Transcript CBT AND ANXIETY - Tuberous Sclerosis Alliance

MOOD and ANXIETY
DISORDERS IN TSC
Dr Petrus de Vries, Developmental
Neuropsychiatrist
&
Lorraine Cuff, CBT Therapist
October 2009
Mental Health problems in
adults with TSC
• High rates of a number of mental health
problems in TSC
• Children and adolescents: Autism
spectrum disorders, ADHD (25-50%)
• Adults: Mood and Anxiety Disorders (3060%)
• What causes these?
Anxiety Disorders in TSC
Different types:
• Panic Attacks
• Agoraphobia
• Social Phobia
• Specific Phobias
• Generalised Anxiety Disorder (GAD)
• Obsessive-Compulsive Disorder (OCD)
Management of Anxiety
Two main strands of treatment:
1. Medications (e.g. SSRIs)
2. ‘Talking Therapies’ such as Cognitive
Behavioural Therapy (CBT)
The best effects are seen when medications
and CBT are combined.
WHAT IS ANXIETY?
A NATURAL EMOTIONAL AND
PHYSICAL RESPONSE TO
ENVIRONMENTAL AND/OR
INTERNAL STIMULI WHICH ACTS
AS A PROTECTIVE FACTOR TO
KEEP US SAFE
( See Fig. 1)
Shakiness – effect of adrenaline
being released into the body
Feeling the urge to empty bladder
and/or bowels – the body’s
way of ‘lightening the load’
enabling greater flight
Heart pounding – increased heart
rate to pump blood to all muscles
giving the ability to run away
faster - Flight
Hyperventilation – increased
breathing which increases oxygen,
supplying oxygen rich blood to
muscles
Feeling hot – result of increased
blood flow around the body
Fight/flight - Physical
Responses
Muscle tension and pain – result
of increased blood flow to muscles
Feeling sick – result of adrenaline
being released
Sweating – the body’s way of
cooling itself down
Cognitive Responses
Fear through increased adrenaline
Fig. 1
Thoughts of danger which increase
alertness and make the person
‘scan’ for danger
WHEN DOES ANXIETY BECOME
A DISORDER?
ANXIETY RESPONSES BECOME
ANXIETY DISORDERS WHEN
DISTORTED THINKING, STRESS,
PHYSICAL SYMPTOMS AND
AVOIDANCE INCREASE AND CREATE
SIGNIFICANT PROBLEMS IN DAILY
LIFE.
WHAT IS COGNITIVE
BEHAVIOURAL THERAPY?
• A therapy using a mixture of cognitive (thought
processing) and behavioural techniques to look
at the links between a person’s environment,
thoughts, feelings and behaviours and the
impact of these on their health and functioning
• Cognitive techniques address thoughts and
thought patterns which may be ‘unhelpful’ and
may trigger and/or increase anxiety
• Behavioural techniques address behaviours
which may be used by a person to reduce their
anxiety or avoid it altogether
Principles of CBT
• A person’s environment, emotions, thoughts (cognitions)
and behaviours are all linked (see fig. 2).
• Our thoughts, ideas, mental images, beliefs and attitudes
can sometimes be ‘errors’ which are unhelpful and lead
to emotional disturbances and physical reactions.
• These emotional and physical disturbances result in
behavioural patterns which are intended to reduce
anxiety (safety and escape behaviours) or avoid anxietyprovoking situations (avoidance behaviours).
• Although the behaviours may initially reduce the physical
symptoms of anxiety, in the longer term they make the
symptoms worse and create vicious cycles (see fig 3).
Situation
THOUGHTS
Overly negative
Self-critical
Thinking things are going to go wrong
Thinking there is danger
Imagining people will judge you harshly
PHYSICAL REACTIONS
Imagining that you will look foolish
FEELINGS
Heart pounding
Feeling hot
Unpleasant
Sweaty
Anxious
Shakiness
Angry
Headache
Depressed
Stomach ache/cramps
Nausea
BEHAVIOURS
Avoid situations
Run away from situations (escape)
Give up
Don’t try to go places or do things
Fig. 2
WHAT IS THE AIM OF CBT?
• To increase self-awareness
• To encourage a better self-understanding
• To help us recognize the ‘negative traps’ or
‘vicious cycles’ we get caught in (see fig. 3)
• To improve self-control by developing
more appropriate cognitive and
behavioural skills
THE NEGATIVE CYCLE
Confirms negative
thought
SITUATION
Negative thoughts
Feel disinterested, unmotivated
Creates doubts/worries
Affect what you do
Produce unpleasant feelings
Make you feel sad, depressed,
anxious and uptight
Fig. 3
Stallard, P. 2002
WHAT CAN YOU DO?
COGNITIVE
• Identify negative thoughts and
thinking patterns which make
you feel unpleasant using a
thought diary (Appendix A)
• Label the type of ‘thinking
error’ (Appendix B)
• Develop balanced thinking by
looking for evidence for and
against the thoughts and
finding new evidence you
might otherwise miss
• Learn new skills i.e.
distraction, positive self-talk,
problem-solving skills
BEHAVIOURAL
• Activity monitoring – link
activity, thoughts and feelings
• Become more active – this
leaves you less time to worry
or listen to your negative
thoughts
• Increase pleasant activities
• Break tasks into small
achievable steps
• Face your fears – try to break
negative cycles by dropping
avoidance, escape and safety
behaviours
Appendix A
SITUATION
Meeting new
people
FEELING
Anxiety
UNHELPFUL
AUTOMATIC THOUGHTS
HOW MUCH DO I
BELIEVE THE THOUGHT?
WHAT ARE THE
THINKING ERRORS?
CHALLENGE
WHAT IS THE EVIDENCE
AGAINST THIS
THOUGHT?
Nobody will like me
I believe this 90%
Black and white thinking
Catastrophizing
Mind reading
I have other friends
People ask my opinion
about things
ALTERNATIVE
THOUGHT
WHATS ANOTHER WAY
OF VIEWING THE
SITUATION?
I am just nervous about
meeting new people
Most people get nervous
HOW MUCH
DO I
BELIEVE MY
ORIGINAL
THOUGHT
NOW?
30%
Thinking Mistakes/Errors
 Arbitrary Inference: Drawing a conclusion in the absence of sufficient evidence. Example: You are involved in a conversation
with an acquaintance. The acquaintance cuts short the conversation and rushes off. You think, “I must be so boring.”
 “YES BUT” thinking: Focusing on one aspect of a situation while ignoring more important and more relevant features. Example:
A friend tells you that you look nice in your new outfit and you say to yourself, “She’s just saying that to be nice ~ she doesn’t
really mean it.”
 Overgeneralization: Applying a conclusion to a wide range of events or situations when it is based on isolated incidents. You find
out that a colleague doesn’t like you, so you conclude that nobody likes you.
 Magnification/Minimization or Black and White Thinking: Enlarging or reducing the importance of events. Minimization is
similar to discounting positives – insisting that positive experiences don’t count. Example: You are on a diet and eat a spoonful of
ice cream and think to yourself, “I’ve blown my diet completely.” Leading to you eating more ice cream
 Personalizing: Relating external events to yourself when there is no obvious basis to do so. Example: You arrive home from
work and your partner is cross and you think to yourself, “I must have upset him/her, it’s all my fault.”
 Catastrophizing: Dwelling on the worst possible outcome of a situation and overestimating the probability that it will occur.
Example: You are due to go to a party at the weekend and say to yourself, “I bet it will be awful, no one will talk to me and I will
look stupid stood all alone.”
 Mind Reading: Assuming people are reacting negatively to you when there is no definite evidence for this. Example: A friend
doesn’t return your call and you say to yourself, “She doesn’t like me anymore, she thinks I’m weird”.
 Emotional Reasoning: You decide how things are on the basis of how you feel. Example: You feel worried about giving a report in
front of your colleagues and say to yourself, “I feel so nervous, everyone will see how nervous I am and something awful will
happen.”
 Labeling: You attach negative labels to yourself and call yourself names. Example: You miss an appointment with the doctor.
Instead of thinking, “I made a mistake,” you say to yourself, “I’m so untrustworthy, I’m stupid.”