an introduc+on to cbt for anxiety · anxiety disorder (gad) stressful life events or personal...

AnIntroduc+ontoCBTforAnxiety

AndrewGrimmer25thJune2016

“Thealarmisworsethanthefire”(Beck,1976)

Aims

•  Toassessanxietyanditsimpact•  Toformulatearangeofanxietydisorders•  Tolearnandprac+seCBTinterven+onsforanxiety– CBTforanxietyisatleastasmucha“doing”therapyasa“talking”therapy

•  I’msorry,wewon’tbeaOemp+ngtocoverPTSD

Self-evaluate

•  Inpairs,pleasediscuss:

– WhatdoIalreadyfeelconfidentaboutintermsofmyunderstandingofCBTforanxiety?

–  InwhatwayswouldIliketodevelopmyknowledgeandskillsinthisworkshop?

Terminology(Clark&Beck,2010)•  Fear:aprimi+veautoma+cneurophysiologicalstateofalarm

involvingthecogni*veappraisalofimminentthreatordangertothesafetyandsecurityofanindividual

•  Anxiety:acomplexcogni+ve,affec+ve,physiologicalandbehavioralresponsesystem(i.e.threatmode)thatisac+vatedwhenan+cipatedeventsorcircumstancesaredeemedtobehighlyaversivebecausetheyareperceivedtobeunpredictable,uncontrollableeventsthatcouldpoten+allythreatenthevitalinterestsofanindividual

•  Worry:arepe++vethoughtprocessoftryingtofindcertaintyinuncertainsitua+onsbyforeseeingandplanningforeveryconceivableoutcomethatcreatesthefeelingsandemo+onsexperiencedasanxiety

•  Panic:overwhelmingterrorinthefaceofimminent,catastrophicdanger

Normalvs.abnormalanxiety?•  Cogni+ons:Isthefearoranxietybasedonafalse

assump+onorfaultyreasoningaboutthepoten+alforthreatordangerinrelevantsitua+ons?

•  Func+oning:Doesthefearoranxietyactuallyinterfereintheperson’sabilitytocopewithaversiveordifficultcircumstances?

•  Persistence:Istheanxietypresentoveranextendedperiodof+me?

•  Triggers:DoestheindividualexperiencefalsealarmsorpanicaOacks?

•  Hypersensi+vity:Isfearoranxietyac+vatedbyafairlywiderangeofsitua+onsinvolvingrela+velymildthreatpoten+al?

Comorbidity

•  Depression:76%life+me-associatedwithamorepersistentcourseofdisturbance,greatersymptomseverity,andgreaterfunc+onalimpairmentordisability

•  Substanceuse:2-4xmorelikely:reciprocalandinter-ac+nginfluences(notjustself-medica+ng)->increasedsuiciderisk

•  Otheranxietydisorders:especiallyGAD

Context

•  Widespread:25-30%life+meprevalence•  Women>men:2:1•  Culture:apprehension,worry,fear,andsoma+carousalarecommoninallculturesbutvaryinexpression

•  Chroniccourse;majorityhaveonsetinchildhood/adolescence

Allofus(inonewayoranother)

•  Writedownonapieceofpaperwhatfrightensyouormakesyouanxious

•  Putitinthe“hat”•  I’llwritethemupbutyouwon’tbeaskedtoiden+fyyourcontribu+on

LeDoux’sparallelneuralpathwaysinauditoryfearcondi+oning

Memory,reasoningandjudgment

Psychophysiology:SNS•  Sympathe+cnervoussystem(SNS)ac+va+on:hyperarousal

symptoms–  constric+onoftheperipheralbloodvessels,–  increasedstrengthoftheskeletalmuscles,–  increasedheartrateandforceofcontrac+on,–  dila+onofthelungstoincreaseoxygensupply,–  dila+onofthepupilsforpossibleimprovedvision,–  cessa+onofdiges+veac+vity,–  increaseinbasalmetabolism,and–  increasedsecre+onofadrenalineandnoradrenalinefromtheadrenalmedulla

Psychophysiology:PNS•  Parasympathe+cnervoussystem(PNS):conserva+on-withdrawalsymptoms– tonicimmobility,– dropinbloodpressure,– fain+ng,– decreasedheartrateandforceofcontrac+on,– constrictedpupils,– relaxedabdominalmuscles,and– constric+onofthelungs

Features:physiological(1)Increasedheartrate,palpita+ons;(2)shortnessofbreath,rapidbreathing;(3)chestpainorpressure;(4)chokingsensa+on;(5)dizzy,lightheaded;(6)sweaty,hotflushes,chills;(7)nausea,upsetstomach,diarrhoea;(8)trembling,shaking;(9)+nglingornumbnessinarms,legs;(10)weakness,unsteady,faintness;(11)tensemuscles,rigidity;(12)drymouth

BiologicalconcomitantsofanxietyBiologicalfactors Cogni*vesequelaeElevatedtonicautonomicac+va+on Increasedsalienceofthreat-related

s+muliSlowerhabitua+onrate SustainedaOen+ontothreatDiminishedautonomicflexibility ReducedabilitytoshimaOen+onGene+cpredisposi+onfornega+veemo+onality

Hypervalentschemasofthreatanddanger

Subcor+calfearpoten+a+on Preconsciousfears+mulusiden+fica+onandimmediatephysiologicalarousal

Extensivecor+calafferentandefferentpathwaystosubcor+calemo+on-relevantcircuitry

Cogni+veappraisalandmemoryinfluencefearpercep+onandmodulatefearexpressionandac+on

Features:cogni+ve(1)fearoflosingcontrol,beingunabletocope;(2)fearofphysicalinjuryordeath;(3)fearof“goingcrazy”;(4)fearofnega+veevalua+onbyothers;(5)frighteningthoughts,images,ormemories;(6)percep+onsofunrealityordetachment;(7)poorconcentra+on,confusion,distrac+ble;(8)narrowingofaOen+on,hypervigilanceforthreat;(9)poormemory;(10)difficultyinreasoning,lossofobjec+vity

Cogni+vetriad

•  Worldisdangerous•  Selfisvulnerableandhelpless•  Futureisuncertain

Features:behavioural

(1)avoidanceofthreatcuesorsitua+ons;(2)escape,flight;(3)pursuitofsafety,reassurance;(4)restlessness,agita+on,pacing;(5)hyperven+la+on;(6)freezing,mo+onless;(7)difficultyspeaking

Features:affec+ve

(1)nervous,tense,wound-up;(2)frightened,fearful,terrified;(3)edgy,jumpy,jiOery;(4)impa+ent,frustrated

Fiveaspectsmodel:Padesky&Mooney

Thoughts

Behaviour Emo+ons

Physicalsensa+ons

Environment

Woozles?

Assessment:what’stheproblem?•  5Ws

–  What–  When–  Where–  Why–  Withwhom

•  FIDO–  Frequency–  Intensity–  Dura+on–  Onset

•  Impact–  Occupa+onal/financial–  Domes+c/self-care–  Social–  Personalinterests–  Rela+onships

•  Features–  Physiological–  Cogni+ve–  Behavioural–  Affec+ve

Videoexercise

•  DrWrightandGina:– AssessingSymptomsofAnxiety

Smallgroupexercise

•  Ingroupsoffive– ComparewhatyoulearnedaboutGina– Discusswhatelseyouthinkitwouldbehelpfultoknow

ADSMs

•  GAD-7:generalanxietymeasure•  SPIN(SocialPhobiaInventory):socialanxiety•  OCI(ObsessiveCompulsiveInventory):OCD•  PDSS(PanicDisorderSeverityScale):Panicdisorder

•  MI(MobilityInventory):Agoraphobia•  PSWQ(PennStateWorryQues+onnaire):GAD•  HIA(HealthAnxietyInventory):Healthanxiety

Func+onalanalysis:“onethingleadstoanother”

•  Boxes:content•  Arrows:process

Antecedents(externalandinternal)

Behaviour(safety-seeking

and/oravoidant)

Consequences(reinforcement)

Two-factortheory(Mowrer)

•  Acquisi+on:classicalcondi+oning•  Persistence:nega+vereinforcement

Trauma+cevent(classical

condi+oning)Avoidance Nega+ve

reinforcement

Two-factortheory:problems

1.  Somes+muliproduceafear-responsemoreeasilythanothers(snakesvs.flowers)

2.  Omennorecalloftrauma+cevent3.  Non-associa+velearning:vicarious/

informa+onal4.  Notalltrauma+ceventsproduceacondi+oned

fearresponse5.  Somephobiasaremorecommonthanothers

(spidersvs.den+sts)

Fearmodule(Öhman&Mineka,2001)

•  “Arela+velyindependentbehavioral,mental,andneuralsystemthatisspecificallytailoredtohelpsolveadap+veproblemsencounteredbypoten+allylife-threateningsitua+onsintheecologyofourdistantforefathers”–  Selec+velysensi+zed:preferen+alaccesstocertaincues/s+muli

– Automa+city:preconsciousac+va+on–  Encapsula+on:impenetrabletoconsciousinfluences–  Specificneuralcircuitry:amygdalapriori+sa+on

Genericcogni+vemodel(Clark&Beck,2010)

Anxietyfeedbackloops

1ryappraisal:threat2ryappraisal:vulnerability

Situa+on/trigger

PhysicalEmo+onalCogni+veeffectsBehaviour

Gene

ralises Sensi+ses

FocusesConfirms

Amplifies

Anxietyequa+on

Anxiety=ProbabilityxAwfulness

Coping+Rescue

Salkovskisetal,1998)

Trigger: hearing a news item about cancer!

Roleplay

•  Intrios:– Client:roleplayananxiousclientthatyouhaveworkedwith(ormakeoneup)

– Therapist:exploreaspecificrecentincidentofanepisodeofanxietyusingtheanxietyequa+on/feedbackloops

– Observer:makeanoteofwhatthetherapistelicitsagainsteachofthecategories

Cogni+vespecificityAnxietydisorder Threatenings*mulus Coreappraisal

Panicdisorder(withorwithoutagoraphobia)

Physical,bodilysensa+ons

Imminentfearofdying(“heartaOack”),losingcontrol(“goingcrazy”)orconsciousness(fain+ng),havingfurtherpanicaOacks

Healthanxiety Physical,bodilysensa+ons

Fearofhavingalife-threateningillness

Generalizedanxietydisorder(GAD)

Stressfullifeeventsorpersonalconcerns

Fearofpossiblefutureadverseorthreateninglifeoutcomes

Socialphobia Social,publicsitua+ons

Fearofnega+veevalua+onfromothers(e.g.,embarrassment,humilia+on)

Obsessive–compulsivedisorder(OCD)

Unacceptableintrusivethoughts,images,orimpulses

Fearoflosingmentalorbehavioralcontrolorotherwisebeingresponsibleforanega+veoutcometoselforothers

Anxietycarousel•  Specificphobia•  Blood-injury-needlephobia•  Panicdisorder•  Agoraphobia•  Emetophobia•  Socialanxietydisorder•  Generalisedanxiety

disorder•  Obsessivecompulsive

disorder•  Bodydysmorphicdisorder•  Healthanxiety

•  Youhave5minutes(approx)to:–  Iden+fythetrigger(s)–  Iden+fythecoreappraisalsofthreatandvulnerability

–  Iden+fyavoidanceandsafetybehaviours

– Checkouttheimpact

Generalprinicples

•  Agenda:priori+sing•  Feedback:clarifyingunderstanding•  Pacing:workingattheclient’sspeed•  Collabora+on:coopera+ngasateam•  Emo+on:helpingtheclienttoregulatedistress,modellingthatanxietyisunpleasantbutnotdangerous

Guideddiscovery

•  Informa+onalques+ons:exploreallfacetsoftheproblem(5areas:boxesandarrows)

•  Summarise:helptheclientretainandfocusonrelevantinforma+on

•  Expressempathy:demonstrateyouunderstandandappreciatetheclient'sdistress

•  Synthesise:elicitandconsolidatelearning

Anxiety-specifictreatmentprinciplesCogni*vetenets Treatmentimplica*ons

Exaggeratedthreatappraisals Recalibratethreat;increasetoleranceforriskanduncertainty

Heightenedhelplessness Increaseself-confidencetodealwiththreatanduncertainty

Inhibitoryprocessingofsafety Improveprocessingofsafetycues;reducesafety-seeking

Impairedconstruc+veorreflec+vethinking

Cogni+verestructuringskills(controlledefforxulthinkingskills);tackleworry

Automa+c(1ry)andstrategic(2ry)processing

Behaviouralandexperien+alexercises

Self-perpetua+ngprocess Correctmisinterpreta+onsofanxietysymptoms

Monitoring•  Diaries:–  thinkaboutwhatyouwanttheclienttolearn

Day/*me Anxiety(0-10)

Thoughts,concernsorworries

Behaviour(avoidanceorsafety-seeking)

Consequences(+&-)

Weds5pm 7/10 WhatifImessupatwork–I’lllook

likeanidiot

WorryPhonedMum

Worrymadeproblemseemevenbigger

Feltreassured,onlylasted30

minutes

Understanding•  Formula+ng–  Idiosyncra+cformula+on:

•  usetheanxietyequa+onforgenericpresenta+ons;checkoutidiosyncra+cmodelsforspecificdisorders

– Cogni+vera+onale:•  makesureyouunderstandtheroleofanxiousappraisal(threat/vulnerability)andavoidance/safetybehaviours

•  Psychoeduca+on– Anxietysymptoms:

•  prac+seexplainingfight,flight,freezeresponse

Exposure:prolongedandrepeated•  Basedonprincipleofhabitua+on– Graded:constructahierarchybasedonSUDs(subjec+veunitsofdistress)–startwithatleast30%

–  Responsepreven+on:inhibitresponseun+lanxietydiminishesbyatleast50%

–  In-session:prac+seexposurein-session–  Invivo:accompanyclientson“fieldtrips”–  Interocep+ve:panicinduc+on(seeCCIPanicSta+ons)–  Imaginal:

•  Firstperson,presenttense,worstcasescenario•  Copingimagery:walkthroughthefrighteningsitua+oninimagina+on

www.getselfhelp.co.uk © Carol Vivyan 2010. Permission to use for therapy purposes. www.get.gg

When we avoid situations because we get too anxious or distressed, if we think about or find ourselves in those situations, our anxiety rises sharply, stays on a level for a while, then slowly starts to decrease gradually….

Length of Time

If we didn’t avoid the situation, just do it anyway and stick with it, then the first time will be the worst. Each time after that, we’ll find that we won’t be quite so anxious as the time before, and the anxiety will start to pass a little quicker than the previous time, so the diagram might look something like:

Length of Time

Level of D

istr

ess

Level of D

istr

ess

Habitua+on

Behaviouralexperiments•  Tes+ngassump+ons:– “if…then...”proposi+onalstatements

Thoughttobetested:“If…then...”

Experiment:whatwhen,where,withwhom

Predic+on(ifthoughtistrue)

Obstacles/barrierstoovercome Solu+ons/strategiestoovercomebarriers

Whathappened? WhatdidIlearn(aboutthethoughttobetested)?

VerbalreaOribu+on:TheoryAvs.TheoryB

Theory A Theory B

Theory BTheory A

PSYCHOLOGYT LS

The problem is ...

Evidence

What do I need to do if Theory A is true? What do I need to do if Theory B is true?

Evidence

The problem is worry that ...

http://psychology.tools

TheoryAvs.TheoryB:healthanxiety

Theory A Theory B

Theory BTheory A

PSYCHOLOGYT LS

The problem is ...

Evidence

What do I need to do if Theory A is true? What do I need to do if Theory B is true?

Evidence

The problem is worry that ...

I have brain cancer I have brain cancer

I have these symptoms:HeadachesDizzinessVision goes blurry sometimes

Doctor tells me it is not cancerThe headaches are worse when I am stressedFocusing on my symptoms makes them worseReassurance makes my symptoms betterI’ve had these symptoms a long time andthey have not got any more serious

Go to the doctor and insist that they treat mestraight away - brain cancer is serious!

Learn how to deal with my worry

http://psychology.tools

VerbalreaOribu+on:P3RPlan(amerPadesky)

Predict:whatbadthingsmighthappenifyoudidthis?

Preparecopingresponses:whatcouldyoudowhenthishappens?

Prac+seyourresponses(when,where,how,withwhom)

Reflect:whathaveyoulearnedaboutyourvulnerability?

•  Anexperimenttotestoutfearsandovercomeavoidance–  Specifywhatyou’vebeenavoiding–  Ratehowanxiousthethoughtofitmakesyoufeel(0-10)

Calming/refocusingtechniques•  Physiological– Progressivemusclerelaxa+on– Breathingretraining

•  Mindfulness:– defusingfromtheanxiousthought/experience:

•  “TheawarenessthatemergesthroughpayingaOen+ononpurpose,inthepresentmoment,andnonjudgmentallytotheunfoldingofexperiencemomentbymoment.”JohnKabatZinn•  quicksandmetaphor;demonsontheboat

•  AOen+ontraining:AdrianWells

Worrystrategies•  Worrystrategies– Worrydiary:

•  Hypothe+calscenariovs.acurrentconcern•  Makeaspecificpredic+on

– Worry+me:toteachthatworryiscontrollable•  Setasideaspecificamountof+meeachdayforworrying•  Ifyoudonotwanttouseyourworry+meforworrying,useitforsomethingelse

– Worrytree(plusproblemsolving):•  IsthereanythingIcanusefullydo?•  If“yes”whenshouldIdoit?•  Letgoofworry

Intoleranceofuncertainty:DugasUncertaintyandchangeinbehaviourDate:

Descrip+onoftheac+onchosen:

Discomfortduringtheac+on

Thoughtsduringtheac+on

Observa+onsamerperformingtheac+on

Intoleranceofuncertainty:exampleUncertaintyandchangeinbehaviourDate:

Descrip+onoftheac+onchosen:Iwillcheckmye-mailonlytwiceperday(tocombatrepeatedchecking).

Discomfortduringtheac+on:IfeelterriblewhenIcan’tcheckmye-mail.Ifeelfeverishandnervous.Ireallywanttogocheckmye-mailrightnow.

Thoughtsduringtheac+on:IthinkI’mgoingtomisssomethingimportant.I’mafraidpeoplewillthinkI’mnotdiligentinmywork.AclientcouldhaveaproblemandIwouldn’tbeabletohelp.

Observa+onsamerperformingtheac+on:Thefirstdaywasverydifficult.Amerafewdays,Irealizeditwasge|ngeasierandtherewasnodramaorcatastrophe.

Worryques+ons•  Whatareyouworryingabout?•  Whatisitaboutitthatconcernsyou?•  Whatistheveryworstthatcouldhappen?

–  Andwhatmakesthatsoawful?•  Whatistherealis+clikelihoodofitoccurring?

–  Howmuchwouldyoubetonit?•  Makeaspecificpredic+on(worryhatesspecifics)

–  Howconfidentareyou(outof10)?–  Howanxiousdoesthatmakeyoufeel(outof10)?

•  Ifyourpredic+oncametrue,whatcouldyoudotodealwithit?–  Howwoulditlookin5years?

•  Whocouldyouturntoforhelp?–  Howwouldtheyhelpyou?

•  Isthereanythingyoucanorshoulddoaboutyourconcern?•  Ifyes,whenshouldyoudoit?

Resources

•  GetSelfHelp:www.get.gg•  PsychologyTools:hOp://psychology.tools•  TherapistAid:hOp://www.therapistaid.com•  LivingLifetotheFull:hOp://www.ll}.com•  CentreforClinicalInterven+ons:hOp://www.cci.health.wa.gov.au

•  MoodGym:hOps://moodgym.anu.edu.au/welcome

Roleplay

•  Intrios:– Client:roleplayananxiousclientthatyouhaveworkedwith(ormakeoneup)

– Therapist:chooseastrategybasedontheclient'spresenta+onandtryitout

– Observer:makeanoteofwhatthetherapistelicitsagainsteachofthecategories

Finalthoughts

•  Inyouroriginalpairs:revisityouroriginalanswers–  InwhatwaysdoIfeelmoreconfidentaboutmyunderstandingofCBTforanxiety?

– HowcouldIapplywhatIhavelearnedfromthisworkshopinmyprac+ce?

Contactdetails

•  www.bristolcbt.co.uk•  bristolcbt.email@gmail.com•  +44(0)7806093773