Transcript CBT for Anxiety - Cambridgecourse.com

CBT for Anxiety
November 2011
Dr Helen Barlow
Clinical Psychologist, CPFT
Definitions of Anxiety
 APA (1975) Apprehension, tension or
uneasiness that stems from the anticipation of
danger, the source of which is largely unknown
or unrecognised
 Characterised by feelings of tension,
apprehension, worry and by activation/arousal of
the autonomic nervous system
 Sense of threat; worry about future (immediate
or distant)
Anxiety Vs Anxiety Disorders
 Anxiety is a normal human response to many
common situations
 Mild anxiety often improves performance and is
adaptive
 Anxiety disorders are more intense, last longer
and may severely interfere with daily life
 Anxiety disorders involve the anticipation of, and
preparation for, negative outcomes of future
events. Sense that danger lies ahead and the
self is threatened in some way.
Anxiety disorders
Person believes that:
 1) the situation is more dangerous
and
2) they are less able to cope than they
actually are
CBT helps them consider and gather
evidence for alternative, less threatening
explanations of their problem
Brief exercise
 In pairs, consider the last time you felt
anxious but confronted the situation
anyway e.g. an exam, party, MDT
meeting, etc.
 Did you believe/feel:
1) that the situation was more dangerous
than perhaps it actually was &
2) that you were less able to cope than you
actually were?
CBT Understanding of Anxiety
 Anxiety is the body’s way of responding to
danger (fight or flight)
 When we think we’re in danger, we scan for
threats – hyper-vigilant, ‘on-edge’
 Catastrophic thinking
 Highly attuned to/misinterpret physical
sensations e.g. heart racing
 Avoidance behaviour
 Safety behaviours maintain anxiety
 Becomes a vicious cycle
DSM-IV: Anxiety disorders
 Panic disorder (with/without agoraphobia)
 Agoraphobia
 Social phobia
 Specific phobias e.g. animals, natural
environment, blood, injections, other
 Obsessive-Compulsive Disorder (OCD)
 Post-Traumatic Stress Disorder (PTSD)
 Acute stress disorder
 Generalised Anxiety Disorder (GAD)
Common symptoms
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Shortness of breath/ smothering sensation
Palpitations, accelerated heart rate
Chest pain or discomfort
Trembling or shaking
Feeling of choking
Sweating
Nausea or stomach distress
Dizzy, lightheaded, or faint
Feelings of unreality or of being detached from yourself
Fear of losing control or going crazy /dying
Numbness or tingling sensations
Panic disorder
 Panic attack = bodily sensations of anxiety +
catastrophic misinterpretation of those as dangerous
 Belief that you are in danger increased anxiety
more sensations & more catastrophic thoughts
vicious cycle between bodily sensations, distorted
thoughts, and anxiety, which can
panic attack.
 Problem is the mistaken belief that you are in danger &
subsequent avoidance
 What might you expect CBT to focus on in the treatment
of panic?
CBT for Panic Disorder
Identify & change the distorted thinking
that maintains anxiety
Desensitise anxiety through graded
exposure to feared situations
Phobic disorders
 A phobia is a persistent and excessive fear of
an object or situation that is not in fact
dangerous
 Leads to desire to avoid even if aware this is not
rational
 May dismiss the fear when they are in a safe
setting but still believe they are in danger when
faced with the phobic situation
 Is disabling and not adaptive- interferes with
daily activities
Why do phobias come about?
 Classical conditioning and maintained by
operant conditioning; may also be learnt from
caregivers
e.g. CC = conditional stimulus (bird) and
unconditional stimulus (loud noise) leads to
conditioned response (fear of birds)
OC = avoidance of birds reinforces that
something to fear (as avoidance reduces
anxiety-phew!) and prevents extinction from
occurring
Agoraphobia
e.g. fear being outside of the home alone or
travelling in a car (escape might be
difficult/embarrassing/ help might not be
available)
 Avoid going out alone/travelling in cars or
endure it with marked distress or fear of having a
panic attack
 Often preceded by separation anxiety/insecure
childhood attachments/low selfefficacy/traumatic events such as loss of
significant other or car crash
Simple phobias
 An intense fear of something that, in reality,
poses little or no actual danger
 Common phobias include closed-in places,
heights, snakes, & needles. Mostly develop in
childhood
 Usually realise the fear is unreasonable
 Thoughts about feared thing causes anxiety
 When exposed, the terror is overwhelming
 Leads to AVOIDANCE
Discussion
Anyone in the room have or know
someone else who has a phobia?
Have they overcome it? How?
Considering the last lecture, what do you
think CBT might focus on when treating a
phobia?
Phobia Treatment: Graded Exposure
Relaxation plus repeated experiences facing your fear- realise that the
situation, while possibly unpleasant, is not harmful. With each exposure,
increased sense of control over your phobia. The phobia begins to lose its
power.
Facing a fear of dogs
 Step 1: Draw a dog on a piece of paper.
 Step 2: Read about dogs.
 Step 3: Look at photos of dogs.
 Step 4: Look at videos of dogs.
 Step 5: Look at dogs through a closed window.
 Step 6: Look through a partly-opened window.
 Step 7: Look at them from a doorway.
 Step 8: Move further out from the doorway.
 Step 9: Ask someone to bring a dog into a nearby room on a lead
 Step 10: Ask someone to bring the dog into the same room, still on a lead.
Plus, Challenging NATs
 Negative thought: “The lift will break down and I’ll get trapped and
suffocate.”
 Is there any evidence that contradicts this thought?
 “I see many people using the lift and it has never broken down.”
 “I cannot remember ever hearing of anyone dying from suffocation in a lift.”
 “There are air vents which will stop the air running out.”
 Could you do anything to resolve this situation if it does occur?
 “I could press the alarm button or use the telephone to call for assistance.”
 Are you making a thinking error?
 “Yes- fortune telling, as I have no evidence to suggest that the lift will break
down.”
 What would you say to a friend who has this fear?
 “I would probably say that the chances of it happening are very slim as you
don’t see or hear about it very often.”
Question
What’s the biggest fear humans
have?
Social Phobia / Social Anxiety
Social phobia/ social anxiety disorder =
marked & persistent fear of
social/performance situations
Fear will be evaluated negatively or act in
a humiliating or embarrassing way
Exposure to social or performance
situations leads to panic or marked
anxiety- tend to avoid or endure with
extreme distress
Social phobia (cont’d)
 Predisposing factors –shy/ anxious temperament
 Significant co-morbidity- depression, substance
misuse, & BDD
 Concerned with autonomic sensations of
blushing, shaking or stammering, which the
person believes may be noticeable to others
 Panic in social situations
 Fear causing a scene & negative evaluation
CBT Understanding of Social
Phobia/Social Anxiety
Avoidance maintains the fear in social
phobia, as people are motivated to avoid
anticipated rejection, deflation & isolation –
never disconfirmed
Safety behaviours keep it going
Role play: CBT for social anxiety
 ‘Kiran’ : Assess the problem.
 Ask him about a recent example when he felt anxious. Identify NATs:
‘What went through your mind as you noticed yourself becoming
anxious’, ‘What was the worst you thought could happen?’ ‘What did
you suppose that others would notice or think?’
 Identify autonomic sensations/ symptoms of anxiety: ‘When you
thought the feared event might happen, what did you notice
happening in your body?’ (e.g. blushing, shaking, sweating).
 Safety behaviours: ‘When you thought the feared event might
happen, did you do anything to try to prevent it from happening?’ ‘Do
you do anything to stop drawing attention to yourself?’
 Increased self-consciousness and imagery: ‘What happens to your
attention when you are most afraid? Do you become more selfconscious? Do you have difficulty following what others are saying?
What do you think Kiran might need to do
to overcome his social anxiety?
Remember:
Thoughts
Feelings
Behaviours
The role of safety behaviours
The role of avoidance
CBT for Social Anxiety
 Behavioural experiments
 Dropping safety behaviours
 Shifting attentional focus in social situations
 Graded exposure, without using safety
behaviours
 Video feedback
 New, alternative thoughts about self/others
 Update images of self in mind
(Clark & Wells, 1995)
Definitions in OCD
 Obsession= persistent thought or image that
pops into mind and triggers distress & is hard to
control or get rid of e.g. fear of contamination, doubts about
harm occurring, sexual thoughts (e.g. being a paedophile), thoughts
of being violent, religious/blasphemous thoughts
 Associated with the power to cause /prevent
harm from occurring i.e. exaggerated sense of
responsibility + excessive attempts to avoid
causing /prevent harm
 Compulsions = Acts repeated over & over to
reduce likelihood of harm until feel ‘right’
e.g. checking, repeating acts, special phrases, ordering, hoarding,
counting
Intrusive thoughts are common!
See list of intrusive thoughts- do you have
any you can think of?
CBT model of OCD
Obsession
Response to reduce anxiety e.g
avoidance/Compulsion
Anxiety
Maintaining factors in OCD
 Avoidance/safety-seeking behaviours i.e. compulsions
 Worry excessively about perceived danger & ‘solutions’
to manage worry end up maintaining anxiety
 Inflated responsibility & magical thinking
 Over-importance of thoughts (all people have intrusive
thoughts)
 Over-estimating danger
 Perfectionism
 Difficulty tolerating uncertainty
 Pink elephant exercise
CBT for OCD
Exposure and response prevention
e.g. hierarchy of exposure to fearthought/image etc until anxiety subsides
e.g touch floor and resist urge to wash
Challenging NATs e.g. re: inflated
responsibility, magical thinking, overimportance of intrusive thoughts, overestimating danger, perfectionism
CBT for PTSD
 DSM criteria for PTSD:
 A. The client must have witnessed or experienced a
serious threat to their life or physical well-being.
B. The client must re-experience the event in some way:
dreams, invasive thoughts or hallucinations.
C. The client must persistently avoid stimuli associated
with the trauma or experience a numbing of general
responsiveness.
D. The client must experience persistent symptoms of
increased arousal.
E. Symptoms must have lasted at least a month.
Cognitive Model of PTSD
 PTSD occurs when individuals process the
trauma in a way which leads to a sense of
serious, current threat
 The sense of current threat arises as a
consequence of :
- Excessively negative appraisals of the trauma
and/or its sequelae
– A disturbance of autobiographical memory
characterised by poor elaboration and
contextualisation
CBT for PTSD: Appraisals
 Appraisals concerning perceived danger lead to fear e.g.
‘ nowhere is safe’
 Appraisals concerning others violating personal rules
and unfair unfairness lead to anger e.g. ‘ others have not
treated me fairly’
 Appraisals concerning one’s responsibility lead to guilt
e.g. ‘ it was my fault’
 Appraisals concerning violation of important internal
standards lead to shame e.g. ‘ I did something
despicable’
 Appraisals concerning perceived loss lead to sadness
e.g. ‘ my life will never be the same again’
CBT Treatment Implications
 The trauma memory needs to be elaborated and
integrated to reduce intrusive re-experiencing
 Appraisals of the trauma or its sequelae which
maintain the current sense of threat need to be
modified
 Safety behaviours which prevent memory
elaboration, exacerbate symptoms or hinder
reassessment of problematic appraisals need to
be dropped
Imaginal Exposure
Develop a detailed verbal narrative in the
present tense, first person
Elicit sensory details, emotions & thoughts
Ask patient how it is affecting them
physically
Leave time for debrief
Homework – listen to taped narrative
Hot spots
Cognitive Restructuring
Focuses on the thoughts and beliefs
generated by the traumatic event
Examines interpretations of the traumatic
event and self & world appraisals
Common themes include guilt, shame,
vulnerability, disgust, anger and sadness
e.g. Hindsight biased thinking
Acute stress disorder
Similar to PTSD but the disturbance lasts
for a minimum of 2 days and a maximum
of 4 weeks and occurs within 4 weeks of
the traumatic event.
Treat with anti-depressants,
benzodiazepines, and CBT anxiety
management techniques (e.g. breathing
techniques and thought challenging and
graded exposure)
Generalised Anxiety Disorder
 Excessive, unrelenting, frequent, disruptive
worry
 Significantly disrupts your job, activities, or social
life
 Is fluctuating & uncontrollable
 The worries are extremely upsetting & stressful
 Worry about all sorts of things, tend to expect
the worst
 Worrying almost every day for at least six
months
Symptoms of GAD
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Physical symptoms of generalized anxiety disorder (GAD)
Muscle tension, aches, or soreness
Trouble falling asleep or staying asleep
Stomach problems, nausea, diarrhoea
Jumpiness
Restlessness
Tire easily
Psychological symptoms of generalized anxiety disorder (GAD)
Irritability
Feelings of dread
Inability to control anxious thoughts
Inability to relax
Difficulty concentrating
Fear of losing control or being rejected
CBT for GAD
 Education
Distinguishing between helpful and unhelpful worry. Increased
understanding of anxiety leads to proactive responses to it
 Monitoring
Monitoring anxiety- triggers, the specific things that worry about, severity &
length of episodes. Helps gain perspective & track progress
 Physical control strategies
Deep breathing and progressive muscle relaxation -decrease the physical
over-arousal of the “fight or flight” response that maintains the state of fear
and anxiety
 Cognitive control strategies
Learning to realistically evaluate and alter the thinking patterns that
contribute to GAD. Challenging negative thoughts & testing beliefs about
worry such as “Worry is uncontrollable” or “If I worry, bad things are less
likely to happen.”
 Behavioural strategies
Tackling avoidance, time management & problem-solving skills
Which anxiety disorder?
 Belief ‘my hands are going to shake, people will
think I’m stupid. I won’t know what to say and
people will think I’m boring’
 “My wife says I’m a worrier…I can’t sleep — I
just feel such dread … and I don’t know why!”
 ‘I feel shaky and sweaty, I’m having a heart
attack’
 ‘If I don’t check my taps I might cause a flood’
 ‘I should have saved the guy in the other train
carriage, I am a horrible person’
Useful Reading
For patients and you:
The Overcoming Series
Overcoming Anxiety
Overcoming Panic
Overcoming Social Anxiety & Shyness
Overcoming OCD
Overcoming Traumatic Stress
For you:
 Cognitive Therapy of Anxiety Disorders –Adrian
Wells