAVIORAL TREATMENT
OF A RAT PHOBIC
Curtis C. Hsia. Ph.D.
While many individuals have a strong
dislike and aversion to rodents, few people meet
the criterion for a specific phobia of rodents.
Two of the major markers to meet criteria for a
specific phobia require the individual to have
either a significant amount of distress or
interference in his or her life (DSM-IV).
Additionally, according to the DSM-I~ the
individual's fears must be excess of the actual
danger and illogical, and exposure to the feared
object causes high levels of anxiety which may
result in a situationally bound panic attack. In
this case report, Miss S' specific ph<)bia of
rodents is presented, as well as her progress
through a four day intensive cognitive
behavioral treatment program.
Cognitive and behavioral treatment-hasbeen
widely accepted as the treatment of choice for
anxiety disorders (Emmelkamp et aI, 1980,
Chambless, D. & Gillis, M., 1993,Paunovic, N.,
& Ost, L., 2000).
Additionally, structured
protocols and workbooks have been developed
for treatment of anxiety disorders (Antony,
Craske & Barlow, 1995) that have also shown
efficacy, all with a focus on the individual
making behavioral changes in his or her
interactions with feared objects, while also
cognitively restructuring negative thoughts
about the feared object. While treatment for a
specific phobia usually takes place over a
number of weeks (typically eight to t€mweekly
hour-long sessions), there has been evidence
that therapy over a shorter period of time, as
short as one day, is as effective as longer therapy
1
(Oest, L., etal, 2001). In this case report, a fourday therapy approach is presented.
Miss S was an 18 year-old female who was
attending a large private university in the
Northeast of the United States. A pretreatment
assessment was conducted using the Anxiety
Disorders Interview Schedule (Fourth edition,
Lifetime version, Brown, DiNardo & Barlow,
1994), a semi-structured assessment that takes
approximately four hours to administer. Based
on self report and the assessment, Miss S was
diagnosed with a Specific Phobia (DSM..,IV
300.29, fear of rats). No other current or past
diagnoses were found.
Regarding her fear of rats, Miss S noted high
levels of interference and distress. At the time of
the assessment, she was living in Boston, which
is known for its rat population, especially in the
areas where she lived. Miss S stated that she
often avoided areas where she believed that rats
would be; this included alleys with trash
dumpsters, and parks, especially at night time.
She further stated that she lived with roommates
because she was afraid of rats being in her
residence without someone to assist her. She
recalled one incident when she found a mouse in
her room during the night; she became very
fearful, screamed, and sought the assistance of
her roommates to remove the mouse.
Additionally, Miss S noted that she
constantly scanned for rats, and if she would see
movement on the ground, she would assume that
is was a rat. When she would see a rat or
believed that she had seen a rat, she would
I. Azusa Pacific University.
PO Box 7000. 901 East Alosta Avenue. Azusa, California, 91702-7000. USA.
[email protected]
become highly distressed, experience a
situationally bound panic attack, try to leave the
situation by exiting the area, or if that were not
possible, she would try to get to a safe area
where the rat could not reach her, such as a chair
or other high place. If Miss S saw a rat on the
television, she would turn the channel quickly.
She refused to look at pictures of rats. If people
around her discussed rats, she would also
become very fearful and would ask them to
refrain from talking about rats. She also stated
that she had nightmares of rats and would wake
up screammg.
Based on her presentation (specifically, lack
of other diagnoses that would interfere with
therapy), it was decided to use an intensive four
day cognitive behavioral treatment protocol.
On days one and two, each session lasted
approximately two hours with the therapist.
Additionally, the homework assigned (a
combination of readings, answering questions
about the reading and her own fears, and
exposure practices) averaged approximately
two to three hours per night. Day three included
approximately two hours of in-session therapy,
and two hours of exposure, with homework
assigned. Day five included over two hours of
exposure. The treatment protocol was based on
an established eight session cognitive
behavioral protocol with an emphasis on
exposure therapy.
Miss S came to the Center for Anxiety and
Related Disorders at Boston University. She
was formally introduced to the psychologist
who would be working with her. After
answering questions from the patient (questions
included specific inquiries about the therapy, the
therapist's background, and what she would be
expected to do during therapy), a review of her
current symptoms was conducted; it was found
that during the interim between the assessment
and the first session she had an increase in
anxiety about rats. To better assess her current
level of functioning, several stimuli were
introduced, always with Miss S' approval before
they were shown. She exhibited high levels of
anxiety when shown pictures of rats from a
book, and moderate levels of anxiety when
shown a toy rubber rat (Miss S noted that since
she knew that the rat was not real before it was
presented, she was not too fearful of it; still, was
not relaxed when the rubber rat was shown, and
she did not like looking at the tail).
An overview of therapy was then conducted,
noting that the first day was primarily
psychoeducation. This entailed an interactive
discussion about what a phobia is, and how her
fears were being maintained. Several key
concepts were introduced on the first day; this
included the Subjective Units of Distress Scale
(SUDS), the three-component theory, and
information about the fight-or-flight system.
The three component system is used to
describe the interaction between cognitions,
behaviors, and physiological response. Each of
the three components (cognitions, behaviors and
physiological response) are described as
building on each other to increase one's fears and
avoidance. For example, if an individual sees a
rat, she may think "A rat! How horrible! It may
bite me!" With such thoughts, the fight or flight
system initiates, which increases physiological
arousal, which can cause a situationally bound
panic attack. Additionally, because of the
cognitions and physical response, she may leave
the area to get away from the rat. The three
component system is used as the basis for the
description of how a fear is maintained, and the
patient is told that each area of the three
component system will be addressed in therapy,
which will lead to the extinction ofthe fear.
The Subjective Units of Distress Scale, or
SUDS, is used to help both the therapist and
patient quantify the level of anxiety being
experienced by the patient. As each individual
may have varying levels of anxiety to the same
stimuli, the SUDS is very useful to keep track
of a patient's progress throughout treatment.
Typically the SUDS ranges between zero and
100; however any set of numbers is acceptable.
A SUDS level of zero is considered to be
completely calm and relaxed. A SUDS of 40 is
considered moderate, and usually an individual
with a phobia would try to leave the situation if
the level were this high. A SUDS of 100
indicates the highest possible level of anxiety,
denoting a worst case scenario (e.g., have
several live rats on her person).
At the end of the first day, Miss S was
assigned homework to complete before she
returned the next day. Homework included
reading assignments out of a workbook which
corresponded to the material covered during the
session; in addition, she was asked to take both
the toy rubber rat and the book of rat
photographs home with her.
She was not
directed to look at the pictures; rather she was
asked just to carry them with her. Miss S stated
that she would be able to complete the
homework and noted a SUDS of30 for carrying
the items in her purse.
The second day of treatment began with a
review of her homework, which she completed
without any problems. She also stated that she
now had no fear of carrying the book of rat
photos with her, and did not have any concerns
about having the rubber rat in her purse; in fact,
she and her friends made it a necklace and had
given it a name.
During day two, cognitive challenging was
introduced. Specifically during day two, the
concept of "probability overestimation" was
defined, described, and practiced. Probability
overestimation is defined as overestimating the
likelihood of a feared event occurring. One
component of phobias is the irrational fear of an
event occurring; oftentimes the patient has not
critically examining the likelihood of said event
actually happening.
During this phase of
treatment, the patient is asked to describe a
feared situation; Miss S immediately described
a scenario of a rat running over her foot, and
another of a rat biting her. Miss S was then
asked to critically examine the first scenario (rat
running over her foot). She was first asked how
often a rat had actually run over her foot (never).
She was then asked how many times this had
happened to one of her friends; she immediately
noted that it had happened to an acquaintance.
The psychologist pointed out that this was
"good" in that it reinforced a key concept in
probability
overestimation;
an accurate
likelihood of events occurring. It was noted that
this happened to just one of her friends once in
her lifetime, and was a rare occurrence. She
agreed that the likelihood that a rat would run
over her foot would be highly unlikely. This was
furthered after an explanation of rat behavior;
rats would not run towards a large animal, as this
would likely cause its death (fight or flight
system for the rat), and would more likely run
away. Additionally, Miss S was asked why she
did not fear other events that would be more
likely and catastrophic (e.g., being run over by a
car). She immediately understood the nature of
the phobia and lack oflogic of her reasoning.
After a short break, Miss S was asked to look
at pictures in the book she had been carrying.
She immediately showed high levels of anxiety,
but agreed to look at the pictures. A picture was
chosen with SUDS ratings of 50; she was asked
to stare at the picture, which she was able to do.
After 5 minutes, her SUDS was down to 20.
Four pictures with SUDS ratings of 50 to 80
were selected for her to look at that evening as
part of her homework. Additionally, Miss S was
assigned to practice at home critically
examining probability overestimation in other
situations that she feared about rats (e.g., being
bitten by a rat), and continue her readings that
reinforced what she had learned on day two.
Day three began with a review of her homework; she was able to accurately estimate
the likelihood of some of her feared events
occurring. She had some questions about the
readings, which were discussed. Miss S was
now able to look at any of the pictures in the rat
book with minimal levels of anxiety; she even
found some ofthe pictures "cute."
Treatment continued with an introduction to
"catastrophization," or the concept of assuming
that any interaction with the feared object (in
this case rats) would result in horrible
consequences (death, or a fate worse than
death). During this portion of the cognitive
treatment, the focus was examining what the
negative cognitions were, and to critically
examine without bias how bad the consequences
really were.
Miss S' worse case scenarios
included having a rat run over her foot, holding a
'rat, and"'eing bitten by a rat. While none of
these outcomes are generally seen as positive by
most people, Miss S so highly feared these
situations that she had avoided many things in
life so that they would not occur without fully
examining her fears.
The following is an
example of the patient/therapist interaction in
discussing catastrophization:
Therapist:
You mentioned that one of
your fears is having a rat run over your
foot. What is so bad about that?
Miss S.: (immediately frowns and shows
some anxiety) It would be disgusting and
creep me out.
Therapist: Ok, what exactly makes it
disgusting and creepy?
Miss S.: Well, the feeling of its feet on
my skin. That gives me the shivers.
Therapist: Have you ever experienced
anything really horrible in your life?
Something that you thought would just
overwhelm you, but you managed to
cope with it?
Miss S.: Well, yes, I can think of a few
times in my life that I've managed to deal
with things that were pretty hard. It took
some time to get over, but I did.
Therapist: How long do you think a rat
would take to run over your foot?
Therapist: Probably. Do
could handle
a few
discomfort, in comparison
other things you've
overcome in your life?
you think you
seconds
of
to some,ofthe
managed
to
Miss S.:
I suppose. But I defHlitely
wouldn't like it, and wouldn't want to do
it if! had a choice.
Therapist: Good! So you know you can
do it now the question becollles, is it
worth it? Is it worth it to be around a rat
to overcome your fears of them, SO you
can do things that you want to? That is
something only you can answer.
Miss S.: But I'll probably scream if! see
it, and I may embarrass myself1 And I'm
scared.
Therapist: That's all perfectly normal
we expect that. Keep in mind rats are
things you've avoided for years. But
have you ever been embarrassed before?
Therapist:
Are you still embarrassed
about them? My guess is that currently
you still aren't embarrassed about things
that happened years ago; in fact you may
now find them funny.
Therapist:
So you've coped with
embarrassing situations· before; perhaps
not as well as you'd like, but you you've
survived. This is no different. All you
need to think about is, is the payoff worth
the cost?
Are you willing to be
embarrassed, deal with high levels of
anxiety for a little while to get over your
fears?
As noted, the focus of the cognitive therapy
over the two days is for the patient to recognize
that the likelihood of her feared events are very
low, and in most cases, even if they do occur,
they are not as bad as she initially imagines.
In the next segment of therapy, Miss S
agreed to watch films of rats. This included
several different movie clips and a documentary
on rats, all of which included extended visual
images of rats in various settings, including in
public areas, inside houses, and on people. After
initial high anxiety, Miss S was able to watch the
films with low SUDS.
This process took
approximately two hours. By the end of the two
hours, the only portion of the film which she
found anxiety provoking was a scene of a man
on his back with several hundred rats on and
around him
For homework, Miss S was assigned to
watch the segment of the film which she found
anxiety provoking for one hour. Additionally,
she was to read provided information on
catastrophizing and desensitization.
Finally,
she was asked to write down why she wanted to
overcome her fears of rats, as she knew that on
the following day she would be asked to face her
fears of rats by actually handling them. While
she was anxious, she stated that she felt ready for
the next day's treatment.
A review of Miss S' homework indicated that
she thoroughly understood the cognitive aspects
of the therapy, and understood that her fears
were illogical. Further she realized that her
concerns were unlikely to occur, and even ifthey
did, they were not as bad as she initially
believed. She also had very little anxiety to
pictures of rats, thoughts of rats, or videos of
rats. While she was highly anxious to actually
be near live rats, she knew from her previous
exposure to other stimuli (pictures, videos) that
after initial anxiety she would most likely
become less anxious and more comfortable
around them. She also recognized that need to
face her fears if she wanted to no longer be
fearful of rats and live her life in a way that she
wanted to. Based on her own self-assessment
and the therapist's, it was agreed that Miss S was
ready for the last step of therapy; exposure to
live rats.
Four live laboratory rats in two cages had
been "loaned" to the Center for Anxiety and
Related Disorders by the animal laboratory of
Boston University. Initially, Miss S was kept
out of the room as the rats were prepped; after
one last check of her readiness to enter the room,
Miss S agreed to enter the room and did so. The
rats were in the middle of the room,
approximately 5 meters from her on a table in
cages. After some initial very high anxiety
(SUDS 99), Miss S slowly walked towards the
cages, and within one minute was standing in
front of the cages. Within two minutes she was
able to touch the rats, and was surprised to find
that their fur was soft. Within three minutes she
was able to pet them and touch their tails. After
five minutes, she allowed the therapist to pick up
a rat and place it in her hands while holding it
secure. Within eight minutes she allowed the
therapist to place it in her lap, again holding it
secure. Within ten minutes, Miss S attempted to
pick up a rat on her own; while she was only able
to hold it for a few seconds, she realized that her
fears were not coming true. She had not been
bitten, and while she had been scratched
numerous times, it was no worse than scratches
from a cat. Additionally, she no longer feared
the rats, found them cute and had sympathy for
them due to the excessive handling of them
during this period. After fifteen minutes, she
was able to pick them up and hold them on her
own, have them put on her shoulders, on her feet
and legs without any anxiety; in fact, she became
concerned for the well-being of the rats during
this period, afraid that she would drop one. As
Miss S initiated each new step, she became very
anxious with a high SUDS rating which would
quickly drop as she stayed with each new task
for several mintues.
After a period of twenty five minutes of
exposure to rats, Miss S stated that she no longer
had any anxiety around the rats, and exposure
was terminated. In discussing the exposure with
her, Miss S expressed her happiness in realizing
that her fears had indeed been unfounded, and
noted that she did not think that she would be
concerned about rats anymore.
Homework
for that evening included
walking around areas in Boston that she would
normally avoid due to rats and call the next day
to report how she did. The next day, Miss S
reported walking for two hours in areas she
normally feared being in without any concerns
about rats. Miss S was then instructed to
continue doing exposure on her own once a
week for a month to make sure that she did not
have any fears; additionally she was to review
her worksheets and book once a week to
reinforce her learning.
Two months after therapy, Miss S was
contacted to assess her progress. She noted that
she had no fears about rats and did not think
about them anymore. She no longer scanned
areas or avoid areas because of rats. She had
been in several situations where she had seen
rats and had not been scared. Additionally, she
was able to apply the cognitive portion of th
Therapy to everyday anxieties (exams in class,
daily hassles) and found life to be more
enjoyable, which is ultimately the goal of
therapy.
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